Maternity Test 2, Analgesia/Anesthesia, Pre Term, Induction, Complications

Which of the following tokens of remembrance would be appropriate for the nurse to provide to parents who are grieving the death of their infant? A. Lock of hair, footprints. B. Baptism or naming. C. Visit from chaplain. D. Sympathy card from staff.

A. Lock of hair, footprints.

An excessive amount of glucose in the maternal blood that is transported to the fetus through the placenta causes: a. macrosomia of the fetus and possible damage to arterial walls b. hypoglycemia of the fetus and possible damage to arterial walls c. macrosomia of the fetus and no possible damage to arterial walls

a. macrosomia of the fetus and possible damage to arterial walls

Which of the following would the nurse have readily available for a client who is receiving magnesium sulfate to treat severe preeclampsia? A) Calcium gluconate B) Potassium chloride C) Ferrous sulfate D) Calcium carbonate

Ans: A The antidote for magnesium sulfate is calcium gluconate, and this should be readily available in case the woman has signs and symptoms of magnesium toxicity.

The laboring woman may rub her abdomen during a contraction to counteract discomfort. This is called ______________________.

effleurage

Which of the following behaviors characterizes the PP mother in the taking in phase? 1. Passive and dependant 2. Striving for independence and autonomy 3. Curious and interested in care of the baby 4. Exhibiting maximum readiness for new learning

1. During the taking in phase, which usually lasts 1-3 days, the mother is passive and dependent and expresses her own needs rather than the neonate's needs. The taking hold phase usually lasts from days 3-10 PP. During this stage, the mother strives for independence and autonomy; she also becomes curious and interested in the care of the baby and is most ready to learn.

A nurse performs an assessment on a client who is 4 hours PP. The nurse notes that the client has cool, clammy skin and is restless and excessively thirsty. The nurse prepares immediately to: 1. Assess for hypovolemia and notify the health care provider 2. Begin hourly pad counts and reassure the client 3. Begin fundal massage and start oxygen by mask 4. Elevate the head of the bed and assess vital signs

1. Symptoms of hypovolemia include cool, clammy, pale skin, sensations of anxiety or impending doom, restlessness, and thirst. When these symptoms are present, the nurse should further assess for hypovolemia and notify the health care provider.

On which of the postpartum days can the client expect lochia serosa? 1. Days 3 and 4 PP 2. Days 3 to 10 PP 3. Days 10-14 PP 4. Days 14 to 42 PP

2. On the third and fourth PP days, the lochia becomes a pale pink or brown and contains old blood, serum, leukocytes, and tissue debris. This type of lochia usually lasts until PP day 10. Lochia rubra usually last for the first 3 to 4 days PP. Lochia alba, which contain leukocytes, decidua, epithelial cells, mucus, and bacteria, may continue for 2 to 6 weeks PP.

A nurse is providing instructions to a mother who has been diagnosed with mastitis. Which of the following statements if made by the mother indicates a need for further teaching? 1. "I need to take antibiotics, and I should begin to feel better in 24-48 hours." 2. "I can use analgesics to assist in alleviating some of the discomfort." 3. "I need to wear a supportive bra to relieve the discomfort." 4. "I need to stop breastfeeding until this condition resolves."

4. In most cases, the mother can continue to breast feed with both breasts. If the affected breast is too sore, the mother can pump the breast gently. Regular emptying of the breast is important to prevent abscess formation. Antibiotic therapy assists in resolving the mastitis within 24-48 hours. Additional supportive measures include ice packs, breast supports, and analgesics.

After expulsion of the placenta in a client who has six living children, an infusion of lactated ringer's solution with 10 units of pitocin is ordered. The nurse understands that this is indicated for this client because: 1. She had a precipitate birth 2. This was an extramural birth 3. Retained placental fragments must be expelled 4. Multigravida's are at increased risk for uterine atony.

4. Multiple full-term pregnancies and deliveries result in overstretched uterine muscles that do not contract efficiently and bleeding may ensue.

Which of the following findings would be a source of concern if noted during the assessment of a woman who is 12 hours postpartum? 1. Postural hypotension 2. Temperature of 100.4°F 3. Bradycardia — pulse rate of 55 BPM 4. Pain in left calf with dorsiflexion of left foot

4. Responses 1 and 3 are expected related to circulatory changes after birth. A temperature of 100.4°F in the first 24 hours is most likely indicative of dehydration which is easily corrected by increasing oral fluid intake. The findings in response 4 indicate a positive Homan sign and are suggestive of thrombophlebitis and should be investigated further.

On the first PP night, a client requests that her baby be sent back to the nursery so she can get some sleep. The client is most likely in which of the following phases? 1. Depression phase 2. Letting-go phase 3. Taking-hold phase 4. Taking-in phase

4. The taking-in phase occurs in the first 24 hours after birth. The mother is concerned with her own needs and requires support from staff and relatives. The taking-hold phase occurs when the mother is ready to take responsibility for her care as well as the infants care. The letting-go phase begins several weeks later, when the mother incorporates the new infant into the family unit.

In evaluating the effectiveness of oxytocin induction, the nurse would expect :a.Contractions lasting 40 to 90 seconds, 2 to 3 minutes apart. b.The intensity of contractions to be at least 110 to 130 mm Hg. c.Labor to progress at least 2 cm/hr dilation. d.At least 30 mU/min of oxytocin will be needed to achieve cervical dilation.

A

A postpartum patient who has an episiotomy is being discharged to home. Which instruction about medications is most important for the patient? A. Take stool softeners regularly. B. Continue prenatal vitamins. C. Include iron supplements. D. Take analgesics as prescribed.

A (The patient who has an episiotomy may have constipation due to discomfort during bowel movements. Therefore the nurse should instruct the patient to use stool softeners to help ease the passage of stools. Prenatal vitamins should be continued in all patients regardless of the episiotomy. All patients should take iron supplements to increase their hemoglobin levels. However, they do not ease the discomfort of episiotomy. Analgesics are usually prescribed for patients who underwent a cesarean.)

A nurse is teaching a postpartum client about breast-feeding. Which of the following instructions should the nurse include? A. The diet should include additional fluids B. Prenatal vitamins should be discontinued C. Soap should be used to cleanse the breasts. D. Birth control measures are unnecessary while breast-feeding.

A A diet for a breast-feeding patient should include additional fluids. Prenatal vitamins should be taken as prescribed and soap should not be used on the breast because it removes natural oils which increases the chance of cracked nipples. Breast-feeding is not a sole method of contraception, so birth control measures should be resumed.

