NUR 242 Exam #2 Review

"The discharge consists of mucus, tissue debris, and blood; this gives it the deep red color."

A nurse examining a client who underwent a vaginal birth 24 hours ago. The client asks the nurse why her discharge is such a deep red color. What explanation is most accurate for the nurse to give?

Every 15 minutes

A nurse has been assigned to the care of a client who has just given birth. How frequently should the nurse perform the assessments during the first hour of birth?

Ensure ice pack is changed frequently

A nurse is applying ice packs to the perineal area of a client who has had a vaginal birth. Which intervention should the nurse perform to ensure that the client gets the optimal benefits if the procedure?

Active bowel sounds; Passing gas; Nondistended abdomen

A nurse is assessing a client during the postpartum period. Which findings indicate normal postpartum adjustment?

Taking-in

While caring for a client following a lengthy labor and birth, the nurse notes that the client repeatedly reviews her labor and birth and is very dependent on her family for care. The nurse is correct in identifying the client to be in which phase of the maternal role adjustment?

Afterpains are more acute in multiparous women secondary to repeated stretching of the uterine muscles, which reduces muscle tone, allowing for altering uterine contraction and relaxation.

Why are after pains more acute in multiparous women?

pelvis

Within 10 days of birth, the fundus of the uterus usually cannot be palpated because it has descended into the true ___

Turn the client on her left side; Administer oxygen by mask; Assess client for underlying causes

A nurse caring for a pregnant client in labor observes that fetal heart rate is below 110. Which interventions should the nurse perform?

Uterine resting tone; Frequency of contractions; Intensity of contractions

The nurse is monitoring a client's uterine contractions. Which factors should the nurse assess to monitor uterine contraction?

Every hour

The nurse is monitoring a pregnant client admitted to a health care center who is in the latent phase of labor. The nurse demonstrates appropriate nursing care by monitoring the fetal heart rate with a Doppler at lease how often?

uterine

The primary power of labor is/are ___ contractions, which are involuntary.

Atony

This state of the uterus allows for excessive

Fourth-degree laceration

Though the anterior rectal wall

Taking-in phase Taking-hold phase -Letting-go phase

Three stages a woman goes through immediately after she gives birth to a child.

Third-degree laceration

Through the anal sphincter muscle

First-degree laceration

Through the skin

Postpartum blues

Transient emotional disturbances

Frank, Complete, Single Footling, Double Footling

Types of breech positions

Vital signs, pain level, and a systematic head-to-toe review of the body system: breasts, uterus, bladder, bowels, lochia, episiotomy/perineum, extremities, and emotional status

What does a postpartum maternal assessment usually include?

The Apgar score assesses five parameters- heart rate (absent, slow, or fast), respiratory effort (absent, weak cry, or good strong yell), muscle tone (limp or lively and active), response to irritation stimulus, and color- that evaluate a newborn's cardiorespiratory adaptation after birth.

What does the Apgar score assess?

-Eating a wide variety of food with high nutrient density -Using foods and recipes that required little or no preparation -Avoiding high-fat, fast foods, and fad weight reduction diets -Avoiding harmful substances like alcohol, tobacco, and drugs -Avoiding excessive intake of fat, salt, sugar, and caffeine -Eating the recommended daily servings from each food group

What nutritional recommendations can the nurse give to the new mother post partum?

A moderate amount of lochia rubra

When assessing the uterus of a 2-day postpartum client, which finding would the nurse evaluate as normal?

mastitis

When palpating the breasts, any evidence of any nodules, masses, or areas of warmth, may indicate a plugged duct that may progress to ___ if not treated promptly.

The 2-day postpartum client who has a blood pressure of 138/90

Which client should the postpartum nurse assess first after receiving shift report?

cesarean

Women who experience ___ births will have less lochia discharge than those having a vaginal birth.

Afterpains

___ are the painful uterine contractions some women experience during the early postpartum period.

Orthostatic hypotension

___ can occur when the woman changes position rapidly from a lying or sitting position to a standing one.

Nonpharmacologic

___ comfort measures are usually simple, safe, effective, and inexpensive to use.

Oxytocin

___ elicits the milk letdown reflex so that milk can be ejected from the alveoli to the nipple.

Pain

___ is considered the fifth vital sign.

Lactation

___ is defined as the secretion of milk by the breasts.

Reciprocity

___ is the process by which the infant's capabilities and behavioral characteristics elicit parental response.

Commitment

___ refers to the enduring nature of the attachment relationship.

Determine if the client is in true or false labor

A 39-weeks gestation client presents to the labor and birth unit reporting abdominal pain. What should the nurse do first?

