OB
The nurse in a prenatal clinic notes bruising on a pregnat woman's abdomen and chest. Which response by the nurse is most appropriate? 1. "Has your partner or anyone close to you threatened or physically hurt you?" 2. "It appears that you may be a victim of domestic abuse. Can you tell me who has been hurting you?"" 3. "During your next prenatal visit we can discuss your relationship with your significant other." 4. "Did you recently take a fall?"
1. "Has your partner or anyone close to you threatened or physically hurt you?" The American College of Obstetrics and Gynecology recommends that all pregnant women be screened for Intimate Partner Abuse with direct questions about physical abuse. Questioning the woman about falling is not appropriate and may provide her with a reason to obfuscate. The bruising should be discussed during the current visit and should not be delayed. The nurse should not make assumptions about the cause of the injuries by directly confronting the woman with a presumption.
A nurse in Labor & Delivery is caring for a woman in active labor who had an epidural placed 30 minutes ago. The fetal heart rate is bradycarding due to prolonged decelaration. The nurse should: 1. Change the woman's position to left lateral. 2. Increase IV rate to 125ml/hr. 3. Obtain informed consent for emergent cesarean birth. 4. Apply oxygen by nasal cannula at 4 LPM.
1. Change the woman's position to left lateral. The fetal heart rate is bradycardic due to a prolonged deceleration. The goal is to increase blood flow to the fetus to improve fetal oxygentation. By turning the woman to her left side, cardiac output is increased.
The nurse who performs vaginal examinations to assess a woman's progress in labor should: 1. Discuss the findings with the woman and her partner. 2. Perform the examination with the woman in the supine position. 3. Wear two clean gloves for each examination. 4. Perform an examination hourly during the active phase of labor.
1. Discuss the findings with the woman and her partner. The nurse should discuss the findings of the vaginal examination with the woman and her partner and report them to the primary care provider. A vaginal examination should be performed only when indicated by the status of the woman and her fetus. The woman should be positioned to avoid supine hypotension. The examiner should wear a sterile glove while performing a vaginal examination for a laboring woman.
The nurse provides home care instructions to the mother of a newborn requiring phototherapy. Which instructions does the nurse provide? Select all that apply. 1. Dress the infant in a diaper to expose as much skin as possible to the lights. 2. Close the infant's eyes and place patches over the eyes before positioning the infant under the lights. 3. Count and record the infant's wet diapers and stools. 4. Ensure the infant receives phototherapy 24 hours per day. 5. Feed the infant every 2 to 3 hours. 6. Check the infant's axillary temperature before every feeding.
1. Dress the infant in a diaper to expose as much skin as possible to the lights. 2. Close the infant's eyes and place patches over the eyes before positioning the infant under the lights. 3. Count and record the infant's wet diapers and stools. 5. Feed the infant every 2 to 3 hours. 6. Check the infant's axillary temperature before every feeding.
While completing a newborn assessment, the nurse should be aware that the most common birth fracture is: 1. Fracture of the clavicle. 2. Cephalohematomatous fracture 3. Skull fracture following forcep delivery. 4. Femur fracture.
1. Fracture of the clavicle. The most common birth injury is fracture of the clavicle (collarbone). It usually heals without treatment, although the arm and shoulder may be immobilized for comfort. Skull fracture and fracture of the femur are rare birth injuries. Cephalohematoma is an area of bleeding between the bone and its fibrous covering. It often appears several hours after birth as a raised lump on the baby's head. The body resorbs the blood. Depending on the size, most cephalohematomas take two weeks to three months to disappear completely. If the area of bleeding is large, some babies may develop jaundice as the red blood cells break down. It is not a fracture.
If a woman is at risk for thrombus and is not ready to ambulate, the nurse might intervene by doing all of these interventions except: 1. Having her sit in a chair. 2. Putting her in antiembolic stockings (TED hose) and/or sequential compression device (SCD) boots. 3. Having her flex, extend, and rotate her feet, ankles, and legs. 4. Maintaining hydration.
1. Having her sit in a chair. Sitting immobile in a chair will not help. Bed exercise and prophylactic footwear might.TED hose and SCD boots are recommended. Bed exercises, such as flexing, extending, and rotating her feet, ankles, and legs, are useful. It is important to ensure good hydration to prevent DVT.
With regard to injuries to the infant's plexus during labor and birth, nurses should be aware that: 1. If the nerves are stretched with no avulsion, they should recover completely in 3 to 6 months. 2. Breastfeeding is not recommended for infants with facial nerve paralysis until the condition resolves. 3. Parents of children with brachial palsy are taught to pick up the child from under the axillae. 4. Erb's palsy is damage to the lower plexus.
1. If the nerves are stretched with no avulsion, they should recover completely in 3 to 6 months. If the nerves are stretched with no avulsion, they should recover completely in 3 to 6 months. However, if the ganglia are disconnected completely from the spinal cord, the damage is permanent. Erb palsy is damage to the upper plexus and is less serious than brachial palsy. Parents of children with brachial palsy are taught to avoid picking up the child under the axillae or by pulling on the arms. Breastfeeding is not contraindicated, but both the mother and infant will need help from the nurse at the start.
The nurse recognizes that uterine hyperstimulation with oxytocin requires emergency interventions. What clinical cues would alert the nurse that the woman is experiencing uterine hyperstimulation? Choose all that apply. 1. Increased uterine activity accompanied by a nonreassuring fetal heart rate (FHR) and pattern 2. Uterine tone >20 mm Hg 3. Uterine contractions lasting >90 seconds and occurring <2 minutes in frequency 4. Uterine contractions lasting <90 seconds and occurring >2 minutes in frequency 5. Uterine tone <20 mm Hg
1. Increased uterine activity accompanied by a nonreassuring fetal heart rate (FHR) and pattern 2. Uterine tone >20 mm Hg 3. Uterine contractions lasting >90 seconds and occurring <2 minutes in frequency Uterine contractions that occur less than 2 minutes apart and last more than 90 seconds, a uterine tone of over 20 mm Hg, and a nonreassuring FHR and pattern are all indications of uterine hyperstimulation with oxytocin administration. Uterine contractions that occur more than 2 minutes apart and last less than 90 seconds are the expected goal of oxytocin induction. A uterine tone of less than 20 mm Hg is normal.