It has been 12 hours since the client's delivery of a newborn. The nurse assesses the client for the process of involution and documents that it is progressing normally when palpation of the client's fundus is noted at which level? A. At the umbilicus B. One fingerbreadth below the umbilicus C. Two fingerbreadth above the umbilicus D. Two fingerbreadth below the umbilicus

A. The term involution is used to describe the rapid reduction in size and the return of the uterus to a normal condition similar to its pre-pregnant state. Immediately following delivery of the placenta the uterus contracts to the size of a large grapefruit The fundus is situated into the midline between the symphysis pubis and the umbilicus. Within 6 to 12 hour after birth the fundus of the uterus rises to the level of the umbilicus. The top of the fundus remains at the level of the umbilicus for about a day and then descends into the pelvis approximately one fingerbreadth on each succeeding day.

The client has just given birth to full-term twins. One twin was stillborn. The nurse concludes that this family will need to do which of the following? A. Simultaneously grieve the loss of one infant while becoming attached to the other .B. Be passive in accepting the death in order to form an attachment to the living infant. C. Control their emotions to prevent undue stress for the surviving twin. D. Minimize the time spent with the dead infant to facilitate attachment to the survivor.

A. Simultaneously grieve the loss of one infant while becoming attached to the other.

What is the most appropriate nursing action to take when a laboring woman hyperventilates? a. Help her breathe into her cupped hands. b. Place her flat on her back. c. Initiate oxygen at 2 liters via mask. d. Notify the doctor.

ANS: A Measures to combat hyperventilation include breathing into cupped hands or a paper bag or holding breath for a few seconds. All of these techniques decrease PCO2.

A woman requests a pudendal block to manage her labor pain. What statement by the woman indicates a need for further explanation about the pudendal block? a. "I'm having a contraction. Can I get the pudendal block now?" b. "I'll get the pudendal block right before I deliver." c. "The nurse midwife will insert the needles into my vagina." d. "It takes a few minutes after the medicine is administered to make me feel numb."

ANS: A The pudendal block does not block pain from contractions and is given just before birth.

The nurse coaches the primigravida not to bear down until the cervix is completely dilated. What may premature bearing down cause? a. Increased use of oxygen b. Cervical laceration c. Uterine rupture d. Compression of the cord

ANS: B Bearing down against a cervix that is not dilated can cause edema and laceration to the cervix.

When giving a narcotic to a laboring client, which statement explains why the nurse should inject the medication at the beginning of a contraction? a. The medication will be rapidly circulated. b.Less medication will be transferred to the fetus. c. The maternal vital signs will not be adversely affected. d. Full benefit of the medication is received during that contraction.

ANS: B Injecting at the beginning of a contraction, when blood flow to the placenta is normally reduced, limits transfer to the fetus. It will not increase the circulation of the medication. It will not alter the vital signs any more than giving it at another time. The full benefit will be received by the woman, but it will decrease the amount reaching the fetus.

A post-anesthesia care nurse is receiving a report on a patient who was delivered under general anesthesia. The operating room nurse states that the patient received a dose of metoclopramide (Reglan) IV in the operating room. The nurse explains to a student nurse the purpose of giving this drug is to do which of the following? A. Allow rapid anesthetic induction B. Increase the speed of gastric emptying C. Promote muscle relaxation D. Reduce stomach acid production

ANS: B Reglan increases the speed of gastric emptying, which helps prevent the aspiration of gastric contents. Pregnant women are at a higher risk of gastric reflux than the general population. Rapid induction is facilitated with a short-acting barbiturate such as thiopental sodium (Pentothal). Muscle relaxation can be facilitated with succinylcholine (Anectine). Ranitidine hydrochloride (Zantac) or cimetidine (Tagamet) can be used to decrease gastric acid production.

The nurse should be aware that an effective plan to achieve adequate pain relief without maternal risk is most effective if: a. The mother gives birth without any analgesic or anesthetic. b. The mother and family's priorities and preferences are incorporated into the plan. c. The primary health care provider decides the best pain relief for the mother and family. d. The nurse informs the family of all alternative methods of pain relief available in the hospital setting.

ANS: B The assessment of the woman, her fetus, and her labor is a joint effort of the nurse and the primary health care providers, who consult with the woman about their findings and recommendations. The needs of each woman are different, and many factors must be considered before a decision is made whether pharmacologic methods, nonpharmacologic methods, or a combination of the two will be used to manage labor pain.

he nerve block used in labor that provides anesthesia to the lower vagina and perineum is a(n): a. local. b. epidural. c. pudendal. d. spinal block.

ANS: C A pudendal block anesthetizes the lower vagina and perineum to provide anesthesia for an episiotomy and use of low forceps, if needed. A local provides anesthesia for the perineum at the site of the episiotomy. An epidural provides anesthesia for the uterus, perineum, and legs. A spinal block provides anesthesia for the uterus, perineum, and down the legs.

A laboring woman received an opioid agonist (meperidine) intravenously 90 minutes before she gave birth. Which medication should be available to reduce the postnatal effects of Demerol on the neonate? a. Fentanyl (Sublimaze) b. Promethazine (Phenergan) c. Naloxone (Narcan) d. Nalbuphine (Nubain)

ANS: C An opioid antagonist can be given to the newborn as one part of the treatment for neonatal narcosis, which is a state of central nervous system (CNS) depression in the newborn produced by an opioid. Opioid antagonists such as naloxone (Narcan) can promptly reverse the CNS depressant effects, especially respiratory depression. Fentanyl, promethazine, and nalbuphine do not act as opioid antagonists to reduce the postnatal effects of Demerol on the neonate. Although meperidine (Demerol) is a low-cost medication and readily available, the use of Demerol in labor has been controversial because of its effects on the neonate.

A client presents to the labor and birth area for emergent birth. Vaginal exam reveals that the client is fully dilated, vertex, +2 station, with ruptured membranes. The client is extremely apprehensive because this is her first childbirth experience and asks for an epidural to be administered now. What is the priority nursing response based on this client assessment? a. Use contact anesthesia for an epidural and prepare the client per protocol. b. Tell the client that she will not need any pain medication because the birth will be over in a matter of minutes and the pain will stop. c. Assist the client with nonpharmacologic methods of pain distraction during this time as you prepare for vaginal birth. d. Call the physician for admitting orders.

ANS: C By assisting the client with nonpharmacologic methods of pain distraction, the nurse is focusing on the client's needs while still preparing for vaginal birth. The client presents in an emergent situation with birth being imminent. Thus, there is not enough time to administer an epidural. Telling the client that she will not need any pain medication because the birth will be over soon does not address the client's concerns of apprehension and therefore is not therapeutic. Because this is an emergency birth situation, the nurse should be attending to the client. If needed, another nurse and/or supervisor can contact the physician.

A nurse is caring for a pregnant woman scheduled to have an epidural block. The nurse reviews the woman's admission laboratory results and finds the following: white blood count (WBC) 6,500/ mm3, hemoglobin 14 mg/dL, hematocrit 38%, platelet count 98,000, and international normalized ratio (INR) 4.2. What action by the nurse is best? A. Document the findings in the woman's chart. B. Ensure a signed consent form is in the chart. C. Notify the health-care provider immediately .D. Start a peripheral IV of normal saline (NS).