"Be sure to change your pajamas to prevent you from chilling."

A client who gave birth 5 days ago reports profuse sweating during the night. What should the nurse recommend to the client in this regard?

He begins by holding the baby frequently

A concerned client tells the nurse that her husband, who was very excited about the baby before birth, is apparently happy but seems to be afraid of caring for the baby. What suggestion should the nurse give to the client's husband to resolve the issue?

Estimated due date; Characteristics of contractions ; Appearance of vaginal blood

A nurse is assigned to conduct an admission assessment on the phone for a pregnant client. Which information should the nurse obtain from the client?

Continue to massage the client's fundus

A nurse is caring for a client administered general anesthesia for an emergency C-section birth. The nurse notes the client's uterus is relaxed upon massage. What would the nurse do next?

Restoration of blood flow to uterus and placenta

A pregnant client is admitted to a maternity clinic after experiencing contractions. The assigned nurse observes that the client experiences pauses between contractions. The nurse knows that which event marks the importance of the pauses between contractions during labor?

It helps to rotate the fetus in a posterior position

A pregnant client is admitted to a maternity clinic for birth. The client wishes to adopt the kneeling position during labor. The nurse knows that which to be an advantage of adopting a kneeling position during labor?

Long axis of fetus is perpendicular to that of the client

A pregnant client is admitted to a maternity clinic for birth. Which assessment finding indicates that the client's fetus is in the transverse lie position?

Spinal abnormality; Hypovolemia; Coagulation defects

A pregnant client requires administration of an epidural block for management of pain during labor. For which conditions should the nurse check the client before administering the epidural block?

The cervix takes around 12 to 16 hours to dilate during first pregnancy

A pregnant client wants to know why the labor of a first time pregnant woman usually lasts longer than that of a woman who has already delivered once and is pregnant a second time. What explanation should the nurse offer?

General anesthesia

A pregnant client with a history of spinal injury is being prepared for a C-section. Which method of anesthesia is to be administered to the client?

nesting

A sudden increase in energy on the part of the expectant woman 24 to 48 hours before the onset of labor is sometimes referred to as ___.

External Rotation

Allows the shoulders to rotate internally to fit the maternal pelvis.

sensitization

An increase in prostaglandins leads to myometrial ___ and to a reduction in cervical resistance.

colostrum

Any discharge from the nipple should be described and documented if it is not ___, also called foremilk.

Bonding

Development of a close emotional attachment to a newborn by the parents during the first 30 to 60 minutes after birth

Process of attachment

Development of strong affectional ties between an infant and a significant other (e.g. mother, father, sibling, caretaker)

Descent

Downward movement of the fetal head until it is within the pelvic inlet. A maneuver that occurs thought the laboring process.

Assess amount of cervical dilation

During admission assessment of a cline in labor, the nurse observes that there is no vaginal bleeding yet. What nursing intervention is appropriate in the absence of vaginal bleeding when the client is in the early stage of labor?

Boggy or relaxed uterus

During assessment of the mother during the postpartum period, what sign should alert the nurse that the client is likely experiencing uterine atony?

uterus

During pregnancy, stretching of the abdominal wall muscles occurs to accommodate the enlarging ___.

hypertension

Elevations in blood pressure from the woman's baseline might suggest pregnancy induced ___.

Pueperium

Encompasses the time after delivery as the woman's body begins to return to the prepregnant state.

-Complete expulsion of amniotic membranes and placenta at birth -Complication-free labor and birth process -Breastfeeding -Ambulation

Factors that facilitate uterine involution

-Prolonged labor and difficult birth -Incomplete expulsion of amniotic membranes and placenta -Uterine infection -Overdistension of uterine muscles

Factors that inhibit involution

accelerations

Fetal ___ are transitory increases in the FHR above the baseline that are associated with sympathetic nervous stimulation.

nonlactating

For ___ women, menstruation usually resumes 7 to 9 weeks after giving birth.

gynecoid, android, anthropoid, platypelloid

Four types of pelvis

Lochia rubra Lochia serosa Lochia alba

Lochia refers to the discharge that occurs after birth. The sequence in which they appear after birth is ___.

Flexion

Occurs as the vertex meets resistance from the cervix, walls of the pelvis, or the pelvic floor.

Engagement

Occurs when the greatest transverse diameter of the head in vertex passes through the pelvic inlet.

decidua

Oxytocin aids in stimulating prostaglandin synthesis through receptors in the ___.

Latent phase, Active phase, Transition phase, Pelvic phase, Placental separation, Placental expulsion

Phases of labor

Proximity

Physical and psychological experience of the parents being close to their infant

-Lithotomy with feet up in stirrups; most convenient position for caregivers -Semisitting with pillows underneath the knees, arms, and back -Lateral/side-lying with curved back and upper leg supported by partner -Sitting on birthing stool: opens pelvis, enhances the pull of gravity, and helps with pushing -Squatting/supported squatting: Gives the woman a sense of control -Kneeling with hands on bed and knees comfortably apart

Positions used for the second stage of labor

Contact

Sensory experiences such as touching, holding, and gazing at the newborn

peribottle

The ___ is a plastic squeeze bottle filled with warm tap water that is sprayed over the perineal area after each voiding and before applying a new perineal pad.

sagittal suture

The ___ is located between the parietal bones and divides the skull into the right and left halves.

tocotransducer

The ___ is placed over the uterine fundus in the area of greatest contractility to electronically monitor uterine contractions.

ischial

The ___ spines serve as landmarks for estimating the descent of the fetal presenting part and have been designated as zero station.

Ice cream; Raw carrots and celery; Orange slices

The nurse is caring for a client of Asian decent 1 day after she has given birth. Which foods is the client most likely going to refuse when her meal tray is delivered?

Incomplete emptying of the bladder; Bladder distention; Urinary retention

The nurse is caring for a client who had been administered an anesthetic block during labor. For which risks should the nurse what in the client?

Lightening

occurs when the fetal presenting part begins to descend into the maternal pelvis

effacement

The thinning out process of the cervix during labor is termed ___.

fundus

The top portion of the uterus, also known as the ___, is routinely assessed to determine uterine involution.

Lochia

The vaginal discharge that occurs after the birth of the placenta.

-Increase in apprehension or irritability -Spontaneous rupture of membranes -Sudden appearance of sweat on upper lip -Increase in blood tinged show -Low grunting sounds from the woman -Complaints of rectal and perineal pressure -Beginning of bearing down efforts

Typical signs of the second stage of labor

Massage the client's fundus

Upon assessment, a nurse notes the client has a pulse of 90 BPM, moderate lochia, and a boggy uterus. What should the nurse do next?

Help the mother initiate breastfeeding within 30 minutes of birth; Encourage on demand breast feeding; Place the baby in uninterrupted skin to skin contact with the mother

When teaching the new mother about breastfeeding, the nurse is correct when providing what instructions?

parasympathetic

Baseline variability represents the interplay between the ___ and sympathetic nervous systems.

subinvolution

If retrogressive changes do not occur as a result of retained placental fragments or infection ___ results.

fern

If the nitrazine test is inconclusive, an additional test, called the ___ test, can be used to confirm rupture of membranes.

hypoglycemia

If the woman is a diabetic, it is critical to alert the newborn nursery of potential ___ in the newborn.

engorgement

Increased prolactin levels and abundant milk supply, combined with inadequate emptying of the breast, may cause breast ___.

The nurse should suggest the following relief measures for the client with nonbreastfeeding engorgement. -Wear a tight, supportive bra 24 hours daily -Apply ice to the breasts for approximately 15 to 20 minutes every other hour -Do not stimulate the breasts by squeezing or manually expressing milk from the nipples -Avoid exposing breasts to warmth

Interventions for non-breastfeeding women

Involution

Involves three retrogressive processes, which include contraction of muscle fibers, catabolism, and regeneration of uterine epithelium.

Notify the health care provider

A 29 week gestation client is admitted with moderate vaginal discharge. The nurse performs a nitrazine test to determine if the membranes have ruptured. The nitrazine tape remains yellow to olive green, with pH between 5 and 6. What should the nurse do next?

Empty the breasts frequently

A breastfeeding client informs the nurse that she is unable to maintain her milk supply. What instruction should the nurse give to the client to improve milk supply?

These contractions help in softening and ripening the cervix

A client experiencing contractions presents at a health care facility. Assessment conducted by the nurse reveals that the client has been experiencing Braxton Hicks contractions. The nurse has to educate the client on the usefulness of Braxton Hicks contractions. Which role do Braxton Hicks contractions pay in aiding labor?

"You should be seen by your health care provider if you have blurred vision."

A client has been discharged after a cesarean birth. Which should the nurse include in the discharge teaching?

Continue to monitor the client

A client in her third trimester of pregnancy arrives at a health care facility with a report of cramping and low back pain; she also notes that she is urinating more frequently and that her breathing has become easier the past few days. Physical examination conducted by the nurse indicates that the client has edema of the lower extremities, along with an increase in vaginal discharge. What should the nurse do next?

Increased sedation

A client in labor is administered lorazepam to help her relax enough so that she can participate effectively during her labor process rather than fighting against it. For which adverse effect of the drug should the nurse monitor?

To constrict the uterine blood vessels

A client in the third stage of labor has experienced placental separation and expulsion. Whys is it necessary for a nurse to massage the woman's uterus briefly until it is firm?

Determine the baby's blood type and rhesus

A client is Rh negative and has given birth to her newborn. What should the nurse do next?

Maintain correct posture and positioning

A client reports pain in the lower back, hips, and joints 10 days after the birth of her baby. What instruction should the nurse give the client after birth the prevent low back pain and injury to the joints.

"Your body usually retains extra fluids during pregnancy, so this is one way it rids itself of the excess fluid."

A client who delivered a baby 36 hours ago informs the nurse that she has been passing unusually large volumes of urine very often. How should the nurse explain this to the client?

Urinary catherization

A client who gave birth about 12 hours ago informs the nurse that she has been voiding small amounts of urine frequently. The nurse examines the client and notes the displacement of the uterus from the midline to the right. What intervention would the nurse perform next?

"Within 1 to 3 weeks, your diaphragm should return to normal and your breathing will feel like it did before pregnancy."

A client who had a vaginal delivery 2 days ago asks the nurse when she will be able to breathe normally again. Which response by the nurse is most accurate?

Offer suggestions based on observation to correct positioning or latching

A client who has a breastfeeding newborn reports sore nipples. Which intervention can the nurse suggest to alleviate the client's condition?

Use of warm sitz bath; Use of anesthetic sprays; Use of witch hazel pads

A client who has given birth a week ago reports discomfort when defecating and ambulating. The birth involved an episiotomy. Which suggestions should the nurse provide to the client to provide local comfort?

Resume intercourse if bright red bleeding stops

A client who has given birth is being discharged from the health care facility. She wants to know how safe it would be for her to have intercourse. Which instructions should the nurse provide to the client regarding intercourse after birth?

Reassure the mother that some newborns "latch on and catch on" right away, and some newborns take more time and patience.

A first-time mother is nervous about breastfeeding. Which intervention would the nurse perform to reduce maternal anxiety about breastfeeding?

Provide the client clear information on all the procedures involved; Encourage the client to have a sense of mastery and self-control; Encourage the client to have a positive reaction to pregnancy

A nurse is assigned the task of educating a pregnant client about birth. Which nursing interventions should the nurse perform as part of prenatal education for the client to ensure a positive birth experience?

Decrease in circulation and perfusion to the fetus

A nurse is caring for a client in labor who is delivering. For which fetal response should the nurse monitor?

Kegel exercises

A nurse is caring for a client who has had a vaginal birth. The nurse understands that pelvic relaxation can occur in any woman experiencing a vaginal birth. Which should the nurse recommend to the client to improve pelvic floor tone?

Fourth-degree

A nurse is caring for a client who has just received an episiotomy. The nurse observes that the laceration extends through the perineal area and continues though the anterior rectal wall. How does the nurse classify the laceration?

Lower uterine segment distention; Stretching and tearing of structures; Dilation of the cervix

A nurse is caring for a client who is in the first stage of labor. The client is experiencing extreme pain due to the labor. The nurse understands which to be causes of the extreme pain in the client?

Hand holding; Massaging; Acupressure

A nurse is caring for a pregnant client during labor. Which methods should the nurse use to provide comfort to the pregnant client?

Dilation of the cervix diameter to 10 cm

A nurse is caring for a pregnant client in labor in a health care facility. The nurse knows that which sign marks the termination of the first stage of labor in the client?

Increase in heart rate; increase in blood pressure; increase in respiratory rate

A nurse is caring for a pregnant client who is in labor. Which maternal physiologic responses should the nurse monitor for in the client, as the client progresses through birth?

Every 30 minutes

A nurse is caring for a pregnant client who is in the active phase of labor. At what interval should the nurse assess the client's vital signs?

Tell the client to take an NSAID orally

A nurse is caring for the client who gave birth a week ago. The client informs the nurse that she experiences painful uterine contractions when breastfeeding the baby. What should the nurse do next?

Lower quadrant of maternal abdomen

A nurse is required to obtain the fetal heart rate for a pregnant client. If the presentation is cephalic, which maternal site should the nurse monitor to hear the FHR clearly?