What position would be least effective when gravity is desired to assist in fetal descent? 1. Lithotomy 2. Kneeling 3. Walking 4. Squatting
1. Lithotomy The predominant position in the United States for physician-attended births is the lithotomy position, which requires a woman to be in a reclined position with her legs in stirrups. Gravity has little effect in this non-physiologic position. Kneeling, sitting, and walking help align the fetus with the pelvic outlet and allow gravity to assist in fetal descent.
While taking a diet history, the nurse might be told that the expectant mother has cravings for ice chips, cornstarch, and baking soda. This represents a nutritional problem known as: 1. Pica 2. Anorexia abnormalis 3. Pyrosis 4. Preeclampsia
1. Pica
A woman at 39 weeks of gestation with a history of preeclampsia is admitted to the labor and birth unit. She suddenly experiences increased contraction frequency of every 1 to 2 minutes; dark red vaginal bleeding; and a tense, painful abdomen. The nurse suspects the onset of: 1. Placental abruption 2. Placenta previa 3. Uterine rupture 4. Eclamptic seizure
1. Placental abruption Uterine tenderness in the presence of increasing tone may be the earliest finding of premature separation of the placenta (abruptio placentae or placental abruption). Women with hypertension are at increased risk for an abruption. Eclamptic seizures are evidenced by the presence of generalized tonic-clonic convulsions. Uterine rupture presents as hypotonic uterine activity, signs of hypovolemia and in many cases the absence of pain. Placenta previa presents with bright red, painless vaginal bleeding.
A pregnant woman's amniotic membranes rupture. Prolapsed cord is suspected. What intervention would be the top priority? 1. Placing the woman in the knee-chest position 2. Administering oxygen by face mask 3. Preparing the woman for a cesarean birth 4. Covering the cord in sterile gauze soaked in saline
1. Placing the woman in the knee-chest position The woman is assisted into a position (e.g., modified Sims position, Trendelenburg position, or the knee-chest position) in which gravity keeps the pressure of the presenting part off the cord. Though covering the cord in sterile gauze soaked saline, preparing the woman for a cesarean, and starting oxygen by face mark are appropriate nursing interventions in the event of a prolapsed cord, the intervention of top priority would be positioning the mother to relieve cord compression.
A nurse develops a plan of care for a pregnant woman at 28 weeks gestation who is receiving heparin sodium for a newly-diagnosed DVT. The nurse includes which interventions in the care plan? Select all that apply. 1. Provide client with a soft toothbrush. 2. Request physician prescription for coumadin and request that hepain be discontinued. 3.Apply pressure to venipuncture and other injection sites. 4. Administer acetylsalicylic acid (aspirin) for headache per prescription. 5. Have the antidote (protamine sulfate) available. 6. Monitor the client ofr bruising and bleeding.
1. Provide client with a soft toothbrush. 3.Apply pressure to venipuncture and other injection sites. 5. Have the antidote (protamine sulfate) available. 6. Monitor the client for bruising and bleeding. Heparin sodium is an anticoagulant, and measures are implemented to monitor for and prevent bleeding: monitor for bruising and bleeding, avoiding puncture sites and applying pressure to venipuncture and other injection sites, avoid the use of firm toothbrushes. The antidote for heparin sodium (protamine sulfate) should be available in the event of bleeding. Coumadin is contraindicated during pregnancy.
When assessing a pregnant woman at 28 weeks gestation who is diagnosed with Class II heart disease, it is important that the nurse be alert for signs indicating cardiac decompensation. A sign of cardiac decompensation is: 1. Rapid, irregular, weak pulse. 2. Supine hypotension. 3. Wheezing with inspiration and expiration. 4. Dry, hacking cough.
1. Rapid, irregular, weak pulse. Rapid, irregular, and weak pulse is a common finding in cardiac decompensation. Other signs include a moist, productive, frequent cough and crackles upon auscultation at lung bases. Hypotension is not related to cardiac decompensation.
Postbirth uterine/vaginal discharge, called lochia: 1. Should smell like normal menstrual flow unless an infection is present. 2. Is usually greater after cesarean births. 3. Will usually decrease with ambulation and breastfeeding. 4. Is similar to a light menstrual period for the first 6 to 12 hours.
1. Should smell like normal menstrual flow unless an infection is present. An offensive odor usually indicates an infection. Lochia flow should approximate a heavy menstrual period for the first 2 hours and then steadily decrease. Less lochia usually is seen after cesarean births and usually increases with ambulation and breastfeeding.
The nurse has received a report about a woman in labor. The woman's last vaginal examination was recorded as 3 cm, 30%, and -2. The nurse's interpretation of this assessment is that: 1. The cervix is 3 cm dilated, it is effaced 30%, and the presenting part is 2 cm above the ischial spines. 2. The cervix is dilated 3 cm, it is effaced 30%, and the presenting part is 2 cm below the ischial spines. 3. The cervix is effaced 3 cm, it is dilated 30%, and the presenting part is 2 cm above the ischial spines 4. The cervix is effaced 3 cm, it is dilated 30%, and the presenting part is 2 cm below the ischial spines.
1. The cervix is 3 cm dilated, it is effaced 30%, and the presenting part is 2 cm above the ischial spines. The correct description of the vaginal examination for this woman in labor is the cervix is 3 cm dilated, it is effaced 30%, and the presenting part is 2 cm above the ischial spines. The sterile vaginal examination is recorded as centimeters of cervical dilation, percentage of cervical dilation, and the relationship of the presenting part to the ischial spines (either above or below).
A 25-year-old gravida 2, para 2-0-0-2 gave birth 4 hours ago to a 9-pound, 7-ounce boy after augmentation of labor with Pitocin. She puts on her call light and asks for her nurse right away, stating, "I'm bleeding a lot." The most likely cause of postpartum hemorrhage in this woman is: 1. Uterine atony 2. Unrepaired vaginal lacerations 3. Puerperal infection 4. Retained placental fragments
1. Uterine atony This woman gave birth to a macrosomic boy after Pitocin augmentation. The most likely cause of bleeding 4 hours after delivery, combined with these risk factors, is uterine atony. Although retained placental fragments may cause postpartum hemorrhage, this typically would be detected in the first hour after delivery of the placenta and is not the most likely cause of hemorrhage in this woman. Although unrepaired vaginal lacerations may cause bleeding, they typically would occur in the period immediately after birth. Puerperal infection can cause subinvolution and subsequent bleeding; however, this typically would be detected 24 hours after delivery.