ANS: C Contraindications to spinal/epidural blocks include maternal refusal, local or systemic infection, coagulopathies, actual or anticipated maternal hemorrhage, allergy to a specific agent being used, or lack of trained staff. This woman's platelet count is low and her INR is high, leading to concern about coagulopathies. The nurse should notify the health-care provider immediately. Documentation should always be thorough, but further action is needed. A signed consent form should be in the chart for an invasive procedure; however, this is not the priority at this point. An IV will probably be needed prior to delivery (depending on institutional protocol), but, again, this is not the priority in the setting of a patient with abnormal laboratory results.

Which clinical effect can occur in the presence of increased maternal pain perception during labor? a. Increase in uterine contractions in response to catecholamine secretion b. Decrease in blood pressure in response to alpha receptors c. Decreased perfusion to the placenta in response to catecholamine secretion d. Increased uterine blood flow, causing increase in maternal blood pressure

ANS: C Decreased perfusion to and from the placenta occurs as result of catecholamine secretion. A decrease in uterine contractions is seen in response to catecholamine secretion. Maternal blood pressure is increased in response to alpha receptors. Decreased uterine blood flow causes an increase in maternal blood pressure.

A woman in labor has just received an epidural block. The most important nursing intervention is to: a. Limit parenteral fluids. b. Monitor the fetus for possible tachycardia. c. Monitor the maternal blood pressure for possible hypotension. d. Monitor the maternal pulse for possible bradycardia.

ANS: C The most important nursing intervention for a woman who has received an epidural block is to monitor the maternal blood pressure frequently for signs of hypotension. Intravenous fluids are increased for a woman receiving an epidural, to prevent hypotension. The nurse observes for signs of fetal bradycardia. The nurse monitors for signs of maternal tachycardia secondary to hypotension.

Which of these medications is commonly used to control postpartum bleeding related to uterine atony? a. Magnesium sulfate b. Phytonadione c. Oxytocin d. Warfarin

ANS: C a. Magnesium sulfate is commonly used for PIH and preterm labor. It is a smooth muscle relaxant and can cause the uterus to relax.b. Phytonadione (vitamin K) is important for clotting but will not cause the uterus to contract.c. Oxytocin is commonly used to control postpartum bleeding related to uterine atony.d. Warfarin is an anticoagulant and will increase the risk of hemorrhage.

The nurse detects hypotension in a laboring client after an epidural. Which actions should the nurse plan to implement? (Select all that apply.) a. Encourage the client to drink fluids. b. Place the client in a Trendelenburg position. c. Administer a normal saline bolus as prescribed. d. Administer oxygen at 8 to 10 L/min per face mask. e. Administer IV ephedrine in 5- to 10-mg increments as prescribed.

ANS: C, D, E If hypotension occurs after an epidural has been placed, techniques such as a rapid nondextrose IV fluid bolus, maternal repositioning, and oxygen administration are implemented. If those interventions are ineffective, IV ephedrine in 5- to 10-mg increments can be prescribed to promote vasoconstriction to raise the blood pressure. The client in active labor should not be encouraged to drink fluids. In a Trendelenburg position, the body is flat, with the feet elevated. This would not be a position to use for a pregnant client.

The primary side effect of maternal narcotic analgesia in the newborn is: a. tachypnea. b. bradycardia. c. acrocyanosis. d. respiratory depression.

ANS: D An infant delivered within 1 to 4 hours of maternal analgesic administration is at risk for respiratory depression from the sedative effects of the narcotic. The infant who is having a side effect to maternal analgesics normally would have a decrease in respirations, not an increase. Bradycardia is not the anticipated side effect of maternal analgesics. Acrocyanosis is an expected finding in a newborn and is not related to maternal analgesics.

A patient who received an epidural block asks why her blood pressure is taken so often. What is the nurse's best response to explain the frequent blood pressure assessments? a. They ensure that unsafe levels of hypertension do not occur. b. They help assess for the need for further pain relief. c. They monitor the progress of labor. d. They ensure adequate placental perfusion.

ANS: D The hypotension that accompanies an epidural block may cause inadequate perfusion of the placenta, leading to fetal hypoxia.

To improve placental blood flow immediately after the injection of an epidural anesthetic, the nurse should: a. give the woman oxygen .b. turn the woman to the right side. c. decrease the intravenous infusion rate. d. place a wedge under the woman's right hip.

ANS: D Tilting the woman's pelvis to the left side relieves compression of the vena cava and compensates for a lower blood pressure without interfering with dispersal of the epidural medication. Oxygen administration will not improve placental blood flow. The woman needs to maintain the supine position for proper dispersal of the medication. However, placing a wedge under the hip will relieve compression of the vena cava. The intravenous infusion rate needs to be increased to prevent hypotension.

The nurse providing care for a woman with preterm labor who is receiving terbutaline would include which intervention to identify side effects of the drug? a.Assessing deep tendon reflexes (DTRs) b.Assessing for chest discomfort and palpitations c.Assessing for bradycardia d.Assessing for hypoglycemia

B

postpartum period the nurse plans to take the woman's vital signs: A. Every 30 minutes during the first hour and then every hour for the next two hours. B. Every 15 minutes during the first hour and then every 30 minutes for the next two hours. C. Every hour for the first 2 hours and then every 4 hours D. Every 5 minutes for the first 30 minutes and then every hour for the next 4 hours.

B Every 15 minutes during the first hour and then every 30 minutes for the next two hours.

During the latent phase of labor, the nurse suggests that the woman play cards with her husband. The nurse is aware that this will help the woman deal with the pain of contractions. This technique is called: a. Cutaneous stimulation. b. Gate control theory. c. Thermal stimulation. d. Hydrotherapy.

B In the gate control theory of pain, the use of cognitive processes can affect the perception of stimuli as painful. Diversional activities in early labor and focal points or breathing techniques later in labor are examples of the gate control theory of pain. Cutaneous stimulation is using touch to relax the muscles. Thermal stimulation is the use of warmth to relax the muscles. Hydrotherapy is the use of water for relaxation.

A nurse is evaluating the mother-infant bonding process during the postpartum period. An indication of a maladaptive interaction would be if the mother: A. Expressed discomfort with the role of motherhood B. Encouraged the nurse to feed the baby because she continues to be too tired C. Showed that she was willing to learn how to care for the umbilical cord D. Talked to the baby

B. An indication of a maladaptive interaction is refusal to interact with or care for the infant. Options C and D identify situations in which the mother plans to or is demonstrating interaction with the infant. Expressing discomfort with the role of motherhood is not maladaptive.

A primigravida at 40 weeks of gestation is having uterine contractions every 1.5 to 2 minutes and says 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 likely status of this woman's labor? a.She is exhibiting hypotonic uterine dysfunction. b.She is experiencing a normal latent stage. c.She is exhibiting hypertonic uterine dysfunction. d.She is experiencing pelvic dystocia.

