Maternity Nursing 2 of 2

A postpartum client is getting ready for discharge. The nurse suspects that the client is in need of further teaching related to breast-feeding when she states: 1. "I don't need birth control since I will be breast-feeding." 2. "I need to increase my caloric intake by 500 calories a day." 3. "I shouldn't use soap to wash my breasts since I will bebreast-feeding." 4. "I need to be sure that I increase my fluid intake and take my prenatal vitamins while breast-feeding."

1. "I don't need birth control since I will be breast-feeding." Rationale: Amenorrhea may occur during breast-feeding, but the client can still ovulate without menstruating. The use of soap on the breasts is avoided because it tends to remove natural oils, which can lead to cracked nipples. The caloric intake should be increased by 200 to 500 cal/day (per health care provider's prescription), and the diet should include additional fluids and prenatal vitamins, as prescribed. Test-Taking Strategy: Note the strategic words "need of further teaching." These words indicate a negative event query and the need to select the incorrect statement. Recalling the physiology related to amenorrhea and ovulation during breast-feeding will direct you to the correct option. Review teaching points for the woman who is breast-feeding if you had difficulty answering this question. Level of Cognitive Ability: Evaluating Client Needs: Health Promotion and Maintenance Integrated Process: Teaching and Learning Content Area: Maternity/Postpartum Reference: Leifer, p. 266. 2011.

A nursing instructor asks a nursing student to describe the procedure for administering erythromycin ointment to the eyes of a neonate. The instructor determines that the student needs to research this procedure further if the student states: 1. "I will flush the eyes after instilling the ointment." 2. "I will cleanse the neonate's eyes before instilling theointment." 3. "The administration of the eye ointment is within 1 hour after delivery." 4. "I will instill the eye ointment into each of the neonate's conjunctival sacs."

1. "I will flush the eyes after instilling the ointment." Rationale: Eye prophylaxis protects the neonate against Neisseria gonorrhoeae and Chlamydia trachomatis. The eyes are not flushed after the instillation of the medication, because the flush will wash away the administered medication. Options 2, 3, and 4 are correct statements regarding the procedure for administering eye medication to the neonate. Test-Taking Strategy: Use the process of elimination, and note the strategic words "needs to research." These words indicate a negative event query and ask you to select an option that is an incorrect statement. Visualize the effect of each statement. This will direct you to option 1. Review the procedure for administering eye medication to the neonate if you had difficulty with this question. Level of Cognitive Ability: Evaluating Client Needs: Physiological Integrity Integrated Process: Teaching and Learning Content Area: Newborn References: Kee, Hayes, McCuistion, p. 439. 2009. Lehne, p. 1136. 2010.

A 31-week preterm labor client dilated to 4 centimeters has been started on magnesium sulfate. Her contractions have stopped. If the client's labor can be inhibited for the next 48hours, what medication does the nurse anticipate will beprescribed? 1. Betamethasone 2. Nalbuphine (Nubain) 3. Misoprostol (Cytotec) 4. Rh0(D) immune globulin (RhoGAM)

1. Betamethasone Rationale: Betamethasone, which is a glucocorticoid, is given to stimulate fetal lung maturation. It is used for clients in preterm labor between 28 and 32 weeks' gestation if the labor can be inhibited for 48 hours. Nalbuphine (Nubain) is an opioid analgesic. Misoprostol (Cytotec) is a prostaglandin that is given to ripen and soften the cervix and to stimulate uterine contractions. Rh0(D) immune globulin (RhoGAM) is given to RH-negative clients to prevent sensitization. Test-Taking Strategy: Use the process of elimination. Noting the strategic words "31-week preterm labor client" and recalling that betamethasone is used to stimulate surfactant release will direct you to the correct option. Review the purpose and actions of the medications in the options if you had difficulty with this question. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Maternity/Intrapartum Reference: Kee, Hayes, McCuistion, p. 823. 2009.

After delivery, the nurse checks the height of the uterine fundus. The nurse expects that the position of the fundus would most likely be noted: 1. To the right of the abdomen 2. At the level of the umbilicus 3. About 4 cm above the level of the umbilicus 4. One fingerbreadth above the symphysis pubis

2. At the level of the umbilicus Rationale: After delivery, the uterine fundus should be at the level of the umbilicus or one to three fingerbreadths below it and in the midline of the abdomen. If the fundus is 4 cm above the umbilicus, this may indicate that there are blood clots in the uterus that need to be expelled by fundal massage. If the fundus is noted to the right of the abdomen, it may indicate a full bladder. By about 10 days postpartum, the uterus will be in the symphysis pubis area. Test-Taking Strategy: Note the strategic words "after delivery" and visualize the process of involution.Remember that after delivery, the uterine fundus should be at the level of the umbilicus or one to three fingerbreadths below it and in the midline of the abdomen. Review expected postdelivery findings if you had difficulty with this question. Level of Cognitive Ability: Understanding Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Maternity/Postpartum Reference: Leifer, p. 201. 2011.

A neonate has just been circumcised. The nurse would expect the surgical site to appear: 1. Pink, without drainage 2. Reddened, with a small amount of bloody drainage 3. Reddened, with a small amount of yellow exudate on theglans 4. Reddened, with a large amount of bloody drainage that requires a dressing change every 30 minutes

2. Reddened, with a small amount of bloody drainage Rationale: The glans penis is normally dark red. After circumcision, a small amount of bloody drainage is expected. During the normal healing process, the glans becomes covered with a yellow exudate. If excessive bleeding is noted from the circumcision, the nurse applies gentle pressure to the site of bleeding with a sterile gauze pad. If the bleeding is not controlled, the health care provider is notified, because a blood vessel may need to be ligated. Test-Taking Strategy: Use the process of elimination, and focus on the subject of the expected appearance. Remember that a small amount of bloody drainage is expected. Review the expected findings after circumcision if you had difficulty with this question. Level of Cognitive Ability: Understanding Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Newborn References: Christensen, Kockrow, pp. 850, 875-876. 2011. Foundations of nursing. Leifer, pp. 290-292. 2011.