Most women with uncomplicated pregnancies can use the nurse as their primary source for nutritional information. The nurse or midwife should refer a client to a registered dietitian for in-depth nutritional counseling when the following exist(s)? Choose all that apply. 1. Vegetarian diets 2. Obesity 3. Ethnic or cultural food patterns 4. A distaste for Vegetables 5. Preexisting or gestational diabetes
1. Vegetarian diets 2. Obesity 3. Ethnic or cultural food patterns 5. Preexisting or gestational diabetes 1. The vegetarian client needs to have her dietary intake carefully assessed to ensure that the optimum combination of amino acids and protein intake is achieved. Very strict vegetarians (vegans) who consume only plant products may also require vitamin B and mineral supplementation. 2. According to the Institute of Medicine, a client with a body mass index in the obese range should gain at least 7 kg to ensure a healthy outcome. This client may well require in-depth counseling on optimum food choices. 3. Consultation with a dietitian may ensure that cultural food beliefs are congruent with modern knowledge of fetal development and that adjustments can be made to ensure that all nutritional needs will be met. 5. Conditions such as diabetes can require in-depth dietary planning and evaluation. To prevent issues with hypoglycemia and hyperglycemia and an increased risk for perinatal morbidity and mortality, this client would benefit from a referral to a dietitian.
Your client is being induced because of her worsening preeclampsia. She is also receiving magnesium sulfate. It appears that her labor has not become active despite several hours of oxytocin administration. She asks the nurse, "Why is it taking so long?" The most appropriate response by the nurse would be: 1. "The length of labor varies for different women." 2. "The magnesium is relaxing your uterus and competing with the oxytocin. It may increase the duration of your labor." 3. "Your baby is just being stubborn." 4. "Sometimes labor just takes a long time. I know it's frustrating."
2. "The magnesium is relaxing your uterus and competing with the oxytocin. It may increase the duration of your labor." Because magnesium sulfate is a tocolytic agent, its use may increase the duration of labor. The amount of oxytocin needed to stimulate labor may be more than that needed for the woman who is not receiving magnesium sulfate. "I don't know why it is taking so long." is not an appropriate statement for the nurse to make. Although the length of labor does vary for difference women, the most likely reason this woman's labor is protracted is the tocolytic effects of magnesium sulfate. The behavior of the fetus has no bearing on the length of labor.
What options for saying goodbye would the nurse want to discuss with a woman who is diagnosed with having a stillborn girl? 1. The nurse should avoid discussion of grief options at this time; there is plenty of time after the baby is born. 2. "When your baby is born, would you like to see and hold her?" 3. "What funeral home do you want notified after the baby is born?" 4. "Would you like a picture taken of your baby after birth?"
2. "When your baby is born, would you like to see and hold her?" Mothers and fathers may find it helpful to see the infant after delivery. The parents' wishes should be respected. Interventions and support from the nursing and medical staff after a prenatal loss are extremely important in the healing of the parents. Although this may be an intervention, the initial intervention should be related directly to the parents' wishes with regard to seeing or holding their dead infant. Although this information may be relevant, it is not the most appropriate option at this time. Burial arrangements can be discussed after the infant is born.
The role of the nurse with regard to informed consent is to: 1. Call the physician to see the client. 2. Act as a client advocate and help clarify the procedure and the options. 3. Inform the client about the procedure and have her sign the consent form 4. Witness the signing of the consent form.
2. Act as a client advocate and help clarify the procedure and the options. Nurses play a part in the informed consent process by clarifying and describing procedures or by acting as the woman's advocate and asking the primary health care provider for further explanations. The physician is responsible for informing the woman of her options, explaining the procedure, and advising the client about potential risk factors. The physician must be present to explain the procedure to the client. However, the nurse's responsibilities go further than simply asking the physician to see the client. The nurse may witness the signing of the consent form. However, depending on the state's guidelines, the woman's husband or another hospital health care employee may sign as witness.
Preconception counseling is critical to the outcome of diabetic pregnancies because poor glycemic control before and during early pregnancy is associated with: 1. Hyperemesis gravidarum 2. Congenital anomalies of the fetus 3. Frequent episodes of maternal hypoglycemia 4. Polyhydramnios
2. Congenital anomalies of the fetus Preconception counseling is particularly important because strict metabolic control before conception and in the early weeks of gestation is instrumental in decreasing the risks of congenital anomalies. Frequent episodes of maternal hypoglycemia may occur during the first trimester (not before conception) as a result of hormone changes and the effects on insulin production and usage. Hydramnios occurs about 10 times more often in diabetic pregnancies than in nondiabetic pregnancies. Typically it is seen in the third trimester of pregnancy. Hyperemesis gravidarum may exacerbate hypoglycemic events as the decreased food intake by the mother and glucose transfer to the fetus contribute to hypoglycemia.
Excessive blood loss after childbirth can have several causes; the most common is: 1. Unrepaired lacerations of the vaginal or cervix. 2. Failure of the uterine muscle to contract firmly. 3. Retained placental fragments. 4. Vaginal or vulvar hematoma.
2. Failure of the uterine muscle to contract firmly. Uterine atony can best be prevented by maintaining good uterine tone and preventing bladder distention. Although vaginal or vulvar hematomas, unpaired lacerations of the vagina or cervix, and retained placental fragments are possible causes of excessive blood loss, uterine muscle failure (uterine atony) is the most common cause.
Complications and risks associated with cesarean births include (choose all that apply): 1. Pulmonary edema. 2. Fetal injury. 3.Infection. 4. Wound dehiscence. 5. Hemorrhage.
2. Fetal injury. 3.Infection. 4. Wound dehiscence. 5. Hemorrhage. All of these are possible complications and risks associated with cesarean section.
The nurse knows that which stage of labor varies the most in length? 1. Fourth 2. First 3. Second 4. Third
2. First The first stage of labor is considered to last from the onset of regular uterine contractions to full dilation of the cervix. The first stage is much longer than the second and third stages combined. In a first-time pregnancy the first stage of labor can take up to 20 hours. The second stage of labor lasts from the time the cervix is fully dilated to the birth of the fetus. The average length is 20 minutes for a multiparous woman and 50 minutes for a nulliparous woman. The third stage of labor lasts from the birth of the fetus until the placenta is delivered. This stage may be as short as 3 minutes or as long as 1 hour. The fourth stage of labor, recovery, lasts about 2 hours after delivery of the placenta.