C

All the following women in labor are requesting pain medication. To which one should the nurse administer an opioid analgesic first? a. Primigravida, 2 cm dilated, 50% effaced, grimacing slightly with each contraction b. Gravida 4, 9 cm dilated, 100% effaced, wants to push with each contraction c. Gravida 2, 6 cm dilated, 100% effaced, rocks back and forth in bed with each contraction d. Primigravida, 1 cm dilated, moans loudly with each contraction, has present history of heroin use

C The gravida 2 is well established into the labor and the medication will not slow the contractions. The primigravida who is 2 cm dilated is too early into the labor; the medication may slow or stop her contractions. The gravida 4 is too near birth and the medication may affect the newborn's respiratory effort. The primigravida who is 1 cm dilated has a history of heroin use; further opioid medication is not recommended.

A nurse is monitoring the amount of lochia drainage in a client who is 2 hours postpartum and notes that the client has saturated a perineal pad in 1 hour. The nurse reports the amount of lochial flow as: A. Scant B. Light C. Heavy D. Excessive

C Scant = 2.5cm or less Light = 2.5cm - 10cm Moderate = >10cm Heavy = soaked pad in 1-2 hours Excessive = soaked pad in 15 minutes

Which statement regarding postpartum depression (PPD) is essential for the nurse to be aware of when attempting to formulate a plan of care? A) PPD symptoms are consistently severe .B) This syndrome affects only new mothers. C) PPD can easily go undetected. D) Only mental health professionals should teach new parents about this condition.

C) PPD can easily go undetected.Rationale:PPD symptoms range from mild to severe, with women having good days and bad days. Screening should be done for mothers and fathers. PPD may also occur in new fathers. PPD can go undetected because parents do not voluntarily admit to this type of emotional distress out of embarrassment, fear, or guilt. The nurse should include information on PPD and how to differentiate this from the baby blues for all clients on discharge. Nurses also can urge new parents to report symptoms and seek follow-up care promptly if they occur.

A nurse is performing an assessment on a 2-day postpartum mother. The mother complains of severe pain and an intense feeling of swelling and pressure in the vulvar area. After hearing these complaints the nurse specifically checks the client's... A. Episiotomy for drainage B. Rectum for hemorrhoids C. Vulva for a hematoma D. Vagina for lacerations

C. Hematoma is suspected when the client reports pain or pressure in the vulvar area. Massive hemorrhage into the tissues can occur, resulting in hypovolemia and shock; therefore the clients complaints must be assessed so that interventions can begin immediately.

A client who is breast-feeding her newborn infant is experiencing nipple soreness. To relieve the soreness, the nurse suggests that the client: A. Avoid rotating breast-feeding positions. B. Stop nursing until the nipples heal C. Substitute a bottle-feeding until the nipples heal. D. Position the infant with the ear, shoulder, and hip in straight alignment with the infant's stomach against the mother

D. The nurse would suggest the mother position the infant in this manner. Rotating breast-feeding positions; breaking suction with the little finger; nursing frequently; begin feeding on the less sore nipple; not allowing the newborn to chew on the nipple or to sleep holding the nipple in the mouth and applying tea bags soaked in warm water to the nipple are also measures to alleviate nipple soreness.

A nurse is preparing to perform a fundal assessment on a postpartum client. The initial nursing action in performing this assessment is which of the following? 1. Ask the client to turn on her side 2. Ask the client to lie flat on her back with the knees and legs flat and straight. 3. Ask the mother to urinate and empty her bladder 4. Massage the fundus gently before determining the level of the fundus.

3. Before starting the fundal assessment, the nurse should ask the mother to empty her bladder so that an accurate assessment can be done. When the nurse is performing fundal assessment, the nurse asks the woman to lie flat on her back with the knees flexed. Massaging the fundus is not appropriate unless the fundus is boggy and soft, and then it should be massaged gently until firm.

A nurse is preparing to assess the uterine fundus of a client in the immediate postpartum period. When the nurse locates the fundus, she notes that the uterus feels soft and boggy. Which of the following nursing interventions would be most appropriate initially? 1. Massage the fundus until it is firm 2. Elevate the mothers legs 3. Push on the uterus to assist in expressing clots 4. Encourage the mother to void

1. If the uterus is not contracted firmly, the first intervention is to massage the fundus until it is firm and to express clots that may have accumulated in the uterus. Pushing on an uncontracted uterus can invert the uterus and cause massive hemorrhage. Elevating the client's legs and encouraging the client to void will not assist in managing uterine atony. If the uterus does not remain contracted as a result of the uterine massage, the problem may be distended bladder and the nurse should assist the mother to urinate, but this would not be the initial action.

A pregnant woman's amniotic membranes rupture. Prolapsed umbilical cord is suspected. What intervention would be the top priority? a.Placing the woman in the knee-chest position b.Covering the cord in sterile gauze soaked in saline c.Preparing the woman for a cesarean birth d.Starting oxygen by face mask

A

A stillborn baby was delivered in the birth suite a few hours ago. After the delivery the family remained together, holding and touching the baby. Which statement by the nurse would further assist the family in their initial period of grief? A. "What can I do for you? B. "Now you have an angel in heaven." C. "Don't worry, there is nothing you could have done to prevent this from happening." D. "We will see to it that you have an early discharge so that you don't have to be reminded of this experience."

A. "What can I do for you?

Which of the following women can the nurse anticipate having difficulty dealing with labor pain? a. Primigravida who has attended childbirth preparation classes b. A woman having her second baby; the first child was in a posterior position and the labor lasted 18 hours. c. A woman having her sixth child and who has not attended any prenatal teaching classes d. Primigravida who has her mother as her birth support person. The mother is encouraging her with every contraction.

B Previous experiences with pain can alter a woman's perception of labor pain. The woman with a prolonged labor and posterior position with the last birth will come to this labor anxious about the outcome and amount of pain. Preparation for labor and previous positive experiences will help the woman tolerate the pain. A support person who has been through the process and is encouraging can also assist the woman in a positive way.

When helping a woman cope with postpartum blues, the nurse should offer what appropriate suggestions? (Select all that apply.) A) The father should take over care of the baby, because postpartum blues are exclusively a female problem. B) Get plenty of rest .C) Plan to get out of the house occasionally .D) Asking for help will not foster independence.

B) Get plenty of rest.C) Plan to get out of the house occasionally.

The nurse plans to facilitate bereavement after a fetal demise in utero by doing which of the following? A. Protecting the parents from having to see the dead fetus. B. Encouraging culturally determined naming and burial practices .C. Encouraging the client to tell the older children nothing. D. Avoiding the financial stress of an autopsy.

B. Encouraging culturally determined naming and burial practices.

A woman at 26 weeks of gestation is being assessed to determine whether she is experiencing preterm labor. What finding indicates that preterm labor is occurring? a.Estriol is not found in maternal saliva. b.Irregular, mild uterine contractions are occurring every 12 to 15 minutes. c.Fetal fibronectin is present in vaginal secretions. d.The cervix is effacing and dilated to 2 cm.

D

In evaluating the effectiveness of magnesium sulfate for the treatment of preterm labor, what finding would alert the nurse to possible side effects? a.Urine output of 160 mL in 4 hours b.Deep tendon reflexes 2+ and no clonus c.Respiratory rate of 16 breaths/min d.Serum magnesium level of 10 mg/dL

D

Several hours into labor, a woman complains of dizziness, numbness, and tingling of her hands and mouth. What does the nurse recognize these symptoms signify? a. Hypertension b. Anxiety c. Anoxia d. Hyperventilation

ANS: D Hyperventilation is sometimes a problem if a woman is breathing rapidly.

A nurse is assessing a client in the 4th stage if labor and notes that the fundus is firm but that bleeding is excessive. The initial nursing action would be which of the following? 1. Massage the fundus 2. Place the mother in the Trendelenburg's position 3. Notify the physician 4. Record the findings

3. If the bleeding is excessive, the cause may be laceration of the cervix or birth canal. Massaging the fundus if it is firm will not assist in controlling the bleeding. Trendelenburg's position is to be avoided because it may interfere with cardiac function.

A woman in preterm labor at 30 weeks of gestation receives two 12-mg doses of betamethasone intramuscularly. The purpose of this pharmacologic treatment is to: a.Stimulate fetal surfactant production. b.Reduce maternal and fetal tachycardia associated with ritodrine administration. c.Suppress uterine contractions. d.Maintain adequate maternal respiratory effort and ventilation during magnesium sulfate therapy.

A

A second-day postpartum client with diabetes mellitus has scant lochia with a foul odor and a temperature of 101.6 degrees F. The physician suspects infection and writes orders to treat the client. Which of the following orders written by the physician would the nurse complete first? A. Obtain culture and sensitivity of lochia and urine B. Administer Ceftriaxone (Rocephin) C. Check the client's temperature D. Increase the intake of oral fluids.

A .Culture and sensitivity results should be obtained before any antibiotic therapy is begun to avoid masking the microorganisms identified in the culture. Options B and D are standard parts of therapy for this type of infection but are not completed first. Although the client's temperature is monitored, checking the temperature is not the first action.The data in the question indicate that the temperature has already been checked.

A nurse obtains the vital signs on a mother who delivered a healthy newborn infant 2 hours ago and notes that the mother's temperature is 102 F. The appropriate nursing action would be to: A. Notify the physician B. Remove the blanket from the client's bed C. Document the finding and recheck the temperature in 4 hours. D. Administer Acetaminophen (Tylenol) and recheck the temperature in 4 hours.

A .Vital signs are to return to normal within the first hour postpartum if no complication arise. If the temperature is greater than 2F above normal this may indicate infection, and the physician should be notified. Options B, C, and D are inaccurate nursing interventions for the client's temperature of 102F 2 hours following delivery.

A woman in labor receives a dose of hydromorphone hydrochloride (Dilaudid) at 11:30 a.m. She gives birth at 12:45 p.m. What action by the nurse takes priority? A. Assess the neonate frequently for respiratory depression .B. Encourage the woman to void every 2 hours postpartum. C. Perform a head-to-toe assessment on the neonate. D. Promote skin-to-skin contact and bonding as soon as possible.

ANS: A With Dilaudid, if birth occurs within 1 to 4 hours after administration, the nurse must assess the neonate frequently for respiratory depression. The other options are appropriate, but not the priority for this situation.

A nurse is preparing a list of self-care instructions for a postpartum client who was diagnosed with mastitis. Which of the following instructions would be included on the list? (Select All That Apply) A. Wear a supportive bra B. Rest during the acute phase C. Maintain a fluid intake of at least 3000 ml D Continue to breast-feed if the breasts are not too sore. E. Take the prescribed antibiotics until the soreness subsides. F. Avoid decompression of the breasts by breast-feeding or breast pump.

A, B, C, D Client instructions include resting during the acute phase, maintaining a fluid intake of at least 3000ml/day (if not contraindicated), taking analgesics to relieve discomfort. Antibiotics may be prescribed and are taken UNTIL THE COMPLETE PRESCRIBED COURSE IS FINISHED. Additional supportive measures include the use of moist heat or ice packs and wearing 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.

When a pregnant woman arrives at the labor suite, she tells the nurse that she wants to have an epidural for delivery. What is a contraindication to an epidural block? a. Abnormal clotting b. Previous cesarean delivery c. History of migraine headaches d. History of diabetes mellitus

ANS: A An epidural block is not used if a woman has abnormal blood clotting.

A woman is experiencing back labor and complains of intense pain in her lower back. An effective relief measure would be to use: a. Counterpressure against the sacrum. b. Pant-blow (breaths and puffs) breathing techniques. c. Effleurage. d. Conscious relaxation or guided imagery.

ANS: A Counterpressure is steady pressure applied by a support person to the sacral area with the fist or heel of the hand. This technique helps the woman cope with the sensations of internal pressure and pain in the lower back. The pain management techniques of pant-blow, effleurage, and conscious relaxation or guided imagery are usually helpful for contractions per the gate-control theory.

A woman in active labor receives an analgesic opioid agonist. Which medication relieves severe, persistent, or recurrent pain; creates a sense of well-being; overcomes inhibitory factors; and may even relax the cervix but should be used cautiously in women with cardiac disease? a. Meperidine (Demerol) b. Promethazine (Phenergan) c. Butorphanol tartrate (Stadol) d. Nalbuphine (Nubain)

ANS: A Meperidine is the most commonly used opioid agonist analgesic for women in labor throughout the world. It overcomes inhibitory factors in labor and may even relax the cervix. Because tachycardia is a possible adverse reaction, meperidine is used cautiously in women with cardiac disease. Phenergan is an ataractic (tranquilizer) that may be used to augment the desirable effects of the opioid analgesics but has few of the undesirable effects of those drugs. Stadol and Nubain are opioid agonist-antagonist analgesics.

The best time to teach nonpharmacologic pain control methods to an unprepared laboring client is during which stage? a. Latent phase b. Active phase c. Second stage d. Transition phase

ANS: A The latent phase of labor is the best time for intrapartum teaching because the woman is usually anxious enough to be attentive yet comfortable enough to understand the teaching. During the active phase, the woman is focused internally and unable to concentrate on teaching. During the second stage, the woman is focused on pushing. She normally handles the pain better at this point because she is active in doing something to hasten the birth. During transition, the woman is focused on keeping control; she is unable to focus on anyone else or learn at this time.

The nurse is educating a pregnant client who has gestational diabetes. Which of the following statements should the nurse make to the client? Select all that apply. a. Cakes, candies, cookies, and regular soft drinks should be avoided. b. Gestational diabetes increases the risk that the mother will develop diabetes later in life. c. Gestational diabetes usually resolves after the baby is born. d. Insulin injections may be necessary. e. The baby will likely be born with diabetes f. The mother should strive to gain no more weight during the pregnancy.

ANS: A, B, C, D Gestational diabetes can occur between the 16th and 28th week of pregnancy.If not responsive to diet and exercise, insulin injections may be necessary.Concentrated sugars should be avoided.Weight gain should continue, but not in excessive amounts.Usually, gestational diabetes disappears after the infant is born. However, diabetes can develop 5 to 10 years after the pregnancy

How does the pain of childbirth differ from other types of pain? (Select all that apply.) a. Childbirth pain is part of a normal process. b. Childbirth pain seldom needs narcotic relief. c. Position changes relieve pain and facilitate delivery. d. Childbirth pain declines following birth.e. Childbirth pain is self-limited.

ANS: A, C, D, E Childbirth pain differs from other types of pain because it is part of a normal, natural, and expected process, can be relieved by change of position, declines immediately following birth, and is self-limiting. Childbirth pain requires pharmacological management with narcotics in many cases.

The priority intervention for a client with epidural anesthesia whose blood pressure is 80/50 mm Hg is: a. reposition to supine position. b. administer ephedrine, 5 mg IV push. c. maintain IV infusion rate at 150 mL/hr. d. Notify anesthesia about maternal hypotension.

ANS: B A significant blood pressure decrease is a drop to 100 mm Hg or lower systolic. If hypotension is significant, ephedrine is ordered to increase the blood pressure to normal values. The supine position will further decrease maternal blood pressure by compressing the major vessels. Maintaining the IV infusion rate will not return blood pressure to normal values as quickly as needed; immediate action needs to be taken, and notifying anesthesia would be time-consuming.

A client in labor is approaching the transition stage and already has an epidural in place. An additional dose of medication has been prescribed and administered to the client. Which priority intervention should be done by the nurse to help evaluate CLINICAL response to treatment? a. Obtain a pain scale response from the client based on a 0 to 10 scale. b. Document maternal blood pressure and fetal heart rates following medication administration and observe for any variations. c. Document intake and output on the electronic health record (EHR). d. Increase the flow rate of prescribed parenteral fluid to maintain hydration.

ANS: B Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN) evidence-based practice guidelines note that maternal blood pressure and fetal heart tones should be assessed following any bolus of additional medication via the epidural route. Obtaining a pain scale response is not typically used for the laboring client but used for postoperative and/or chronic pain clients. Intake and output should be documented as part of the clinical record but is not the priority intervention based on this client's situation. Increasing the flow rate of parenteral fluids requires a physician's order, and there is no clinical evidence that this is needed. Giving parenteral fluids in excess can lead to fluid retention and fluid volume excess.

What is the Dick-Read method of childbirth preparation based on? a. Mild sedation throughout labor b. Relaxation techniques c. Skin stimulation d. Deep massage

ANS: B The Dick-Read method depends on the use of relaxation techniques to reduce the discomforts of labor.

A woman in labor has just received an epidural block. The most important nursing intervention is to: a. Limit parenteral fluids .b. Monitor the fetus for possible tachycardia. c. Monitor the maternal blood pressure for possible hypotension. d. Monitor the maternal pulse for possible bradycardia.

ANS: C The most important nursing intervention for a woman who has received an epidural block is to monitor the maternal blood pressure frequently for signs of hypotension. Intravenous fluids are increased for a woman receiving an epidural, to prevent hypotension. The nurse observes for signs of fetal bradycardia. The nurse monitors for signs of maternal tachycardia secondary to hypotension.

After reviewing a client's history, which factor would the nurse identify as placing her at risk for gestational hypertension? A) Mother had gestational hypertension during pregnancy. B) Client has a twin sister .C) Sister-in-law had gestational hypertension. D) This is the client's second pregnancy.

Ans: A A family history of gestational hypertension, such as a mother or sister, is considered a risk factor for the client. Having a twin sister or having a sister-in-law with gestational hypertension would not increase the client's risk. If the client had a history of preeclampsia in her first pregnancy, then she would be at risk in her second pregnancy.

Maternal hypotension is a potential side effect of regional anesthesia and analgesia. What nursing interventions could you use to raise the client's blood pressure (Select all that apply)? a. Place the woman in a supine position. b. Place the woman in a lateral position. c. Increase intravenous (IV) fluids. d. Administer oxygen.e. Perform a vaginal examination.

ANS: B, C, D Nursing interventions for maternal hypotension arising from analgesia or anesthesia include turning the woman to a lateral position, increasing IV fluids, administering oxygen via face mask, elevating the woman's legs, notifying the physician, administering an IV vasopressor, and monitoring the maternal and fetal status at least every 5 minutes until these are stable. Placing the client in a supine position would cause venous compression, thereby limiting blood flow to and oxygenation of the placenta and fetus. A sterile vaginal examination has no bearing on maternal blood pressure.

A nurse is caring for a woman who is going to have an epidural block. The physician orders that an IV be started. Which of the following solutions would be appropriate for the nurse to choose? (Select all that apply.) A. D5 (5% dextrose) with 0.45 normal saline (NS) B. D5 and water (D5W) C. Lactated Ringer's (LR) solution D. Normal saline (NS) E. Normal saline (NS) with 10% dextrose

ANS: C, D Most institutions use dextrose-free IV solutions for women in labor because dextrose can cause fetal hyperglycemia with rebound hypoglycemia in the few hours after birth. The other three options all contain dextrose.

The obstetric nurse is preparing the patient for an emergency cesarean birth, with no time to administer spinal anesthesia. The nurse is aware and prepared for the greatest risk of administering general anesthesia to the patient. This risk is: a. Respiratory depression. b. Uterine relaxation. c. Inadequate muscle relaxation. d. Aspiration of stomach contents.

ANS: D Aspiration of acidic gastric contents with possible airway obstruction is a potentially fatal complication of general anesthesia. Respirations can be altered during general anesthesia, and the anesthesiologist will take precautions to maintain proper oxygenation. Uterine relaxation can occur with some anesthesia; however, this can be monitored and prevented. Inadequate muscle relaxation can be improved with medication.

A nurse suspects that a pregnant client may be experiencing abruption placenta based on assessment of which of the following? (Select all that apply.) A) Dark red vaginal bleeding B) Insidious onset C) Absence of pain D) Rigid uterus E) Absent fetal heart tones

Ans: A, D, E Feedback:Assessment findings associated with abruption placenta include a sudden onset, with concealed or visible bleeding, dark red bleeding, constant pain or uterine tenderness on palpation, firm to rigid uterine tone, and fetal distress or absent fetal heart tones.

A patient in active labor requests an epidural for pain management. What is the nurse's priority action for this patient? a. Assess the fetal heart rate pattern over the next 30 minutes. b. Take the patient's blood pressure every 5 minutes for 15 minutes. c. Determine the patient's contraction pattern for the next 30 minutes. d. Initiate an IV infusion of lactated Ringer's solution at 2000 mL/hr over 30 minutes.

ANS: D Rapid infusion of a NONdextrose IV solution, often warmed, such as lactated Ringer's or normal saline, before initiation of the block fills the vascular system to offset vasodilation. Preload IV quantities are at least 500 to 1000 mL infused rapidly. Vasodilation with corresponding hypotension can reduce placental perfusion and is most likely to occur within the first 15 minutes after the initiation of the epidural. Determining the fetal heart rate every 30 minutes is the standard of care. The patient is in active labor, which indicates a contraction pattern resulting in cervical dilation.

A nurse is teaching a childbirth education class. Which information about excessive pain in labor should the nurse include in the session? a. It usually results in a more rapid labor. b. It has no effect on the outcome of labor. c. It is considered to be a normal occurrence. d. It may result in decreased placental perfusion.

ANS: D When experiencing excessive pain, the woman may react with a stress response that diverts blood flow from the uterus and the fetus. Excessive pain may prolong the labor because of increased anxiety in the woman. It may affect the outcome of the labor, depending on the cause and the effect on the woman. Pain is considered normal for labor. However, excessive pain may be an indication of other problems and must be assessed.

A nurse is preparing to administer RhoGam to a client who delivered a fetal demise. Which of the following must the nurse check before giving the injection? a. Verify that the direct Coombs test results are positive. b. Check that the fetus was at least 28 weeks gestation. c. Make sure that the client is at least 3 days postdelivery. d. Confirm that the client is Rh negative.

ANS: D a. The direct Coombs test is irrelevant, and because the baby has died, the Coombs will likely not be performed.b. RhoGam should be given no matter how old the fetus was.c. RhoGam must be administered before 72 hours postpartum.d. RhoGam is contraindicated for clients who are Rh+ (positive). The nurse must confirm that any client receiving RhoGam is Rh negative.

A 25 year-old woman gave birth to her second child 6 hours ago. She informs the nurse that she is bleeding more than with her previous birth experience. The initial nursing action is to: a. Explain that this is normal for second-time moms. b. Assess the location and firmness of the fundus. c. Change her pad and return in 1 hour and reassess. d. Give her 10 units of oxytocin as per standing order.

ANS: b a. The nurse should NOT inform the patient that this is normal until she has assessed for the degree and potential cause of bleeding.b. It is important to first assess for uterine atony or displaced uterus from full bladder.c. If the uterus is firm and midline, then the nurse should change the pad and return within 30 minutes to assess the amount of lochia.d. The nurse would give oxytocin if the uterus is boggy and does not respond to uterine massage.

A woman is receiving magnesium sulfate as part of her treatment for severe preeclampsia. The nurse is monitoring the woman's serum magnesium levels. Which level would the nurse identify as therapeutic? A) 3.3 mEq/L B) 6.1 mEq/L C) 8.4 mEq/L D) 10.8 mEq/L

Ans: B Although exact levels may vary among agencies, serum magnesium levels ranging from 4 to 7 mEq/L are considered therapeutic, whereas levels more than 8 mEq/dL are generally considered toxic.

A woman with placenta previa is being treated with expectant management. The woman and fetus are stable. The nurse is assessing the woman for possible discharge home. Which statement by the woman would suggest to the nurse that home care might be inappropriate? A) "My mother lives next door and can drive me here if necessary." B) "I have a toddler and preschooler at home who need my attention." C) "I know to call my health care provider right away if I start to bleed again." D) "I realize the importance of following the instructions for my care."

Ans: B Having a toddler and preschooler at home needing attention suggest that the woman would have difficulty maintaining bed rest at home. Therefore, expectant management at home may not be appropriate. Expectant management is appropriate if the mother and fetus are both stable, there is no active bleeding, the client has readily available access to reliable transportation, and can comprehend instructions.

The nurse is developing a plan of care for a woman who is pregnant with twins. The nurse includes interventions focusing on which of the following because of the woman's increased risk? A) Oligohydramnios B) Preeclampsia C) Post-term labor D) Chorioamnionitis

Ans: B Women with multiple gestations are at high risk for preeclampsia, preterm labor, hydramnios, hyperemesis gravidarum, anemia, and antepartal hemorrhage. There is no association between multiple gestations and the development of chorioamnionitis.

A client is diagnosed with gestational hypertension and is receiving magnesium sulfate. Which finding would the nurse interpret as indicating a therapeutic level of medication? A) Urinary output of 20 mL per hour B) Respiratory rate of 10 breaths/minute C) Deep tendons reflexes 2+ D) Difficulty in arousing

Ans: C With magnesium sulfate, deep tendon reflexes of 2+ would be considered normal and therefore a therapeutic level of the drug. Urinary output of less than 30 mL, a respiratory rate of less than 12 breaths/minute, and a diminished level of consciousness would indicate magnesium toxicity.

The nurse is reviewing the laboratory test results of a pregnant client. Which one of the following findings would alert the nurse to the development of HELLP syndrome? A) Hyperglycemia B) Elevated platelet count C) Leukocytosis D) Elevated liver enzymes

Ans: D HELLP is an acronym for hemolysis, elevated liver enzymes, and low platelets. Hyperglycemia or leukocytosis is not a part of this syndrome.

A nurse is assessing a pregnant woman with gestational hypertension. Which of the following would lead the nurse to suspect that the client has developed severe preeclampsia? A) Urine protein 300 mg/24 hours B) Blood pressure 150/96 mm Hg C) Mild facial edema D) Hyperreflexia

Ans: D Severe preeclampsia is characterized by blood pressure over 160/110 mm Hg, urine protein levels greater than 500 mg/24 hours and hyperreflexia. Mild facial edema is associated with mild preeclampsia.

A pregnant woman at 29 weeks of gestation has been diagnosed with preterm labor. Her labor is being controlled with tocolytic medications. She asks when she would be able to go home. Which response by the nurse is most accurate? a."After the baby is born." b."When we can stabilize your preterm labor and arrange home health visits." c."Whenever the doctor says that it is okay." d."It depends on what kind of insurance coverage you have."

B

The nurse is caring for a client whose labor is being augmented with oxytocin. He or she recognizes that the oxytocin should be discontinued immediately if there is evidence of: a.Uterine contractions occurring every 8 to 10 minutes. b.A fetal heart rate (FHR) of 180 with absence of variability. c.The client's needing to void. d.Rupture of the client's amniotic membranes.

B

A nurse in the postpartum unit is caring for a client who has just delivered a newborn infant following a pregnancy with a placenta previa. The nurse reviews the plan of care and prepares to monitor the client for which risk associated with placenta previa? A. Infection B. Hemorrhage C. Chronic hypertension D. Disseminated intravascular coagulation

B. In placenta previa, the placenta is implanted in the lower uterine segment. The lower uterine segment does not contain the same intertwining musculature as the fundus of the uterus, and this site is more prone to bleeding. Options A, C, and D are not risks that are related specifically to placenta previa.

After a precipitous delivery, a nurse notes that the new mother is passive and only touches her newborn infant briefly with her fingertips. The nurse should do which of the following to help the woman process what has happened? A. Encourage the mother to breast-feed soon after birth. B. Support the mother in her reaction to the newborn infant. C. Tell the mother that it is important to hold the newborn infant. D. Document a complete account of the mother's reaction on the birth record.

B. Precipitous labor is labor that lasts less than 3 hours. Women who have experienced precipitous labor often describe the feelings of disbelief that their labor progressed so rapidly. To assist the client to process what has happened the best option is to support the client in her reaction to the newborn infant. Options A, C, and D do not acknowledge the client's feelings.

The father of a stillborn infant tells the nurse he wants to hold the child. What is the nurse's best response? A. Encourage him to discuss this with his wife first. B. Dress the infant in a t-shirt and diaper and let him hold the infant. C. Tell him that it would be better not to hold the infant. D. Give him photographs of the infant that the nurse took instead.

B. Dress the infant in a t-shirt and diaper and let him hold the infant

Prepidil (prostaglandin gel) has been ordered for a pregnant woman at 43 weeks of gestation. The nurse recognizes that this medication will be administered to: a.Enhance uteroplacental perfusion in an aging placenta. b.Increase amniotic fluid volume. c.Ripen the cervix in preparation for labor induction. d.Stimulate the amniotic membranes to rupture.

C

On assessment of a client who is 30 minutes into the fourth stage of labor, the nurse finds the client's perineal pad saturated with blood and blood soaked into the bed linen under the client's buttocks. The nurse's initial action is which of the following. A. Call the physician B. Assess the client's vital signs C. Gently massage the uterine fundus D. Administer a 300ml bolus of a 20 units/L Oxytocin(Pitocin) solution

C .The most frequent cause of excessive bleeding or hemorrhage after childbirth is uterine atony. A major intervention to restore adequate tone is stimulation of the uterine muscle via gently massaging the uterine fundus. Options A, B and D may be necessary eventually but are not initial actions. The initial action is to alleviate the problem.

A discharge nurse is discussing mastitis with a postpartum client. Which of the following statements by the client would indicate a need for further instruction? A. "If I develop a hot, reddened, triangle-shaped area on my breast, I should contact my healthcare provider." B. " I may develop mastitis if I wear underwire bras, experience excessive fatigue, or suddenly decrease the number of feedings." C."If I develop a fever, chills, or body aches at any time after discharge I should stop breast feeding immediately." D. "Antibiotics, rest, warm compresses, and adequate fluid intake are all important for the treatment of mastitis."

C .The mother should NOT discontinue breast-feeding

Methylergonovine (Methergine) is prescribed for a woman who has just delivered a healthy newborn infant. The priority assessment before administering the medication is to check the clients: A. Lochia B. Uterine tone C. Blood pressure D. Deep tendon reflexes

C. A priority assessment before the administration of Methergine is blood pressure. Methergine is contraindicated in hypertension and must be administered cautiously in the presence of elevated blood pressure. The physician should be notified if hypertension is present. Options A and B are general components of postpartum assessment and nonspecific to the prescribed medication in this case. Option D is related to the administration of magnesium sulfate.

A nurse is monitoring a client in the immediate postpartum period for signs of hemorrhage. Which of the following signs, if noted, would be an early sign of excessive blood loss? A. A temperature of 100.4 F B. A blood pressure change from 130/88 to 124/80mmHg C. An increase in the pulse rate from 88 to 102 D. An increase in the RR from 18 to 22 breaths/min

C. During the fourth stage of labor vitals should be checked every 15 min during the first hour. An increasing in pulse is an early sign of excessive blood loss because the heart pumps faster to compensate for reduced blood volume. The blood pressure decreases as the blood volume diminishes but a decreased blood pressure would not be the earliest sign of hemorrhage. A slight increase in temperature is normal immediately postpartum. The RR is slightly increased from normal but not significant in this case.

A macrosomic infant is born after a difficult forceps-assisted delivery. After stabilization the infant is weighed, and the birth weight is 4550 g (9 pounds, 6 ounces). The nurse's most appropriate action is to: a. Leave the infant in the room with the mother. b. Take the infant immediately to the nursery. c. Perform a gestational age assessment to determine whether the infant is large for gestational age. d. Monitor blood glucose levels frequently and observe closely for signs of hypoglycemia.

D (This infant is macrosomic (more than 4000 g) and is at high risk for hypoglycemia. Blood glucose levels should be monitored frequently, and the infant should be observed closely for signs of hypoglycemia. Observation may occur in the nursery or in the mother's room, depending on the condition of the fetus. Regardless of gestational age, this infant is macrosomic.)

a client is in labor and delivery with a diagnosis of HELLP syndrome. the nurse notes the following blood values:Prothrombin time (PT)- 99sec (normal 60-85sec)Partial thromboplastin time (PTT) 30 sec (11-15 sec)for which of the following signs/symptoms would the nurse monitor for the client? a. pink-tinged urine b. early decelerations c. patellar reflexes +1 d. blood pressure 140/90

a this client has likely developed disseminated intravascular coagulation (DIC). the nurse should watch for pink-tinged urine

A pregnant woman who is Rh negative is to receive RhoGAM prophylactically at 28 weeks' gestation. Before receiving the medication, she asks the nurse how the drug works. Which of the following best describes how RhoGAM acts in the expectant mother's body? a) RhoGAM attaches to maternal and paternal Rh antibodies and directly destroys them. b) RhoGAM suppresses the production of maternal antibodies. c) RhoGAM destroys fetal Rh positive red blood cells in the maternal circulation before sensitization can occur d) RhoGAM prevents fetal-maternal bleeding episodes from occurring at the former placenta site.

b) RhoGAM suppresses the production of maternal antibodies.

which of the following lab values should the nurse report to the physician a being consistent with the diagnosis HELLP syndrome? a. hematocrit 48% b. 5.5 mEq/L c. platelets 75,000 d. sodium 130 mEq/L

c low platelets are consistent with the diagnosis of HELLP syndromenormal platelets- 150,000-450,000

a 26 week gestation woman is diagnosed with severe pre-eclampsia with HELLP syndrome. the nurse will assess for which of the following signs/symptoms? a. low serum creatinine b. high serum protein c. bloody stools d. epigastric pain

d epigastric pain is associated with the liver involvement of HELLP syndrome