A woman with preeclampsia is receiving magnesium sulfate. The nurse assigned to care for the client determines that the magnesium sulfate therapy is effective if: 1. Scotomas are present. 2. Seizures do not occur. 3. Ankle clonus is noted. 4. The blood pressure decreases.

2. Seizures do not occur. Rationale: For a client with preeclampsia, the goal of care is directed at preventing eclampsia (seizures). Magnesium sulfate is an anticonvulsant rather than an antihypertensive agent. Although a decrease in blood pressure may be noted initially, this effect is usually transient. Scotomas are areas of complete or partial blindness. Visual disturbances, such as scotomas, often precede an eclamptic seizure. Ankle clonus indicates hyperreflexia and may precede the onset of eclampsia. Test-Taking Strategy: Use the process of elimination. Knowing that magnesium sulfate is an anticonvulsant will direct you to option 2. Review the actions and uses of magnesium sulfate if you had difficulty with this question. Level of Cognitive Ability: Evaluating Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Maternity/Intrapartum References: Hodgson, Kizior, p. 709. 2011. Leifer, p. 94. 2011.

Epidural analgesia is administered to a woman for pain relief after a cesarean birth. The nurse assigned to care for the woman ensures that which medication is readily available ifr espiratory depression occurs? 1. Betamethasone 2. Morphine sulfate 3. Naloxone (Narcan) 4. Meperidine hydrochloride (Demerol)

3. Naloxone (Narcan) Rationale: Opioids are used for epidural analgesia. An adverse effect of epidural analgesia is a delayed respiratory depression. Naloxone (Narcan) is an opioid antagonist, which reverses the effects of opioids and is given for respiratory depression. Morphine sulfate and meperidine hydrochloride are opioid analgesics. Betamethasone is a corticosteroid that is administered to enhance fetal lung maturity. Test-Taking Strategy: Use the process of elimination, and focus on the subject of the question: the antidote for respiratory depression. Eliminate options 2 and 4 first, knowing that these medications are opioid analgesics. Next, eliminate option 1, knowing that this medication is a corticosteroid. Review the purposes and actions of these medications if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Maternity/Postpartum Reference: Hodgson, Kizior, pp. 802-803. 2011.

The nurse is assisting with caring for a postpartum client who is experiencing uterine hemorrhage. When planning to meet the psychosocial needs of the client, the nurse would: 1. Maintain strict bedrest. 2. Monitor the vital signs every 2 hours. 3. Perform firm fundal massage every 2 hours. 4. Keep the client and her family members informed of her progress.

4. Keep the client and her family members informed of her progress. Rationale: Keeping the client and her family informed about her condition will help minimize fear and apprehension. Options 1, 2, and 3 identify physiological interventions. Test-Taking Strategy: Use the process of elimination. Focus on the strategic words "meet the psychosocial needs." Option 4 is the only option that addresses psychosocial needs. Review the interventions that will meet the psychosocial needs of the client if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Caring Content Area: Maternity/Postpartum Reference: McKinney, James, Murray, Ashwill, p. 700. 2009.

A pregnant woman has a positive history of genital herpes, but she has not had lesions during her pregnancy. The nurse plans to provide which of the following information to theclient? 1. "You will be isolated from your newborn after delivery." 2. "There is little risk to your baby during your pregnancy, birth, and after delivery." 3. "Vaginal deliveries can reduce neonatal infection risks, even if you have an active lesion at birth." 4. "You will be evaluated at the time of delivery for herpetic genital tract lesions. If they are present, a cesarean delivery will be needed."

4. "You will be evaluated at the time of delivery for herpetic genital tract lesions. If they are present, a cesarean delivery will be needed." Rationale: If herpetic genital lesions are present at the time of delivery, a cesarean delivery will be necessary to reduce the risk of infecting the neonate. In the absence of herpetic genital lesions, a vaginal delivery may be indicated, unless there are other reasons for performing a cesarean delivery. Maternal isolation is not necessary, but potentially exposed neonates should be cultured on the day of delivery. Test-Taking Strategy: Use the process of elimination. Focusing on the subject of a positive history of genital herpes and recalling the risks to the neonate will direct you to the correct option. Review the methods of transmission of genital herpes to the neonate if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Fundamental Skills: Safety/Infection Control Reference: Perry, Hockenberry, Lowdermilk, Wilson, p. 106. 2010.

The nurse is preparing to care for a newborn who is receiving phototherapy. Choose the measures that would be implemented. Select all that apply. 1. Avoid stimulation. 2. Decrease fluid intake.3. Expose all of the newborn's skin. 4. Monitor the skin temperature closely. 5. Reposition the newborn every 2 hours. 6. Cover the newborn's eyes with shields or patches.

4. Monitor the skin temperature closely. 5. Reposition the newborn every 2 hours. 6. Cover the newborn's eyes with shields or patches. Rationale: Phototherapy is the use of intense fluorescent lights to reduce serum bilirubin levels in the newborn. Injury from treatment (e.g., eye damage, dehydration, sensory deprivation) can occur. Interventions include exposing as much of the newborn's skin as possible; however, the genital area is covered. The newborn's eyes are also covered with shields or patches to ensure that the eyelids are closed. The shields or patches are removed at least once per shift to inspect the eyes for infection or irritation and to allow for eye contact. The nurse measures the quantity of light every 8 hours, monitors the skin temperature closely, and increases fluids to compensate for water loss. The newborn will have loose green stools and green-colored urine. The newborn's skin color is monitored with the fluorescent light turned off every 4 to 8 hours, and he or she is monitored for bronze baby syndrome, which is a grayish-brown discoloration of the skin. The newborn is repositioned every 2 hours, and stimulation is provided. After treatment, the newborn is monitored for signs of hyperbilirubinemia, because rebound elevations are normal after therapy is discontinued. Test-Taking Strategy: Focus on the subject of phototherapy. Recalling that injury from treatment and sensory deprivation can occur will assist you with determining the correct interventions. Review the interventions for the newborn who is receiving phototherapy if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Newborn Reference: Leifer, pp. 341-342. 2011.

The nurse is assisting with planning care for a postpartum woman who has small vulvar hematomas. To assist with reducing the swelling, the nurse should: 1. Check the vital signs every 4 hours. 2. Measure the fundal height every 4 hours. 3. Prepare a heat pack for application to the area. 4. Prepare an ice pack for application to the area.

4. Prepare an ice pack for application to the area. Rationale: The application of ice will reduce the swelling caused by hematoma formation in the vulvar area. Options 1, 2, and 3 will not reduce swelling. Test-Taking Strategy: Use the process of elimination. Focus on the subject of the question—the reduction of swelling. This will assist you with eliminating options 1 and 2. Recalling the principles related to heat and cold will direct you to option 4. Review the nursing care of the client with a hematoma if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Maternity/Postpartum Reference: Leifer, pp. 204, 239-240. 2011.

The client received epidural anesthesia during labor and had a forceps delivery after pushing for 2 hours. At 6 hours postpartum, the client's systolic blood pressure (BP) dropped20 points, the diastolic BP dropped 10 points, and her pulse is120 beats per minute. The client is very anxious and restless. The nurse is told that the client has a vulvar hematoma. On the basis of this diagnosis, the nurse would plan to: 1. Reassure the client. 2. Apply perineal pressure. 3. Monitor the fundal height. 4. Prepare the client for surgery.

4. Prepare the client for surgery. Rationale: The information provided in the question indicates that the client is experiencing blood loss. Surgery would be indicated for this complication to stop the bleeding. Options 1, 2, and 3 would not assist with controlling the bleeding in this emergency situation. Test-Taking Strategy: Focus on the information provided in the question and note that the client has a vulvar hematoma. Note that the signs and symptoms in the question indicate the presence of bleeding; this should direct you to the correct option. Review the nursing interventions related to vulvar hematomas if you had difficulty with this question. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Maternity/Postpartum References: Leifer, p. 239. 2011. McKinney, James, Murray, Ashwill, p. 698. 2009.

The nurse administers erythromycin ointment (0.5%) to the newborn's eyes, and the mother asks the nurse why this is done. The nurse tells the client that this is routinely done to: 1. Prevent cataracts in the neonate born to a woman who is susceptible to rubella. 2. Protect the neonate's eyes from possible infections acquired while hospitalized. 3. Minimize the spread of microorganisms to the neonate from invasive procedures during labor. 4. Prevent ophthalmia neonatorum from occurring after delivery to a neonate born to a woman with an untreated gonococcal infection.

4. Prevent ophthalmia neonatorum from occurring after delivery to a neonate born to a woman with an untreated gonococcal infection. Rationale: Erythromycin ophthalmic ointment 0.5% is used as a prophylactic treatment for ophthalmia neonatorum, which is caused by the bacteria Neisseria gonorrhoeae. The preventive treatment of gonorrhea is required by law. Options 1, 2, and 3 are not the purposes of administering this medication to the newborn infant. Test-Taking Strategy: Use the process of elimination and your knowledge of the purpose of administering erythromycin ophthalmic ointment to the newborn infant. Remember that erythromycin ophthalmic ointment 0.5% is used as a prophylactic treatment of ophthalmia neonatorum in newborns. Review the initial care of the newborn infant if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Newborn Reference: Leifer, pp. 152-153. 2011.

A pregnant client is receiving magnesium sulfate for the management of preeclampsia. A nurse determines that the client is experiencing toxicity from the medication if which of the following is noted on data collection? 1. Proteinuria of 3 + 2. Presence of deep tendon reflexes 3. Serum magnesium level of 6 mEq/L 4. Respirations of 10 breaths per minute

4. Respirations of 10 breaths per minute Rationale: Magnesium toxicity can occur as a result of magnesium sulfate therapy. Signs of magnesium sulfate toxicity relate to the central nervous system depressant effects of the medication and include respiratory depression (respiratory rate less than 12 breaths per minute), a loss of deep tendon reflexes, and a sudden drop in the fetal heart rate, maternal heart rate, and blood pressure. Therapeutic serum levels of magnesium are 4 to 7.5 mEq/L or 5 to 8 mg/dL. Proteinuria of 3 + is likely to be noted in a client with preeclampsia. Test-Taking Strategy: Use the process of elimination. Eliminate option 2 first, because it is a normal finding. Next, eliminate option 3, knowing that the therapeutic serum level of magnesium is between 4 and 7.5 mEq/L. From the remaining options, recalling that proteinuria of 3 + would be noted in a client with preeclampsia will direct you to the correct option. Review the adverse effects of magnesium sulfate if you had difficulty with this question. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Maternity/Intrapartum References: Lehne, pp. 511-512. 2010. Leifer, p. 94. 2011.

The nurse is assigned to care for the client after a cesarean section. To prevent thrombophlebitis, the nurse encourages the woman to take which priority action? 1. Ambulate frequently. 2. Wear support stockings. 3. Apply warm, moist packs to the legs. 4. Remain on bed rest, with the legs elevated.

1. Ambulate frequently. Rationale: Stasis is believed to be a major predisposing factor for the development of thrombophlebitis. Because cesarean delivery poses a risk factor, the client should ambulate early and frequently to promote circulation and prevent stasis. Options 2, 3, and 4 are implemented if thrombophlebitis occurs. Test-Taking Strategy: Focus on the subject of the question, the prevention of thrombophlebitis, and note the strategic word "priority." Options 3 and 4 are implemented if thrombophlebitis occurs. Although wearing support stockings may be prescribed in the postoperative period to promote venous return, ambulating frequently (option 1) is the priority preventive measure. Review the content related to the prevention of thrombophlebitis during the postoperative period if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Maternity/Postpartum Reference: Leifer, p. 210. 2011.

A nurse is monitoring a preterm labor client who is receiving magnesium sulfate intravenously. The nurse monitors for which adverse effect(s) of this medication? Select all that apply. 1. Flushing 2. Hypertension 3. Increased urine output 4. Depressed respirations 5. Extreme muscle weakness 6. Hyperactive deep tendon reflexes

1. Flushing 4. Depressed respirations 5. Extreme muscle weakness Rationale: Magnesium sulfate is a central nervous system depressant, and it relaxes smooth muscle, including the uterus. It is used to stop preterm labor contractions, and it is used for preeclamptic clients to prevent seizures. Adverse effects include flushing, depressed respirations, depressed deep tendon reflexes, hypotension, extreme muscle weakness, decreased urine output, pulmonary edema, and elevated serum magnesium levels. Test-Taking Strategy: Focus on the subject of adverse effects of magnesium sulfate. Recalling that this medication is a central nervous system depressant will assist you with answering correctly. Review the adverse effects of magnesium sulfate if you had difficulty with this question. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Maternity/Intrapartum Reference: Hodgson, Kizior, p. 713. 2011.

The nurse is reinforcing instructions to a new mother about cord care and how to monitor for infection. The nurse tells the mother that which of the following is a sign of infection? 1. A darkened drying stump 2. A moist cord with discharge 3. A purple stump that shows pinkness around the base 4. A purple stump that shows some moistness at the base

2. A moist cord with discharge Rationale: Signs of infection of the umbilical cord are moistness, oozing, discharge, and a reddened base. If signs of infection occur, the health care provider is notified. Antibiotic treatment may be necessary. Test-Taking Strategy: Use the process of elimination. Options 1 and 3 identify normal signs and are eliminated first. From the remaining options, noting the word "discharge" in option 2 will direct you to this option. Review the signs and symptoms of infection if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Teaching and Learning Content Area: Newborn Reference: Leifer, pp. 218-219. 2011.

The nurse notes hypotonia, irritability, and a poor sucking reflex in a full-term newborn infant after admission to the nursery. The nurse suspects fetal alcohol syndrome (FAS) and is aware that which of the following additional signs would be consistent with FAS? 1. A length of 19 inches 2. Abnormal palmar creases 3. A birth weight of 6 pounds and 14 ounces 4. A head circumference that is appropriate for gestational age

2. Abnormal palmar creases Rationale: Features of newborn infants who are diagnosed with FAS include craniofacial abnormalities, intrauterine growth restriction, cardiac abnormalities, abnormal palmar creases, and respiratory distress. Options 1, 3, and 4 are normal findings in the full-term newborn infant. Test-Taking Strategy: Use the process of elimination and your knowledge regarding the normal findings in the full-term newborn infant to answer this question. Note that options 1, 3, and 4 are comparable or alike and that they represent normal findings. Review the content related to normal newborn infant findings and FAS if you had difficulty with this question. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Newborn Reference: Leifer, p. 109. 2011.

Methylergonovine (Methergine) is prescribed for a woman to treat postpartum hemorrhage. Before the administration of methylergonovine, the priority nursing action is to check the: 1. Uterine tone 2. Blood pressure 3. Amount of lochia 4. Deep tendon reflexes

2. Blood pressure Rationale: Methylergonovine, which is an ergot alkaloid, is an agent that is used to prevent or control postpartum hemorrhage by contracting the uterus. Methylergonovine causes continuous uterine contractions and may elevate the blood pressure. A priority before the administration of the medication is to check the blood pressure. The health care provider should be notified if hypertension is present. Although options 1, 3, and 4 may be components of the postpartum data collection procedures, option 2 is related specifically to the administration of this medication. Test-Taking Strategy: Use the process of elimination. Eliminate options 1 and 3 first, because they are comparable or alike and related to one another. From the remaining options, use the ABCs—airway, breathing, and circulation. Obtaining the blood pressure is a method of checking circulation. Review the adverse effects of methylergonovine if you had difficulty with this question. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Maternity/Postpartum Reference: Hodgson, Kizior, p. 744. 2011.

The nurse is assigned to assist with caring for a neonate born to a mother with acquired immunodeficiency syndrome(AIDS). The nurse understands that which of the following should be included in the plan of care? 1. Monitor the neonate's vital signs routinely. 2. Maintain standard precautions at all times while caring for the neonate. 3. Instruct breast-feeding mothers regarding the treatment of their nipples with an antifungal cream. 4. Initiate a referral to evaluate for blindness, deafness, learning, or behavioral problems in the neonate.

2. Maintain standard precautions at all times while caring for the neonate. Rationale: The neonate born to a mother with AIDS must be cared for with strict attention to standard precautions. This prevents the transmission of the infection from the neonate, if he or she is infected, to others, and it prevents the transmission of other infectious agents to the possibly immunocompromised neonate. A mother with AIDS should not breast-feed. Options 1 and 4 are not specifically associated with the care of a potentially AIDS-infected neonate. Test-Taking Strategy: Use the process of elimination and your knowledge regarding the care of a neonate infant born to a woman with AIDS. Eliminate options 1 and 4 first, because they are not specifically associated with the care of a potentially infected neonate. Recalling that AIDS-infected mothers should not breast-feed will direct you to option 2. Review the care of a neonate born to a woman with AIDS if you had difficulty with this question. Level of Cognitive Ability: Understanding Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Planning Content Area: Newborn References: Christensen, Kockrow, pp. 903-904. 2011. Foundations of nursing. Leifer, pp. 733, 771. 2011.

After birth, the nurse prevents hypothermia as a result of evaporation in the newborn by: 1. Warming the crib pad 2. Closing the doors of the room 3. Drying the baby with a warm blanket 4. Turning on the overhead radiant warmer

2. Closing the doors of the room 3. Drying the baby with a warm blanket Rationale: Evaporation occurs when moisture from the newborn's wet body surface dissipates heat along with moisture. By keeping the newborn dry (and by drying the wet newborn at birth), evaporation is prevented. Conduction occurs when the newborn is on a cold surface, such as a cold pad or mattress. Convection occurs as air moves across the newborn's skin from an open door and heat is transferred to the air. Radiation occurs when heat from the newborn radiates to a colder surface. Test-Taking Strategy: Recalling the methods of preventing heat loss in a newborn and focusing on the subject of evaporation will direct you to the correct option. Review the methods of heat loss if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Newborn Reference: Leifer, pp. 150, 215. 2011.

The nurse in the newborn nursery receives a telephone call to prepare for the admission of an infant born at 43 weeks' gestation with Apgar scores of 1 and 4. When planning for thead mission of this infant, the nurse's highest priority should beto: 1. Turn on the apnea and cardiorespiratory monitor. 2. Connect the resuscitation bag to the oxygen outlet. 3. Set up the intravenous line with 5% dextrose in water. 4. Set the radiant warmer control temperature at 36.5° C(97.6° F).

2. Connect the resuscitation bag to the oxygen outlet. Rationale: The highest priority during the admission to the nursery of a newborn with low Apgar scores is airway support, which would involve preparing respiratory resuscitation equipment. The remaining options are also important, although they are of lower initial priority. The newborn infant will be placed on a cardiorespiratory monitor. Setting up an intravenous line with 5% dextrose in water would provide circulatory support and may be prescribed. The radiant warmer will provide an external heat source, which is necessary to prevent further respiratory distress. Test-Taking Strategy: Use the process of elimination, and note the strategic words "highest priority." This question asks you to prioritize care on the basis of information about a newborn infant's condition. Use the ABCs— airway, breathing, and circulation. A method of planning for airway support is to have the resuscitation bag connected to an oxygen source. Review the care of the newborn infant with low Apgar scores if you had difficulty with this question. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Critical Care Reference: Perry, Hockenberry, Lowdermilk, Wilson, pp. 644, 647. 2010.

The nurse suspects that the client has a pulmonary embolism. The most important nursing action is to: 1. Monitor the vital signs. 2. Elevate the head of the bed. 3. Increase the intravenous flow rate. 4. Administer oxygen by face mask, as prescribed.

4. Administer oxygen by face mask, as prescribed. Rationale: Because pulmonary circulation is compromised in the presence of an embolus, cardiorespiratory support is initiated by oxygen administration. Options 1 and 2 may be components of the plan of care, but they are not the most important actions. The nurse would not increase the intravenous rate without a prescription from the health care provider to do so. Test-Taking Strategy: Note the strategic words "most important," and use the ABCs—airway, breathing, and circulation. This will direct you to the correct option - oxygen is the priority. Review the care of the client in the event of a pulmonary embolism if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Critical Care References: McKinney, James, Murray, Ashwill, p. 705. 2009. Swearingen, p. 127. 2012.

The nurse is planning to teach cord care to a new mother. The nurse plans to tell the mother that: 1. Alcohol is the only agent used to clean the cord. 2. It takes 21 days for the cord to dry up and fall off. 3. Cord care is done only at birth to control bleeding. 4. The process of keeping the cord clean and dry will decrease bacterial growth.

4. The process of keeping the cord clean and dry will decrease bacterial growth. Rationale: The cord should be kept clean and dry to decrease bacterial growth; this includes keeping the diaper folded below the cord to keep urine away from the cord. The cord should be cleansed two to three times a day. It usually falls off within 7 to 14 days. Agents other than alcohol may be prescribed to clean the cord. Test-Taking Strategy: Use the process of elimination. Eliminate options 1 and 3, noting the closed-ended word "only." Recall that cord care is required until the cord dries up and falls off, and that agents other than alcohol may be prescribed for cord care. Option 2 is incorrect, because the cord should fall off between 7 and 14 days after birth. Review the concepts of cord care if you had difficulty with this question. Level of Cognitive Ability: Understanding Client Needs: Physiological Integrity Integrated Process: Teaching and Learning Content Area: Newborn Reference: Leifer, pp. 218-219. 2011.

224. After episiotomy and the delivery of a newborn, the nurse performs a perineal check on the mother. The nurse notes a trickle of bright red blood coming from the perineum. The nurse checks the fundus and notes that it is firm. The nurse determines that: 1. This is a normal expectation after episiotomy. 2. The mother should be allowed bathroom privileges only. 3. The bright red bleeding is abnormal and should bereported. 4. The perineal assessment should be performed morefrequently.

3. The bright red bleeding is abnormal and should bereported. Rationale: Lochial flow should be distinguished from bleeding that originates from a laceration or an episiotomy, which is usually brighter red than lochia and presents as a continuous trickle of bleeding, even though the fundus of the uterus is firm. This bright red bleeding is abnormal and needs to be reported. Therefore, the other options are incorrect interpretations. Test-Taking Strategy: Note the strategic words "trickle" and "bright red." This should be an indication that the flow is not normal. Review the lochial flow and the complications associated with episiotomy if you had difficulty with this question. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Maternity/Postpartum References: Christensen, Kockrow, p. 849. 2011. Foundations of nursing. Leifer, p. 202. 2011.

The nurse is caring for a postpartum client. At 4 hours postpartum, the client's temperature is 102° F (38.9° C). The appropriate nursing action would be to: 1. Apply cool packs to the abdomen. 2. Continue to monitor the temperature. 3. Remove the blanket from the client's bed. 4. Notify the registered nurse, who will then contact the health care provider (HCP).

4. Notify the registered nurse, who will then contact the health care provider (HCP). Rationale: During the first 24 hours postpartum, the mother's temperature may be elevated as a result of dehydration. However, if the temperature is more than 2° F above normal, this may indicate infection, and the HCP will need to be notified. Applying cool packs to the abdomen is an inappropriate action and additionally, this action requires a prescription. The remaining options may be a component of care but are not the most appropriate based on the data in the question. Test-Taking Strategy: Use the process of elimination. Focus on the strategic words "4 hours" and "102° F." Noting that this temperature is extreme as compared with the normal temperature will direct you to option 4. Review the expected postpartum findings if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Maternity/Postpartum Reference: Leifer, p. 232. 2011.

The nurse is reinforcing measures regarding the care of the newborn with a mother. To bathe the newborn, the mother should be taught to: 1. Begin with the eyes and face. 2. Start with the dirtiest area first. 3. Begin with the feet and work upward. 4. Only wash the diaper area, because this is the only part of the baby that gets soiled.

1. Begin with the eyes and face. Rationale: Bathing should start at the eyes and face, which are usually the cleanest areas. Next, the external ears and behind the ears are cleansed. The newborn's neck should be washed, because formula, breast milk, or lint will often accumulate in the folds of the neck. The hands and arms are then washed. The baby's legs are washed, with the diaper area being washed last. Test-Taking Strategy: Use the basic techniques of bathing a client to answer the question. Remember, when bathing an adult or a baby, start with the cleanest part of the body and proceed to the dirtiest part. Options 2, 3, and 4 are incorrect. Review the techniques for bathing a newborn if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Teaching and Learning Content Area: Newborn References: Christensen, Kockrow, p. 965. 2011. Foundations of nursing. Leifer, p. 296. 2011.

The nurse notes that the 4-hour postpartum client has cool, clammy skin and that she is restless and excessively thirsty. The nurse immediately notifies the registered nurse and then: 1. Checks the vital signs 2. Begins fundal massage 3. Encourages ambulation 4. Encourages the client to drink fluids

1. Checks the vital signs Rationale: Symptoms of hypovolemia include cool, clammy, and pale skin; feelings of anxiety and restlessness; and thirst. The nurse would check the vital signs. The nurse would not ambulate the client or encourage fluids until specific prescriptions are given to do so. There is no information in the question to indicate the need for fundal massage. Test-Taking Strategy: Focus on the symptoms in the question. Use the ABCs —airway, breathing, and circulation—to direct you to the correct option. Review the nursing care of the client with hypovolemia if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Critical Care References: Leifer, p. 236. 2011. McKinney, James, Murray, Ashwill, p. 701. 2009.

The nurse palpates the fundus and checks the character of the lochia of a postpartum client who is in the fourth stage of labor. The nurse expects the lochia to be: 1. Red 2. Pink 3. White 4. Serosanguineous

1. Red Rationale: The color of the lochia during the fourth stage of labor is bright red, and this may last from 1 to 3 days. The color of the lochia then changes to a pinkish brown, and occurs from day 4 to 10 postpartum. Finally, the lochia changes to a creamy white color that occurs from day 10 to 14 postpartum. Test-Taking Strategy: Focus on the strategic words "fourth stage of labor"; this will direct you to the correct option. In the immediate postpartum period, the lochia is red in color. Review the expected postpartum findings if you had difficulty with this question. Level of Cognitive Ability: Understanding Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Maternity/Postpartum Reference: Leifer, pp. 201-202. 2011.

Preterm newborns are at risk for developing respiratory distress syndrome (RDS). The nurse monitors for the clinical signs associated with RDS, knowing that these signs include: 1. Tachypnea and retractions 2. Acrocyanosis and grunting 3. Hypotension and bradycardia 4. The presence of a barrel chest with acrocyanosis

1. Tachypnea and retractions Rationale: The newborn infant with RDS may present with clinical signs of cyanosis, tachypnea, apnea, nasal flaring, chest wall retractions, or audible grunts. Acrocyanosis is a bluish discoloration of the hands and feet that is associated with immature peripheral circulation, and it is not uncommon during the first few hours of life. Options 2, 3, and 4 do not indicate clinical signs of RDS. Test-Taking Strategy: Use the process of elimination. Recalling that acrocyanosis may be a normal sign in a newborn infant will assist you with eliminating options 2 and 4. From the remaining options, it is necessary to be familiar with the signs of RDS. In addition, note the relationship between the diagnosis and the signs noted in option 1. Review the signs of RDS if you had difficulty with this question. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Newborn References: Christensen, Kockrow, p. 917. 2011. Foundations of nursing. Leifer, pp. 307-308. 2011.

The nurse is caring for a postpartum client with a diagnosis of thrombophlebitis. The client suddenly complains of chest pain and dyspnea. The nurse would initially check the: 1. Vital signs 2. Fundal height 3. Presence of calf pain 4. Level of consciousness (LOC)

1. Vital signs Rationale: Pulmonary embolism is a complication of thrombophlebitis. Changes in the vital signs are one of the first things to occur with pulmonary embolism, because pulmonary blood flow is compromised. Fundal height is unrelated to the subject of the question. Calf pain is an indicator of thrombophlebitis. Level of consciousness may change as the condition worsens; worsening would indicate hypoxia. Test-Taking Strategy: Note the strategic word "initially." Use the ABCs— airway, breathing, and circulation—to direct you to the correct option. Review the complications of thrombophlebitis if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Critical Care References: Christensen, Kockrow, pp. 913-914. 2011. Foundations of nursing. Leifer, pp. 240-241. 2011.

The nurse is preparing a list of self-care instructions for a postpartum client who has been diagnosed with mastitis. Choose the instructions that would be included on the list. Select all that apply. 1. Wear a supportive, non-underwire bra. 2. Rest during the acute phase. 3. Maintain a fluid intake of at least 3000 mL. 4. Continue to breast-feed if the breasts are not too sore. 5. Take the prescribed antibiotics until the sorenesssubsides. 6. Avoid decompression of the breasts by breast-feeding or breast pump.

1. Wear a supportive, non-underwire bra. 2. Rest during the acute phase. 3. Maintain a fluid intake of at least 3000 mL. 4. Continue to breast-feed if the breasts are not too sore. Rationale: Mastitis is an infection of the lactating breast. Client instructions include resting during the acute phase, maintaining a fluid intake of at least 3000 mL per day, and taking analgesics to relieve discomfort. Antibiotics may be prescribed and are taken until the complete prescribed course is finished. They are not stopped when the soreness subsides. Additional supportive measures include the use of moist heat or ice packs and the wearing of a supportive bra. Continued decompression of the breast by breast-feeding or breast pump is important to empty the breast and prevent the formation of an abscess. Test-Taking Strategy: Think about the pathophysiology associated with mastitis. Recalling that supportive measures include rest, moist heat or ice packs, antibiotics, analgesics, increased fluid intake, breast support, and the decompression of the breasts will assist you with answering the question. Review the treatment of mastitis if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Teaching and Learning Content Area: Maternity/Postpartum References: Christensen, Kockrow, pp. 901-902. 2011. Foundations of nursing. Leifer, pp. 242-244. 2011.

The nurse is caring for a post term neonate immediately after admission to the nursery. The priority nursing action would be to monitor: 1. Urinary output 2. Blood glucose levels 3. Total bilirubin levels 4. Hemoglobin and hematocrit level

2. Blood glucose levels Rationale: The most common metabolic complication in the postterm newborn is hypoglycemia, which can produce central nervous system abnormalities and mental retardation if it is not corrected immediately. Urinary output, although important, is not the highest priority action. The polycythemia contributes to increased bilirubin levels, usually beginning on the second day after delivery. Hemoglobin and hematocrit levels are monitored, because the postterm neonate may exhibit polycythemia; however, this also does not require immediate attention. Test-Taking Strategy: Use the process of elimination, and note the strategic word "priority." Recalling that hypoglycemia is a primary concern in the postterm newborn will direct you to the correct option. Review the care of the postterm newborn if you had difficulty with this question. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Newborn Reference: Leifer, p. 318. 2011.

A pregnant human immunodeficiency virus (HIV)-positive woman delivers a baby. The nurse provides guidance to help the client make decisions regarding newborn care. The nurse determines that additional guidance is needed if the woman states that she will: 1. Be sure to wash her hands before feeding the newborn. 2. Breast-feed, especially for the first 6 weeks postpartum. 3. Be sure to wash her hands before and after bathroom use. 4. Administer the prescribed antiviral medication to the newborn for the first 6 weeks after delivery.

2. Breast-feed, especially for the first 6 weeks postpartum. Rationale: The mode of perinatal transmission of HIV to the fetus or neonate of an HIV-positive woman can occur during the antenatal, intrapartal, or postpartum periods. HIV transmission can occur during breast-feeding; thus, HIV-positive clients need to bottle-feed their neonates. Antiviral medications will be prescribed for the neonate for the first 6 weeks of life. The principles related to handwashing need to be taught to the mother. Test-Taking Strategy: Use the process of elimination, and note the strategic words "additional guidance is needed." These words indicate a negative event query and ask you to select an option that is an incorrect statement. Options 1 and 3 can be eliminated first, because they are comparable or alike. From the remaining options, recalling the modes of transmission of HIV from the mother to the newborn will direct you to option 2. Review these modes of HIV transmission if you had difficulty with this question. Level of Cognitive Ability: Evaluating Client Needs: Safe and Effective Care Environment Integrated Process: Teaching and Learning Content Area: Fundamental Skills: Safety/Infection Control Reference: Leifer, p. 222. 2011.

A client asks the nurse why her newborn baby needs an injection of vitamin K. The nurse makes which statement to the client? 1. "Your newborn needs vitamin K to develop immunity." 2. "The vitamin K will protect your newborn from becomingjaundiced." 3. "Newborns are deficient in vitamin K. This injection prevents your baby from abnormal bleeding." 4. "Newborns have sterile bowels. The vitamin K will colonize the bowel with the necessary bacteria."

3. "Newborns are deficient in vitamin K. This injection prevents your baby from abnormal bleeding." Rationale: Vitamin K is necessary for the body to synthesize coagulation factors, and it is administered to the newborn infant to prevent abnormal bleeding. It promotes the liver's formation of the clotting factors II, VII, IX, and X. Newborn infants are deficient in vitamin K, because the bowel does not have the bacteria necessary for synthesizing this fat-soluble vitamin. The normal flora in the intestinal tract produces vitamin K, but the newborn's bowel does not support the normal production of vitamin K until bacteria have adequately colonized it. The bowel becomes colonized by bacteria as food is ingested. Vitamin K does not promote the development of immunity or prevent the infant from becoming jaundiced. Test-Taking Strategy: Use the process of elimination. Because jaundice and immunity are not related to the action of vitamin K, eliminate options 1 and 2. From the remaining options, recall the action of vitamin K to direct you to option 3. Review the purpose of vitamin K injection if you had difficulty with this question. Level of Cognitive Ability: Applying Client's Needs: Psychological Integrity Integrated Process: Nursing Process/Implementation Content Area: Newborn Reference: Leifer, p. 153. 2011.

A nurse is caring for a client who is receiving oxytocin(Pitocin) to induce labor. The nurse discontinues the oxytocin infusion and notifies the registered nurse if which of the following is noted on data collection of the client? 1. Fatigue 2. Drowsiness 3. Uterine hyperstimulation 4. Early decelerations of the fetal heart rate

3. Uterine hyperstimulation Rationale: Oxytocin stimulates uterine contractions, and it is one of the common pharmacological methods used to induce labor. An adverse effect associated with the administration of the medication is the hyperstimulation of uterine contractions. Therefore, oxytocin infusion must be stopped when any signs of uterine hyperstimulation are present. Fatigue and drowsiness may be caused by the labor experience. Early decelerations of the fetal heart rate are a reassuring sign and do not indicate fetal distress. Test-Taking Strategy: Use the process of elimination, and focus on the subject of an adverse effect to oxytocin. Options 1 and 2 can be eliminated first because they are comparable or alike. From the remaining options, recalling that early decelerations of the fetal heart rate are a reassuring sign will direct you to option 3. Review the nursing responsibilities associated with oxytocin if you had difficulty with this question. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Maternity/Intrapartum References: Hodgson, Kizior, pp. 879-880. 2011. Kee, Hayes, McCuistion, p. 850. 2009.

Rh0(D) immune globulin (RhoGAM) is prescribed for a woman after the delivery of a newborn infant, and the nurse provides information to the woman about the purpose of the medication. The nurse determines that the woman understands the purpose of the medication if the woman states that it will protect her next baby from which of the following? 1. Having Rh-positive blood 2. Developing a rubella infection 3. Developing physiological jaundice 4. Being affected by Rh incompatibility

4. Being affected by Rh incompatibility Rationale: Rh incompatibility can occur when an Rh-negative mother becomes sensitized to the Rh antigen. Sensitization may develop when an Rhnegative woman becomes pregnant with a fetus who is Rh positive. During pregnancy and at delivery, some of the baby's Rh-positive blood can enter the maternal circulation, thus causing the woman's immune system to form antibodies against the Rh-positive blood. The administration of Rh0(D) immune globulin prevents the woman from developing antibodies against Rh-positive blood by providing passive antibody protection against the Rh antigen. Test-Taking Strategy: Use the process of elimination. Options 2 and 3 can be eliminated first. From the remaining options, note the relationship between the name of the medication, Rh0(D) immune globulin, and the word "incompatibility" in the correct option. Review the purpose of Rh0(D) immune globulin if you had difficulty with this question. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Teaching and Learning Content Area: Maternity/Postpartum References: Hodgson, Kizior, pp. 1007-1008. 2011. Kee, Hayes, McCuistion, p. 867. 2009.

A mother is breast-feeding her newborn baby and experiences breast engorgement. The nurse encourages the mother to do which of the following to provide relief of the engorgement? 1. Breast-feed only during the daytime hours. 2. Apply cold compresses to the breast before feeding. 3. Avoid the use of a bra while the breasts are engorged. 4. Massage the breasts before feeding to stimulate let-down.

4. Massage the breasts before feeding to stimulate let-down. Rationale: Comfort measures for breast engorgement include massaging the breasts before feeding to stimulate let-down, wearing a supportive and wellfitting bra at all times, taking a warm shower or applying warm compresses just before feeding, and alternating breasts during feeding. Test-Taking Strategy: Use the process of elimination to answer the question. Eliminate option 1 because of the closed-ended word "only." From the remaining options, recalling the self-care measures that promote the comfort of the mother with breast engorgement will direct you to the correct option. Review these measures if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Implementation Content Area: Maternity/Postpartum References: Leifer, pp. 227-228. 2011. Perry, Hockenberry, Lowdermilk, Wilson, pp. 696-697. 2010.

Methylergonovine (Methergine) is prescribed for a client with postpartum hemorrhage. Before administering the medication, a nurse contacts the health care provider who prescribed the medication if which of the following conditions is documented in the client's medical history? 1. Hypotension 2. Hypothyroidism 3. Diabetes mellitus 4. Peripheral vascular disease

4. Peripheral vascular disease Rationale: Methylergonovine is an ergot alkaloid that is used to treat postpartum hemorrhage. Ergot alkaloids are avoided in clients with significant cardiovascular disease, peripheral vascular disease, hypertension, eclampsia, or preeclampsia, because these conditions are worsened by the vasoconstrictive effects of the ergot alkaloids. Options 1, 2, and 3 are not contraindications related to the use of ergot alkaloids. Test-Taking Strategy: Use the process of elimination. Recalling that ergot alkaloids produce vasoconstriction will direct you to option 4. Review the effects of ergot alkaloids and the associated contraindications if you had difficulty with this question. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Maternity/Postpartum Reference: Hodgson, Kizior, p. 743. 2011.

The nurse is assigned to care for the client during the postpartum period. The client asks the nurse what the term involution means. The nurse responds to the client, knowing that involution is: 1. The inverted uterus returning to normal 2. The gradual reversal of the uterine muscle into the abdominal cavity . The descent of the uterus into the pelvic cavity, which occurs at a rate of 2 cm/day 4. The progressive descent of the uterus into the pelvic cavity, which occurs at a rate of approximately 1 cm/day

4. The progressive descent of the uterus into the pelvic cavity, which occurs at a rate of approximately 1 cm/day Rationale: Involution is the progressive descent of the uterus into the pelvic cavity. After birth, descent occurs at a rate of approximately one fingerbreadth or 1 cm per day. The other options do not accurately describe involution. Test-Taking Strategy: Use your knowledge of medical terminology to help you to define the word involution. This will assist with directing you to the correct option. Review the process of involution if you had difficulty with this question. Level of Cognitive Ability: Understanding Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Implementation Content Area: Maternity/Postpartum References: Leifer, pp. 200, 244. 2011. McKinney, James, Murray, Ashwill, p. 456. 2009.