The most important nursing action in preventing neonatal infection is: 1. Standard precautions. 2. Good handwashing. 3. Isolation of infected infants. 4. Separate gown technique.
2. Good handwashing. Virtually all controlled clinical trials have demonstrated that effective handwashing is responsible for the prevention of nosocomial infection in nursery units. Measures to be taken include Standard Precautions, careful and thorough cleaning, frequent replacement of used equipment, and disposal of excrement and linens in an appropriate manner. Overcrowding must be avoided in nurseries. However, the most important nursing action for preventing neonatal infection is effective handwashing.
During a client's physical examination the nurse notes that the lower uterine segment is soft on palpation. The nurse would document this finding as: 1. McDonald's sign 2. Hegar's sign 3. Goodell's sign 4. Chadwick's sign
2. Hegar's sign At approximately 6 weeks of gestation, softening and compressibility of the lower uterine segment occur; this is called Hegar's sign. McDonald's sign indicates a fast food restaurant. Chadwick's sign is the blue-violet coloring of the cervix caused by increased vascularity; this occurs around the fourth week of gestation. Softening of the cervical tip is called Goodell's sign, which may be observed around the sixth week of pregnancy.
A woman in the active phase of the first stage of labor is using a shallow pattern of breathing, which is about twice the normal adult breathing rate. She starts to complain about feeling lightheaded and dizzy and states that her fingers are tingling. The nurse should: 1. Notify the woman's physician. 2. Help her breathe into a paper bag 3. Administer oxygen via a mask or nasal cannula. 4. Tell the woman to slow the pace of her breathing.
2. Help her breathe into a paper bag This woman is experiencing the side effects of hyperventilation, which include the symptoms of lightheadedness, dizziness, tingling of the fingers, or circumoral numbness. Having the woman breathe into a paper bag held tightly around her mouth and nose may eliminate respiratory alkalosis. This enables her to rebreathe carbon dioxide and replace bicarbonate ions.
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? Choose all that apply. 1. Administer oxygen by nasal cannula at 4 LPM. 2. Increase intravenous (IV) fluids. 3. Perform a sterile vaginal exam. 4. Place the woman in a lateral position. 5. Place the woman in a supine position.
2. Increase intravenous (IV) fluids. 4. Place the woman in a lateral position. 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 at 10 LPM, 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.
Which infant would be more likely to have Rh incompatibility? 1. Infant who is Rh positive and whose mother is Rh positive 2. Infant of an Rh-negative mother and a father who is Rh positive and homozygous for the Rh factor 3. Infant of an Rh-negative mother and a father who is Rh positive and heterozygous for the Rh factor 4. Infant who is Rh negative and whose mother is Rh negative
2. Infant of an Rh-negative mother and a father who is Rh positive and homozygous for the Rh factor If the mother is Rh negative and the father is Rh positive and homozygous for the Rh factor, all the offspring will be Rh positive. Only Rh-positive offspring of an Rh-negative mother are at risk for Rh incompatibility. If the mother is Rh negative and the father is Rh positive and heterozygous for the factor, there is a 50% chance that each infant born of the union will be Rh positive and a 50% chance that each will be born Rh negative.
Two days ago a woman gave birth to a full-term infant. Last night she awakened several times to urinate and noted that her gown and bedding were wet from profuse diaphoresis. One mechanism for the diaphoresis and diuresis that this woman is experiencing during the early postpartum period is: 1. Elevated temperature caused by postpartum infection. 2. Loss of increased blood volume associated with pregnancy 3. Increased basal metabolic rate after giving birth. 4. Increased venous pressure in the lower extremities.
2. Loss of increased blood volume associated with pregnancy Within 12 hours of birth women begin to lose the excess tissue fluid that has accumulated during pregnancy. One mechanism for reducing these retained fluids is the profuse diaphoresis that often occurs, especially at night, for the first 2 or 3 days after childbirth. Postpartal diuresis is another mechanism by which the body rids itself of excess fluid. An elevated temperature would cause chills and may cause dehydration, not diaphoresis and diuresis. Diaphoresis and diuresis sometimes are referred to as reversal of the water metabolism of pregnancy, not as the basal metabolic rate. Postpartal diuresis may be caused by the removal of increased venous pressure in the lower extremities.
A woman arrives at the clinic for a pregnancy test. The first day of her last menstrual period (LMP) was February 14, 2013. Her expected date of birth (EDB) would be: 1. November 7, 2013 2. November 21, 2013. 3. December 9, 2013 4. October 17, 2013
2. November 21, 2013.
The nurse teaching a prenatal education class identifies a long list of topics to discuss. Whis is most appropriate for inclusion in information about the first trimester of pregnancy? 1. Preparation for labor and delivery. 2. Nutrition and activity during pregnancy. 3. Coping with heartburn and ankle edema. 4. Strategies for dealing with colic.
2. Nutrition and activity during pregnancy. Nutrition and activity are important concerns from the first trimester and beyond. Labor and birth are third trimester issues, and parenting is of most concern in the third trimester and after birth. Heartburn and ankle edema do not usually occur until the third trimester.
The early postpartum period is a time of emotional and physical vulnerability. Many mothers can easily become psychologically overwhelmed by the reality of their new parental responsibilities. Fatigue compounds these issues. Although the baby blues are a common occurrence in the postpartum period, about one-half million women in America experience a more severe syndrome known as postpartum depression (PPD). Which statement regarding PPD is essential for the nurse to be aware of when attempting to formulate a nursing diagnosis? 1. PPD symptoms are consistently severe. 2. PPD can easily go undetected. 3. This syndrome affects only new mothers. 4. Only mental health professionals should teach new parents about this condition.
2. PPD can easily go undetected. PPD can go undetected because parents do not voluntarily admit to this type of emotional distress out of embarrassment, fear, or guilt. PPD symptoms range from mild to severe, with women having both good and bad days. Both mothers and fathers should be screened. PPD in new fathers ranges from 1% to 26%. 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.
Magnesium sulfate is given to women with preeclampsia and eclampsia to: 1 .Improve patellar reflexes and increase respiratory efficiency. 2. Prevent and treat seizures. 3. Decrease severity of headaches. 4. Prevent a boggy uterus and increased bleeding after delivery.
2. Prevent and treat seizures. Magnesium sulfate is the drug of choice to prevent seizures, although it can cause other problems. Loss of patellar reflexes and respiratory depression are signs of magnesium toxicity. Magnesium sulfate does not decrease the severity of headaches in preeclamptic women. Women are at risk for a boggy uterus and heavy lochial flow as a result of magnesium sulfate therapy.
With shortened hospital stays, new mothers are often discharged before they begin to experience symptoms of the baby bluesor postpartum depression. As part of the discharge teaching, the nurse can prepare the mother for this adjustment to her new role by instructing her regarding self-care activities to help prevent postpartum depression. The most accurate statement as related to these activities is to: 1. Stay home and avoid outside activities to ensure adequate rest. 2. Realize that this is a common occurrence that affects many women. 3. Keep feelings of sadness and adjustment to your new role to yourself. 4. Be certain that you are the only caregiver for your baby to facilitate infant attachment.
2. Realize that this is a common occurrence that affects many women. Should the new mother experience symptoms of the baby blues, it is important that she be aware that this is nothing to be ashamed of. As many as 15% of new mothers experience similar symptoms. Although it is important for the mother to obtain enough rest, she should not distance herself from family and friends. Her spouse or partner can communicate the best visiting times so the new mother can obtain adequate rest. It is also important that she not isolate herself at home during this time of role adjustment. Even if breastfeeding, other family members can participate in the infant's care. If depression occurs, the symptoms can often interfere with mothering functions and this support will be essential. The new mother should share her feelings with someone else. It is also important that she not overcommit herself or think she has to be "superwoman." A telephone call to the hospital warm line may provide reassurance with lactation issues and other infant care questions. Should symptoms continue, a referral to a professional therapist may be necessary.
A woman with preeclampsia has a seizure. The nurse's primary responsibility during the seizure is to: 1. Administer oxygen by mask. 2. Stay with the client and call for help. 3. Insert an oral airway. 4. Suction the mouth to prevent aspiration.
2. Stay with the client and call for help. If a client becomes eclamptic, the nurse should stay with him or her and call for help. Insertion of an oral airway during seizure activity is no longer the standard of care. The nurse should attempt to keep the airway patent by turning the client's head to the side to prevent aspiration. Once the seizure has ended, it may be necessary to suction the client's mouth. Oxygen would be administered after the convulsion has ended.
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: 1. Prevent premature rupture of membranes. 2. Stimulate fetal surfactant production. 3. Suppress uterine contractions. 4. Maintain adequate maternal respiratory effort and ventilation during magnesium sulfate therapy.
2. Stimulate fetal surfactant production. Antenatal glucocorticoids given as intramuscular injections to the mother accelerate fetal lung maturity. Betamethasone has no effect on uterine contractions, nor does it prevent premature rupture of membranes. Calcium gluconate would be given to reverse the respiratory depressive effects of magnesium sulfate therapy.
The nurse expects to administer an oxytocic (e.g., Pitocin, Methergine) to a woman after expulsion of her placenta to: (choose all that apply) 1. Relieve pain. 2. Stimulate uterine contraction. 3. Facilitate rest and relaxation. 4. Prevent postpartum hemorrhage.
2. Stimulate uterine contraction. 4. Prevent postpartum hemorrhage. Oxytocics stimulate uterine contractions, which reduce blood loss after the third stage of labor. They cause the uterus to contract, which reduces blood loss and results in painful contractions. Oxytocics do not facilitate rest and relaxation
A 22-year-old woman pregnant with a single fetus has a preconception body mass index (BMI) of 24. When she was seen in the clinic at 14 weeks of gestation, she had gained 1.8 kg (4 lb) since conception. How would the nurse interpret this? 1. This weight gain indicates that the woman's infant is at risk for intrauterine growth restriction (IUGR). 2. The woman's weight gain is appropriate for this stage of pregnancy. 3. This weight gain indicates possible gestational hypertension. 4. This weight gain cannot be evaluated until the woman has been observed for several more weeks.
2. The woman's weight gain is appropriate for this stage of pregnancy. The woman's weight gain is appropriate for this stage of pregnancy is an accurate statement. This woman's BMI is in the normal range. During the first trimester the average total weight gain is only 1 to 2.5 kg.
To reassure and educate pregnant clients about changes in their cardiovascular system, obstetric nurses should be aware that: 1. A pregnant woman experiencing disturbed cardiac rhythm, such as sinus arrhythmia requires close medical and obstetric observation, no matter how healthy she otherwise may appear. 2. Palpitations are twice as likely to occur in twin gestations. 3. Changes in heart size and position and increases in blood volume create auditory changes from 20 weeks to term. 4. Blood volume in pregnancy triples by the third trimester.
3. Changes in heart size and position and increases in blood volume create auditory changes from 20 weeks to term.
When assessing a woman in the first stage of labor, the nurse recognizes that the most conclusive sign that uterine contractions are effective would be: 1. Increase in bloody show. 2. Descent of the fetus. 3. Dilation of the cervix. 4. Rupture of the amniotic membranes
3. Dilation of the cervix. The vaginal examination reveals whether the woman is in true labor. Cervical change, especially dilation, in the presence of adequate labor indicates that the woman is in true labor. Descent of the fetus, or engagement, may occur before labor. Rupture of membranes may occur with or without the presence of labor. Bloody show may indicate slow, progressive cervical change (e.g., effacement) in both true and false labor.
A woman gave birth to a 7-pound, 3-ounce infant boy 2 hours ago. The nurse determines that the woman's bladder is distended because her fundus is now 3 cm above the umbilicus and to the right of the midline. In the immediate postpartum period, the most serious consequence likely to occur from bladder distention is: 1. Bladder wall atony. 2. Urinary tract infection. 3. Excessive uterine bleeding. 4. A ruptured bladder.
3. Excessive uterine bleeding. Excessive bleeding can occur immediately after birth if the bladder becomes distended because it pushes the uterus up and to the side and prevents it from contracting firmly. A urinary tract infection may result from overdistention of the bladder, but it is not the most serious consequence. A ruptured bladder may result from a severely overdistended bladder. However, vaginal bleeding most likely would occur before the bladder reaches this level of overdistention. Bladder distention may result from bladder wall atony. The most serious concern associated with bladder distention is excessive uterine bleeding.
Which condition, not uncommon in pregnancy, is likely to require careful medical assessment during the puerperium? 1. Periodic numbness and tingling of the fingers 2. Carpal tunnel syndrome 3. Headaches 4. Varicosities
3. Headaches In the postpartum period can have a number of causes, some of which deserve medical attention. Total or nearly total regression of varicosities is expected after childbirth. However, headaches might deserve attention. Carpal tunnel syndrome is relieved in childbirth when the compression on the median nerve is lessened. However, headaches might deserve attention. Periodic numbness of the fingers usually disappears after birth unless carrying the baby aggravates the condition. However, headaches might deserve attention.
A pregnant woman is in her third trimester. She asks the nurse to explain how she can tell true labor from false labor. The nurse would tell her that true labor contractions: 1. Alternate between a regular and irregular pattern. 2. Decrease with activity. 3. Increase with activity such as ambulation. 4. Are frequently accompanied by the rupture of the bag of waters
3. Increase with activity such as ambulation. True labor contractions become more intense with walking. False labor contractions often stop with walking or position changes. Rupture of membranes may occur before or during labor. True labor contractions are regular.
Nurses should be aware that the induction of labor: 1. Is almost always done for medical reasons. 2. Is also known as a trial of labor (TOL). 3. Is rated for chance of success by use of the Bishop score 4. Can be achieved by external and internal version techniques.
3. Is rated for chance of success by use of the Bishop score Induction of labor is likely to be more successful with a Bishop score of 9 or higher for first-time mothers and 5 or higher for veterans. Version is turning of the fetus to a better position by a physician for an easier or safer birth. A trial of labor is the observance of a woman and her fetus for several hours of active labor to assess the safety of vaginal birth. Two thirds of cases of induced labor are elective and not done for medical reasons.
In understanding and guiding a woman through her acceptance of pregnancy, a maternity nurse should be aware that: 1. Ambivalent feelings during pregnancy usually are seen only in emotionally immature or very young mothers. 2. Conflicts such as not wanting to be pregnant or childrearing and career-related decisions need not be addressed during pregnancy, because they will resolve themselves naturally after birth. 3. Mood swings are common for many pregnant women and are the result of anticipated changes in lifestyle, as well as profound hormonal changes. 4. Nonacceptance of the pregnancy very often equates to rejection of the child.
3. Mood swings are common for many pregnant women and are the result of anticipated changes in lifestyle, as well as profound hormonal changes.
After giving birth to a healthy infant boy, a primiparous woman, 16, is admitted to the postpartum unit. An appropriate nursing diagnosis for her at this time is risk for impaired parenting related to deficient knowledge of newborn care. In planning for the woman's discharge, what should the nurse be certain to include in the plan of care? 1. Tell the woman how to feed and bathe her infant. 2. Provide detailed written instructions on bathing her infant. 3. Provide time for the woman to bathe her infant after she views an infant bath demonstration. 4. Advise the woman that all mothers instinctively know how to care for their infants.
3. Provide time for the woman to bathe her infant after she views an infant bath demonstration. Having the mother demonstrate infant care is a valuable method of assessing the client's understanding of her newly acquired knowledge, especially in this age group, because she may inadvertently neglect her child. Although verbalizing how to care for the infant is a form of client education, it is not the most developmentally appropriate teaching for a teenage mother. Although providing written information is useful, it is not the most developmentally appropriate teaching for a teenage mother. Advising the woman that all mothers instinctively know how to care for their infants is an inappropriate statement; it is belittling and false.
The interval between the birth of the newborn and the return of the reproductive organs to their normal nonpregnant state is called the: 1. Involutionary period because of post-birth uterine changes. 2. Lochia period because of the nature of the vaginal discharge 3. Puerperium, or fourth trimester of pregnancy. 4. Mini-tri period because it lasts only 3 to 6 weeks.
3. Puerperium, or fourth trimester of pregnancy. The puerperium, also called the fourth trimester or the postpartum period of pregnancy, lasts about 3 to 6 weeks. Involution marks the end of the puerperium, or the fourth trimester of pregnancy. Lochia refers to the various vaginal discharges during the puerperium, or fourth trimester of pregnancy.
When assessing a multiparous woman who has just given birth to an 8-pound boy, the nurse notes that the woman's fundus is firm and has become globular in shape. A gush of dark red blood comes from her vagina. The nurse concludes that: 1. A cervical tear occurred during the birth. 2. The woman is beginning to hemorrhage. 3. The placenta has separated. 4. Clots have formed in the upper uterine segment.
3. The placenta has separated. Placental separation is indicated by a firmly contracting uterus, a change in the uterus from a discoid to a globular ovoid shape, a sudden gush of dark red blood from the introitus, an apparent lengthening of the umbilical cord, and a finding of vaginal fullness. Cervical tears that do not extend to the vagina result in minimal blood loss. Signs of hemorrhage are a boggy uterus, bright red vaginal bleeding, alterations in vital signs, pallor, lightheadedness, restlessness, decreased urinary output, and alteration in the level of consciousness. If clots have formed in the upper uterine segment, the nurse would expect to find the uterus boggy and displaced to the side.
A 26-year-old pregnant woman, gravida 2, para 1-0-0-1 is 28 weeks pregnant when she experiences bright red, painless vaginal bleeding. On her arrival at the hospital, what would be an expected diagnostic procedure? 1. Contraction stress test (CST) 2. Internal fetal monitoring 3. Ultrasound for placental location 4. Amniocentesis for fetal lung maturity
3. Ultrasound for placental location The presence of painless bleeding should always alert the health care team to the possibility of placenta previa. This can be confirmed through ultrasonography. Amniocentesis would not be performed on a woman who is experiencing bleeding. In the event of an imminent delivery, the fetus would be presumed to have immature lungs at this gestational age, and the mother would be given corticosteroids to aid in fetal lung maturity. A CST would not be performed at a preterm gestational age. Furthermore, bleeding would be a contraindication to this test. Internal fetal monitoring would be contraindicated in the presence of bleeding.
With regard to fetal positioning during labor, nurses should be aware that: 1. The largest transverse diameter of the presenting part is the suboccipitobregmatic diameter. 2. Position is a measure of the degree of descent of the presenting part of the fetus through the birth canal. 3. Engagement is the term used to describe the beginning of labor. 4. Birth is imminent when the presenting part is at +4 to +5 cm, below the ischial spines.
4. Birth is imminent when the presenting part is at +4 to +5 cm below the spine. The station of the presenting part should be noted at the beginning of labor so that the rate of descent can be determined. Position is the relation of the presenting part of the fetus to the four quadrants of the mother's pelvis; station is the measure of degree of descent. The largest diameter usually is the biparietal diameter. The suboccipitobregmatic diameter is the smallest, although one of the most critical. Engagement often occurs in the weeks just before labor in nulliparas and before or during labor in multiparas.
In planning for the care of a 30-year-old woman with pregestational diabetes, the nurse recognizes that the most important factor affecting pregnancy outcome is the: 1. Amount of insulin required daily. 2. Number of years since diagnosed. 3. Mother's age. 4. Degree of glycemic control during pregnancy.
4. Degree of glycemic control during pregnancy. Women with excellent glucose control and no blood vessel disease should have good pregnancy outcomes. Although advanced maternal age may pose some health risks, the most important factor for the woman with pregestational diabetes remains the degree of glycemic control during pregnancy. The number of years since diagnosis and the amount of insulin required are not as relevant to outcomes as the degree of glycemic control. (4)
The nurse teaches a pregnant woman about the presumptive, probable, and positive signs of pregnancy. The woman demonstrates understanding of the nurse's instructions if she states that a positive sign of pregnancy is: 1. Quickening. 2. A positive pregnancy test. 3. Braxton Hicks contractions. 4. Fetal movement palpated by the nurse-midwife.
4. Fetal movement palpated by the nurse-midwife.
An infant diagnosed with erythroblastosis fetalis would characteristically exhibit: 1. Enlargement of the heart. 2. Ascites. 3. Edema. 4. Immature red blood cells.
4. Immature red blood cells. Erythroblastosis fetalis occurs when the fetus compensates for the anemia associated with Rh incompatibility by producing large numbers of immature erythrocytes to replace those hemolyzed. Edema would occur with hydrops fetalis, a more severe form of erythroblastosis fetalis. The fetus with hydrops fetalis may exhibit effusions into the peritoneal, pericardial, and pleural spaces. The infant with hydrops fetalis displays signs of ascites.
Screening at 24 weeks of gestation reveals that a pregnant woman has gestational diabetes mellitus (GDM). In planning her care the nurse and the woman mutually agree that an expected outcome is to prevent injury to the fetus as a result of GDM. The nurse identifies that the fetus is at greatest risk for: 1. Low birthweight 2. Congenital anomalies 3. Preterm birth 4. Macrosomia
4. Macrosomia Poor glycemic control later in pregnancy increases the rate of fetal macrosomia. Poor glycemic control during the preconception time frame and into the early weeks of the pregnancy is associated with congenital anomalies. Preterm labor or birth is more likely to occur with severe diabetes and is the greatest risk in women with pregestational diabetes. Increased weight, or macrosomia, is the greatest risk factor for this woman.
On examining a woman who gave birth 5 hours ago, the nurse finds that the woman has completely saturated a perineal pad within 15 minutes. The nurse's first action is to: 1. Call the health care provider. 2. Begin an intravenous (IV) infusion of Ringer's lactate solution. 3. Assess the woman's vital signs. 4. Massage the woman's fundus.
4. Massage the woman's fundus. The nurse should assess the uterus for atony. Uterine tone must be established to prevent excessive blood loss. The nurse may begin an IV infusion to restore circulatory volume, but this would not be the first action. Blood pressure is not a reliable indicator of impending shock from impending hemorrhage; assessing vital signs should not be the nurse's first action. The physician would be notified after the nurse completes the assessment of the woman.
The slight overlapping of cranial bones or shaping of the fetal head during labor is called: 1. Lightening 2. Crowning 3. Ferguson's shaping 4. Molding
4. Molding Fetal head formation is called molding. Molding permits adaptation to various diameters of the maternal pelvis. Lightening is the mother's sensation of decreased abdominal distention, which usually occurs the week before labor. Fetal head formation is called molding. The Ferguson reflex is the contraction of the uterus after stimulation of the cervix. Crowning is the appearance of the presenting fetal part at the vaginal orifice during labor.
A woman in labor has just received an epidural block. The most important nursing intervention is to: 1. Limit parenteral fluids 2. Monitor the maternal pulse for possible bradycardia. 3. Monitor the fetus for possible tachycardia. 4. Monitor the maternal blood pressure for possible hypotension.
4. Monitor the maternal blood pressure for possible hypotension. 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.
An 18-year-old client who has reached 16 weeks of gestation was recently diagnosed with pregestational diabetes. She attends her prenatal appointment accompanied by one of her girlfriends. This young woman appears more concerned about how her pregnancy will affect her social life rather than her recent diagnosis of diabetes. A number of nursing diagnoses are applicable to assist in planning adequate care. The most appropriate diagnosis at this time is: 1. Risk for injury to the fetus related to potential birth trauma. 2. Deficient knowledge related to insulin administration. 3. Risk for injury to the mother related to hypoglycemia or hyperglycemia. 4. Noncompliance related to lack of understanding of diabetes and pregnancy and requirements of the treatment plan.
4. Noncompliance related to lack of understanding of diabetes and pregnancy and requirements of the treatment plan. Before a treatment plan is developed or goals for the outcome of care are outlined, this client must come to an understanding of diabetes and the potential effects on her pregnancy. She appears to have greater concern for changes to her social life than adoption of a new self-care regimen. Risk for injury to the fetus related to either placental insufficiency or birth trauma may come much later in the pregnancy. At this time the client is having difficulty acknowledging the adjustments that she needs to make to her lifestyle to care for herself during pregnancy. The client may not yet be on insulin. Insulin requirements increase with gestation. The importance of glycemic control must be part of health teaching for this client. However, she has not yet acknowledged that changes to her lifestyle need to be made and may not participate in the plan of care until understanding takes place.
A newborn is jaundiced and receiving phototherapy via ultraviolet bank lights. An appropriate nursing intervention when caring for an infant with hyperbilirubinemia and receiving phototherapy by this method would be to: 1. Apply an oil-based lotion to the newborn's skin to prevent dying and cracking. 2. Change the newborn's position every 4 hours. 3. Limit the newborn's intake of milk to prevent nausea, vomiting, and diarrhea. 4. Place eye shields over the newborn's closed eyes.
4. Place eye shields over the newborn's closed eyes. The infant's eyes must be protected by an opaque mask to prevent overexposure to the light. Eye shields should cover the eyes completely but not occlude the nares. Lotions and ointments should not be applied to the infant because they absorb heat, and this can cause burns. The lights increase insensible water loss, placing the infant at risk for fluid loss and dehydration. Therefore it is important that the infant be adequately hydrated. The infant should be turned every 2 hours to expose all body surfaces to the light.
Which hormone remains elevated in the immediate postpartum period of the breastfeeding woman? 1. Human placental lactogen 2. Estrogen 3. Progesterone 4. Prolactin
4. Prolactin Prolactin levels in the blood increase progressively throughout pregnancy. In women who breastfeed, prolactin levels remain elevated into the sixth week after birth. Estrogen and progesterone levels decrease markedly after expulsion of the placenta, reaching their lowest levels 1 week into the postpartum period. Human placental lactogen levels decrease dramatically after expulsion of the placenta.
An 18-year-old pregnant woman, gravida 1, is admitted to the labor and birth unit with moderate contractions every 5 minutes that last 40 seconds. The woman states, "My contractions are so strong that I don't know what to do." The nurse should: 1. Assess for fetal well-being. 2. Disturb the woman as little as possible. 3. Encourage the woman to lie on her side. 4. Recognize that pain is personalized for each individual.
4. Recognize that pain is personalized for each individual. Each woman's pain during childbirth is unique and is influenced by a variety of physiologic, psychosocial, and environmental factors. A critical issue for the nurse is how support can make a difference in the pain of the woman during labor and birth. Assessing for fetal well-being includes no information that would indicate fetal distress or a logical reason to be overly concerned about the well-being of the fetus. The left lateral position is used to alleviate fetal distress, not maternal stress. The nurse has an obligation to provide physical, emotional, and psychosocial care and support to the laboring woman. This client clearly needs support.
The most prevalent clinical manifestation of abruptio placentae (as opposed to placenta previa) is: 1. Vaginal bleeding. 2. Uterine activity. 3. Cramping. 4. Severe abdominal pain.
4. Severe abdominal pain. Pain is absent with placenta previa and may be agonizing with abruptio placentae. Bleeding may be present in varying degrees for both placental conditions. Uterine activity and cramping may be present with both placental conditions.
One of the first symptoms of puerperal infection to assess for in the postpartum woman is: 1. Pain with voiding. 2. Fatigue continuing for longer than 1 week. 3. Profuse vaginal bleeding with ambulation. 4. Temperature of 38° C (100.4° F) or higher on 2 successive days starting 24 hours after birth.
4. Temperature of 38° C (100.4° F) or higher on 2 successive days starting 24 hours after birth. Postpartum or puerperal infection is any clinical infection of the genital tract that occurs within 28 days after miscarriage, induced abortion, or childbirth. The definition used in the United States continues to be the presence of a fever of 38° C (100.4° F) or higher on 2 successive days of the first 10 postpartum days, starting 24 hours after birth. Fatigue would be a late finding associated with infection. Pain with voiding may indicate a urinary tract infection, but it is not typically one of the earlier symptoms of infection. Profuse lochia may be associated with endometritis, but it is not the first symptom associated with infection.
A woman who is about 6 weeks pregnant asks if she can listen to her baby's heartbeat today. What should be included in the nurse's reply? 1. The heartbeat can be heard with an electronic doppler. 2. The heart is not yet beating at 6 weeks gestation. 3. The heartbeat is generally audible around the time that fetal movement is felt. 4. The baby's heart is formed and is beating, but the baby is now so small that the heartbeat can't be heard at this time.
4. The baby's heart is formed and is beating, but the baby is now so small that the heartbeat can't be heard at this time. Fetal heart chambers are formed and the heart is beating by 4 weeks gestation. However, it cannot be heard with a electronic Doppler until approximately 8-12 weeks gestation.
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 might be able to go home. What response by the nurse is most accurate? 1. "After the baby is born." 2. "It depends on what kind of insurance coverage you have." 3. "Whenever the doctor says that it is okay." 4. When we can stabilize your preterm labor and arrange home health visits."
4. When we can stabilize your preterm labor and arrange home health visits." The client's preterm labor is being controlled with tocolytics. Once she is stable, home care may be a viable option for this type of client. Care of a woman with preterm labor is multifactorial; the goal is to prevent delivery. In many cases this may be achieved at home. Care of the preterm client is multidisciplinary and multifactorial. Managed care may dictate earlier hospital discharges or a shift from hospital to home care. Insurance coverage may be one factor in the care of clients, but ultimately client safety remains the most important factor.
A woman's obstetric history indicates that she is pregnant for the fourth time and all of her children from previous pregnancies are living. One was born at 39 weeks of gestation, twins were born at 34 weeks of gestation, and another child was born at 35 weeks of gestation. What is her gravidity and parity using the GTPAL system? A. 4-1-2-0-4 B. 4-2-1-0-3 C. 3-0-3-0-3 D. 3-1-1-1-3
A. 4-1-2-0-4
The nurse knows that access to adequate prenatal care varies significantly among different cultural groups. Select all of the cultural groups least likely to receive adequate prenatal care. Select all that apply Hispanic Asian Whites Native American Black
Hispanic Native American Black
What has had the greatest impact on reducing infant mortality in the United States? Improvements in perinatal care Decreased incidence of congenital anomalies Improved maternal nutrition Increased funding for health care
Improvements in perinatal care
The nurse is taking a health history of a woman who is receiving her intial prenatal visit. The woman tells the nurse, "I am worried that my baby will die of Sudden Infant Death Syndrome." Which of the following is the best response by the nurse? "Can you tell me more about your concern?" "Congenital malformations are more common than SIDS." "The incidence of SIDS has decreased to only 2.6% of all infant deaths." "You seem very anxious, which can affect your baby's well-being."
"Can you tell me more about your concern?"
A nurse is discussing the signs and symptoms of mastitis with a mother who is breastfeeding. What signs and symptoms should the nurse include in her discussion? Choose all that apply. 1. An area of redness on the breast resemgling a pie-like wedge. 2. Breast tenderness. 3. Fever and flulike symptoms 4. Warmth in the breast. 5. A small white blister on the tip of the nipple.
1, 2, 3, 4 Breast tenderness, breast warmth, breast redness, and fever and flulike symptoms are commonly associated with mastitis and should be included in the nurse's discussion of mastitis. A small white blister on the tip of the nipple generally is not associated with mastitis. It is commonly seen in women who have a plugged milk duct.
Medications used to manage postpartum hemorrhage (PPH) include (Choose all that apply): 1. Hemabate 2. Methergine 3. