maternity nursing

Which statements regarding the involution process are correct? Select all that apply. 1 Involution begins immediately after expulsion of the placenta. 2 Involution is the self-destruction of excess hypertrophied tissue. 3 Involution progresses rapidly during the next few days after birth. 4 Involution is the return of the uterus to a nonpregnant state after birth. 5 Involution may be caused by retained placental fragments and infections.

1 Involution begins immediately after expulsion of the placenta. 3 Involution progresses rapidly during the next few days after birth. 4 Involution is the return of the uterus to a nonpregnant state after birth. The involution process is the return of the uterus to a nonpregnant state after birth; it begins immediately after expulsion of the placenta and contraction of the uterine smooth muscle. This process progresses rapidly during the first few days after birth. Subinvolution is the self-destruction of excess hypertrophied tissue; this process may be caused by retained placental fragments or infection.

A 42-year-old client at 39 weeks' gestation has a reactive nonstress test (NST). What should the nurse explain to the client about the positive result? 1 Immediate birth is indicated. 2 This is the desired response at this stage of gestation. 3 Further testing is unnecessary with this desired outcome. 4 The result is inconclusive, indicating the need for further evaluation.

2 This is the desired response at this stage of gestation. An NST indicates that the fetus is healthy because there is an active pattern of fetal heart rate acceleration with movement. The result is positive and desired; immediate birth is not required. Further testing is needed. If the pregnancy continues, another test of fetal well-being will probably be done. The results were positive, not inconclusive.

The nurse is planning care for a middle-aged woman who has been admitted for a vaginal hysterectomy and anterior and posterior repair of the vaginal wall. What should the nurse tell the client to expect in the immediate postoperative period? 1 Placement of a pessary 2 Insertion of a rectal tube 3 Use of a douche periodically 4 Presence of a urinary catheter

4 Presence of a urinary catheter After surgery the urethral orifice may be distorted and edematous; a urine retention catheter keeps the bladder empty, limiting pressure on the operative site. A pessary placed in the vagina is used for a displaced uterus; after an anteroposterior repair (colporrhaphy), vaginal packing is used to support the surgical repair. A rectal tube is used for abdominal distention caused by flatulence; it is rarely necessary. A cleansing douche may be prescribed before, not after, surgery.

During the assessment of a client in labor, the cervix is determined to be dilated 4 cm. What stage of labor does the nurse record? 1 First 2 Second 3 Prodromal 4 Transitional

1 First The first stage of labor is from zero cervical dilation to full cervical dilation (10 cm). The second stage is from full cervical dilation to delivery. The prodromal stage is before cervical dilation begins. The transitional phase is the first stage of labor, from 8 cm of dilation to 10 cm of dilation.

A 30-year-old woman is scheduled for a total abdominal hysterectomy because of noninvasive endometrial cancer. The nurse anticipates the client may have difficulty adjusting emotionally to this type of surgery. What is the most common reason for this difficulty? 1 Loss of femininity 2 Body image changes 3 Diminished sexual desire 4 Slow postmenopausal recovery

1 Loss of femininity Removal of the uterus may produce changes in how some women view themselves sexually because it is a reproductive organ. Although body image changes are possible, they are more likely to occur with surgery that involves obvious external changes. The libido of a postmenopausal woman will probably not be altered unless she has concerns about sexuality. A 30-year-old otherwise healthy woman should have an uneventful recovery.

Which statement made by a pregnant client to a nurse indicates that the client does not understand the teaching regarding fetal growth and development? 1 "The baby is smaller if the mother smokes." 2 "The baby gets food from the amniotic fluid." 3 "The baby's oxygen is provided by the mother." 4 "The baby's umbilical cord has two arteries and one vein."

2 "The baby gets food from the amniotic fluid." The amniotic fluid serves as a protective environment; the fetus depends on the placenta, along with the umbilical blood vessels, for nutrients and oxygen. "The baby is smaller if the mother smokes," "The baby's oxygen is provided by the mother," and "The baby's umbilical cord has two arteries and one vein" are all true statements, and further teaching would not be required.

While the nurse is caring for a client in active labor whose fetus is at station 0, the client's membranes rupture spontaneously. The nurse determines that the fluid is clear and odorless. What should the nurse do next? 1 Change the bedding. 2 Notify the practitioner. 3 Assess the fetal heart rate (FHR). 4 Obtain the client's blood pressure.

3 Assess the fetal heart rate (FHR). The FHR will reflect how the fetus tolerated the rupture of the membranes; if there is compression of the cord, it will be reflected in a change in the FHR. Although the client's comfort is important, it is not the priority. Although the practitioner should be notified, it is not the priority. Blood pressure is not influenced by rupture of the membranes.

A nurse teaches a new mother about neonatal weight loss in the first 3 days of life. How does the nurse explain the cause of this weight loss? 1 An allergy to formula 2 A hypoglycemic response 3 Ineffective feeding techniques 4 Excretion of accumulated excess fluids

4 Excretion of accumulated excess fluids Early weight loss occurs because excess fluid is lost, not body mass. Weight loss is expected; there are no data to support an allergic response. Weight loss is not related to hypoglycemia. Neither breast nor formula feeding will prevent the 10% weight loss that is expected in the first few days of life.

A nurse on the high-risk unit is caring for a client with severe preeclampsia. Which intervention is the most effective in preventing a seizure? 1 Providing a plastic airway 2 Controlling external stimuli 3 Having emergency equipment available 4 Keeping calcium gluconate at the bedside

2 Controlling external stimuli Reducing lights, noise, and stimulation minimizes central nervous system irritability, which can trigger a seizure. A plastic airway will not prevent a seizure. Available emergency equipment will not prevent a seizure, although oxygen and suction equipment may be useful after a seizure. Calcium gluconate is the antidote for magnesium sulfate toxicity; it does not prevent seizures.

A primigravid client who is at 38 weeks' gestation is undergoing a nonstress test. The nurse determines that the baseline fetal heart rate is 130 to 140 beats per minute. It rises to 160 on two occasions and 157 once during a 20-minute period. Each of the episodes in which the heart rate is increased lasts 20 seconds. Which action should the nurse take? 1 Discontinuing the test because the pattern is within the normal range 2 Encouraging the client to drink more fluids to decrease the fetal heart rate 3 Notifying the primary healthcare provider and preparing for an emergency birth 4 Recording this nonreassuring pattern and continuing the test for further evaluation

1 Discontinuing the test because the pattern is within the normal range The baseline heart rate is within the expected range. The accelerations meet the criteria for an increase of 15 beats that lasts at least 15 seconds during a 20-minute period. This is a reassuring pattern that is indicative of fetal well-being. Drinking more fluids is unnecessary because the fetal heart rate is within the expected range. Preparing for an emergency birth is unnecessary because the test results indicate fetal well-being. The test results meet the standards for a reassuring pattern; further evaluation is unnecessary.

Two days after having a cesarean birth, a client tells the nurse that she has pain in her right leg. After an assessment the nurse suspects that the client has a thrombus. What is the nurse's primary response at this time? 1 Maintaining bed rest 2 Applying warm soaks 3 Performing leg exercises 4 Massaging the affected area

1 Maintaining bed rest Although thrombophlebitis is suspected, before a definitive diagnosis can be made the client should be confined to bed so that further complications may be avoided. Applying warm soaks may cause vasodilation, which could allow a thrombus to dislodge and circulate freely. If a thrombus is present, massage may dislodge it and lead to a pulmonary embolism.

During discharge teaching a client who just had a hysterectomy states, "After this surgery, I don't expect to be interested in sex anymore." What should the nurse consider before responding? 1 Many women incorrectly equate hysterectomy with loss of libido. 2 Surgically forced menopause usually results in a decreased sex drive. 3 The loss of estrogen that results from this surgery will cause most women to experience a decrease in libido. 4 Body image changes that occur after this surgery prevent many women from resuming sexual activity.

1 Many women incorrectly equate hysterectomy with loss of libido. The uterus is often erroneously believed necessary for a satisfying sex life. Sexuality after hysterectomy should not be diminished, particularly because the fear of pregnancy no longer exists. Although the estrogen level is reduced, libido is influenced by psychologic as well as hormonal factors. Although body image changes can interfere with sexuality, this is not an expectation for most women.

A 37-year-old client with endometriosis visits the women's health clinic because she has dysmenorrhea and dyspareunia. Which statement is the most accurate description of dysmenorrhea 1 Pain with menses 2 Endometrial hyperplasia 3 Bleeding between menses 4 Heavy bleeding with menses

1 Pain with menses Dysmenorrhea is defined as pain with menses. Endometrial hyperplasia results from anovulation and persistent estrogen stimulation. Bleeding between menses is metrorrhagia. Heavy bleeding with menses is menorrhagia.

Late decelerations are present on the monitor strip of a client who received epidural anesthesia 20 minutes ago. What should the nurse do immediately? 1 Reposition the client from supine to left lateral. 2 Increase the intravenous flow rate from 125 to 150 mL/hr. 3 Administer oxygen at a rate of 8 to 10 L/min by way of face mask. 4 Assess the maternal blood pressure for a systolic pressure below 100 mm Hg.

1 Reposition the client from supine to left lateral. Hypotension is a common side effect of epidural anesthesia that results in decreased placental perfusion and late decelerations on the fetal monitor. The priority intervention is repositioning the client to relieve compression of the vena cava and increase venous return, which in turn increases placental perfusion. Administering oxygen and increasing the flow rate are correct interventions, but neither is the priority because these interventions would not be effective until compression of the vena cava has been relieved and placental perfusion increased. Assessing the maternal blood pressure for a systolic pressure below 100 mm Hg only provides data and does not correct the late deceleration.

A client who is visiting the prenatal clinic for the first time has a serology test for toxoplasmosis. What information about the client's activities in the history indicates to the nurse that there is a need for this test? 1 The client cares for a neighbor's cat 2 The client works as a dog trainer 3 The client uses chemical cleaners 4 The client consumes raw vegetables

1 The client cares for a neighbor's cat Toxoplasmosis is caused by a protozoal parasite; cats acquire the organism by ingesting infected mice or birds, and the cysts are found in their feces. Caring for or working with cats, not dogs, poses a potential problem with toxoplasmosis. Chemical cleaners may be teratogenic, but they do not cause toxoplasmosis. Eating raw vegetables of any kind will not cause toxoplasmosis.

As the nurse inspects the perineum of a client who is in active labor, the client suddenly turns pale and states that she feels as if she is going to faint even though she is lying flat on her back. What is the nurse's priority intervention? 1 Turn her onto her left side 2 Elevate the head of the bed 3 Place her feet on several pillows 4 Give her oxygen via a face mask

1 Turn her onto her left side The client is experiencing supine hypotension, which is caused by compression of the large vessels by the gravid uterus. A side-lying position will relieve the pressure on the vessels, increase venous return, improve cardiac output, and increase blood pressure. Raising the head of the bed will not relieve uterine compression of the large vessels. Elevating the feet will not relieve uterine compression of the large vessels. Oxygen administration will not relieve uterine compression of the large vessels.

A client asks the nurse at the prenatal clinic whether she may continue to have sexual relations while pregnant. What is one indication that the client should refrain from intercourse during pregnancy? 1 Fetal tachycardia 2 Presence of leukorrhea 3 Premature rupture of membranes 4 Imminence of the estimated date of birth

3 Premature rupture of membranes Ruptured membranes leave the products of conception exposed to bacterial invasion. Intact membranes act as a barrier against organisms that may cause an intrauterine infection. Fetal tachycardia may occur during sex, but there is no evidence that it is harmful for the fetus. Leukorrhea is common because of increased production of mucus containing exfoliated vaginal epithelial cells; intercourse is not contraindicated by leukorrhea. Intercourse is not contraindicated near the estimated date of birth if the membranes are intact; modification of sexual positions may be needed because of the enlarged abdomen.

The husband of a client who is in the transition phase of the first stage of labor becomes very tense and anxious and asks a nurse, "Would it be best for me to leave, since I don't seem to be doing my wife much good?" What is the appropriate response by the nurse? 1 "This is the time when your wife needs you. Don't run out on her now." 2 "I know that this is hard for you. Let me try to help you coach her during this difficult phase." 3 "I know that this is hard for you. Why don't you go have a cup of coffee to help you relax and then come back in a little while?" 4 "If you feel that way, you'd best go out and sit in the fathers' waiting room for a while. You'll just end up transmitting your anxiety to your wife."

2 "I know that this is hard for you. Let me try to help you coach her during this difficult phase." Both the father and the mother need additional support during the transition phase of the first stage of labor. Telling the father not to run out on his wife is judgmental; it suggests that the father will be failing his wife by leaving. The husband should be present throughout labor to support his wife, and he should be assisted in this role. Telling the father to sit in the waiting room does not encourage the husband to fulfill his role of supporting his wife during labor.

A client who has undergone a mastectomy because of breast cancer is now undergoing chemotherapy, which has caused hair loss. The client states, "I feel like I've lost my sense of power." What is the nurse's best response? 1 "Hair does not empower a person." 2 "Losing power seems important to you." 3 "Knowledge is power; I'll give you some pamphlets to read." 4 "Hair loss is common; it will grow back, so you shouldn't worry."

2 "Losing power seems important to you." Stating that the loss of power seems important to the client provides an opportunity for the client to discuss her feelings. Stating that hair doesn't empower a person is confrontational and may cut off further communication. Offering to get the client some pamphlets dismisses the client's concern and does not promote the client's further verbalization of feelings. Stating that hair loss is common and the client shouldn't worry dismisses the client's concerns and cuts off further communication.

An older female client tells the nurse in the clinic that she has a cystocele that was diagnosed a year ago. She has urinary frequency and burning on urination. The client asks, "The primary healthcare provider wanted me to have surgery for the cystocele last year; but, I can manage with peripads. It won't hurt not to have surgery, will it?" How should the nurse respond? 1 "Not really, but it should be done." 2 "Yes, you're risking kidney damage." 3 "Yes, you're risking bowel obstruction." 4 "Not really, but you'll be more comfortable if you have it."

2 "Yes, you're risking kidney damage." A cystocele is a herniation of the bladder through the vaginal wall resulting from weakened pelvic structures. In this condition the herniated bladder does not empty effectively, and urinary stasis, chronic infection, and renal failure may result. The surgery improves bladder function and prevents renal failure; it is necessary at this time. Bowel obstruction is a complication of a rectocele, not a cystocele. Although corrective surgery will reduce perineal pressure, its primary purpose is to improve bladder function and prevent complications.

A 15-year-old client tells a school nurse, "I have this awful pain during my periods—it never stops." What should the nurse encourage her to do? 1 Continue daily activities. 2 Have a gynecologic examination. 3 Eat a nutritious diet containing iron. 4 Practice relaxation of abdominal muscles.

2 Have a gynecologic examination. Persistent pain of any kind during menstruation (dysmenorrhea) usually indicates a problem, and the client should seek medical attention. Although diversion is a means of altering pain perception, the presence of pain requires investigation of possible causes. Although a nutritious diet is beneficial, iron does not prevent the pain of dysmenorrhea. Voluntary relaxation of the abdominal muscles does not result in cessation of dysmenorrhea.

The nurse is obtaining the history of a client in the third trimester who is visiting the prenatal clinic for the first time. She tells the nurse she has two toddlers at home, that their father abandoned the family last month, and that she doesn't know what to do. The nurse concludes what about the client's emotional state? 1 Angry that the father has left 2 Overwhelmed by the situation 3 Ambivalent about her pregnancy 4 Denying the reality of her pregnancy

2 Overwhelmed by the situation Because of the difficult home situation, this client is experiencing multiple stressors that could cause difficulty with coping. There is no information to support the conclusion that the client is angry or that she is ambivalent about the pregnancy. The client is attending the prenatal clinic, which indicates that she is aware of reality and is not in denial.

Phototherapy is prescribed for a preterm neonate with hyperbilirubinemia. Which nursing intervention is appropriate to reduce the potentially harmful side effects of the phototherapy? 1 Covering the trunk to prevent hypothermia 2 Using shields on the eyes to protect them from the light 3 Massaging vitamin E oil into the skin to minimize drying 4 Turning after each feeding to reduce exposure of each surface area

2 Using shields on the eyes to protect them from the light The lights used for phototherapy can damage the infant's eyes, and eye shields are standard equipment. Maximal effectiveness is achieved when the infant's entire skin surface is exposed to the light. Vitamin E oil massage is contraindicated, because it can cause burns and result in an overdose of the vitamin. The infant should be turned every 2 hours regardless of feeding times so that all body surfaces are exposed to the light and no single body surface is overexposed.

A 28-year-old woman is diagnosed as having cancer of the left breast. A simple mastectomy is performed. What should the plan of care include immediately after surgery? 1 Changing the client's pressure dressing as necessary 2 Inviting a member of Reach to Recovery to visit the client 3 Placing the client in the semi-Fowler position with the left arm elevated 4 Waiting for a cessation of drainage before the client resumes any activity

3 Placing the client in the semi-Fowler position with the left arm elevated The semi-Fowler position and elevation of the arm on the affected side minimize edema related to the inflammatory process. Pressure dressings are rarely used because portable wound drainage systems are used to remove accumulated fluid from the surgical site. A member of Reach to Recovery will not visit on the day of surgery; the visit will probably be made in the client's home. Activities of daily living that necessitate only slight flexion of the elbow and do not involve abduction of the arm on the affected side are permitted.

What statement by a breast-feeding mother indicates that the nurse's teaching regarding stimulating the let-down reflex has been successful? 1 "I will take a cool shower before each feeding." 2 "I will drink a couple of quarts of fat-free milk a day." 3 "I will wear a snug-fitting breast binder day and night." 4 "I will apply warm packs and massage my breasts before each feeding."

4 "I will apply warm packs and massage my breasts before each feeding." Applying warm packs and massaging the breasts before each feeding help dilate milk ducts, promote emptying of the breasts, and stimulate further lactation. Taking a cool shower before each feeding will contract the milk ducts and interfere with the let-down reflex. Heavy consumption of milk products is not required to stimulate the production of milk. Breast binders may inhibit lactation by fooling the body into thinking that milk secretion is no longer needed.

A mother is inspecting her newborn girl for the first time. The infant's breasts are edematous, and she has a pink vaginal discharge. How should the nurse respond when the mother asks what is wrong? 1 "You seem very concerned. I don't see anything unusual." 2 "Your baby appears to have a problem. I'll notify the pediatrician." 3 "The swelling and discharge will go away. It's nothing to worry about." 4 "The swelling and discharge are expected. They're a response to your hormones."

4 "The swelling and discharge are expected. They're a response to your hormones." The response "The swelling and discharge are expected. They're a response to your hormones." emphasizes that the findings are to be expected and explains why they occur; this may relieve the client's anxiety. Claiming not to see anything unusual denies that there is anything to explain to the mother and is somewhat belittling. Calling the pediatrician is not necessary; these findings are expected. The comment that the swelling and discharge will go away tells the mother that the findings are expected but provides no explanation and is somewhat belittling.

On a return visit to the fertility clinic a couple requests fertility drugs because, despite having a 28-day menstrual cycle and temperature readings that demonstrate an ovulatory pattern, the woman has been unable to conceive. Which guidance should the nurse provide to this couple? 1 A laparoscopy will be scheduled. 2 An endometrial biopsy will be required. 3 A fertility medication will be prescribed. 4 An examination of semen will be needed.

4 An examination of semen will be needed. Because the client has an ovulatory cyclic pattern, the infertility may be a result of a seminal factor; the partner's semen should be examined before more extensive studies or treatments are begun. Laparoscopy and endometrial biopsy are invasive procedures that may be needed after all noninvasive tests are completed and the cause of the infertility remains undetermined. After all diagnostic and treatment options are exhausted, a fertility medication may be prescribed if it is determined that the medication will enhance the probability of conception.

The partner of a woman in labor is having difficulty timing the frequency of contractions and asks the nurse to review the procedure. How should contractions be timed? 1 From the end of one contraction to the end of the next contraction 2 From the end of one contraction to the beginning of the next contraction 3 From the beginning of one contraction to the end of the next contraction 4 From the beginning of one contraction to the beginning of the next contraction

4 From the beginning of one contraction to the beginning of the next contraction The frequency of contractions is timed from the beginning of one contraction to the beginning of the next; this is the definition of one contraction cycle. The beginning, not the end, of a contraction is the starting point for timing the frequency of contractions. The time between the end of one contraction and the beginning of the next contraction is the interval between contractions. Timing from the beginning of one contraction to the end of the next contraction is too long a timeframe and will produce inaccurate information.

The nurse is caring for an assignment of postpartum clients. Which factor puts a client at increased risk for postpartum hemorrhage? 1 Breastfeeding in the birthing room 2 Receiving a pudendal block for the birth 3 Having a third stage of labor that lasts 10 minutes 4 Giving birth to a baby weighing 9 lb 8 oz (4309 g)

4 Giving birth to a baby weighing 9 lb 8 oz (4309 g) The chance of postpartum hemorrhage is five times greater with large infants because uterine contractions may be impaired after the birth. Early breastfeeding will stimulate uterine contractions and lessen the chance of hemorrhage. Having a pudendal block for the birth does not contribute to postpartum hemorrhage, because the anesthetic for a pudendal block does not affect uterine contractions. Ten minutes is a short third stage; a prolonged third stage of labor, 30 minutes or more, may lead to postpartum hemorrhage.

During the second reactive period a newborn becomes more alert and responsive and there is an increase in mucus production and gagging. What should the nurse's initial intervention be? 1 Report this finding 2 Administer nasal oxygen 3 Lower the head of the bassinette 4 Remove secretions from the pharynx

4 Remove secretions from the pharynx An increase in mucus production is expected during the second reactive period; mucus should be removed either by swiping the oral cavity with a gloved finger or with the use of an aspiration device. Reporting this finding is unnecessary; identifying and treating human responses is within the scope of nursing practice. Oxygen administration is useless if mucus is blocking the respiratory passages. Although lowering the head of the bassinette may help secretions drain, the newborn cannot remove secretions that block respirations.