Inhale slowly through nose and exhale through pursed lips

A nurse is teaching a couple about patterned breathing during their birth education. Which technique should the nurse suggest for slow-paced breathing?

Breasts are hard; Breasts are tender

A nurse is to care for a client during the postpartum period. The client reports pain and discomfort in her breasts. What signs should a nurse look for to find out if the client has engorged breasts?

Educate the client on how to perform Kegel exercises

A postpartum client is having difficulty stopping her urine stream. Which should the nurse do next?

Initiate the technique only when the client is in active labor

A pregnant client has opted for hydrotherapy for pain management during labor. Which should the nurse consider when assisting the client during the birthing process?

Respiratory rate

A pregnant client has opted for hydrotherapy for pain management during labor. Which should the nurse consider when assisting the client during the birthing process?

Fetal anomalies

A pregnant client in labor has to undergo a sonogram to confirm the fetal position of a shoulder presentation. For which condition associated with shoulder presentation during a vaginal birth should the nurse assess?

-Ascertain whether the woman is in true of false labor -Check the fundus to ensure that it is firm ( size and consistency of a grapefruit), located in the midline and below the umbilicus -Position the woman and cleanse the vulva and perineal areas -Check for crowning, low grunting sounds from the woman, and increase in blood-tinged show -Check for lengthening of the umbilical cord protruding from the vagina

Nursing Interventions during the various stages of labor and birth, in order

-Fever more than 100.4 after the first 24 hours following birth -Foul-smelling lochia or an unexpected change in color or amount -Visual changes, such as blurred vision or spots, or headaches -Calf pain experienced with dorsiflexion of the foot -Swelling, redness, or discharge at the episiotomy site -Dysuria, burning, or incomplete emptying of the bladder -Shortness of breath or difficulty breathing -Depression or extreme mood swings

Postpartum Danger Signs

Reduction in cervical resistance; Myometrial contractions; Softening and thinning of the cervix

The assessment of a pregnant client, who is toward the end of her third trimester, reveals that she has increased prostaglandin levels. For which factors should the nurse assess the client?

passageway

The birth ___ is the route through which the fetus must travel to be birthed vaginally.

molding

The elongated shape of the fetal skull at birth as a result of overlapping of the cranial bones is known as ___.

Engrossment

The father's developing a bond with his newborn, which is a time of intense absorption, preoccupation, and interest.

Extension

The head emerges through extension under the symphysis pubis, along the shoulders.

Administration of oxygen by mask

The nurse caring for a client in preterm labor observes abnormal fetal heart rate patterns. Which nursing intervention should the nurse perform next?

Determining the presentation of the fetus; Determining the position of the fetus; Determining the lie of the fetus

The nurse explains Leopold's maneuvers to a pregnant client. For which purposes are these maneuvers performed?

External electronic fetal monitoring

The nurse is assessing the laboring client to determine fetal oxygenation status. What indirect assessment method will the nurse likely use?

Document the lochia as scant

The nurse observes a 2 inch lochia stain on the perineal pad of a 1 day postpartum client. Which of the following should the nurse do next?

uteroplacental

The nurse reviews the prenatal record to identify risk factors that may contribute to a decrease in ___ circulation during pregnancy and/or labor.

diaphoresis

The profuse ___ that is common during the early postpartum period is one of the most noticeable adaptations in the integumentary system and is a way of eliminating excess body fluids retained during pregnancy.

Second-degree laceration

Through the muscles of the perineal body

gynecoid

Vaginal birth is most favorable with a ___ type of pelvis because the inlet is round and the outlet is roomy.

Advantage: Electronic fetal monitoring produces a continuous record of the FHR, unlike the intermittent auscultation, when gaps are likely. Disadvantage: Continuous monitoring can limit the maternal movement and encourages her to like in the supine position, which reduces placental perfusion.

What are the advantages and disadvantages to continuous fetal monitoring?

The nurse should include biographical data such as the woman's name and age, and the name of the delivering health care provider, prenatal record, past health and family history, prenatal education, medications, risk factors, reason for admission, history of previous preterm births, allergies, the last time the client ate, method for infant feeding, name of birth attendant and pediatrician, and pain management plan.

What information should a nurse include when taking the maternal health history?

Artifact

___ describes the irregular variations or absence of fetal heart rate due to erroneous causes on the fetal monitor record.

0

___ station is designated when the presenting part is at the level of the maternal ischial spines.

Prolactin

___, which is secreted from the anterior pituitary gland in increasing levels throughout pregnancy, triggers synthesis and secretion of milk after giving birth.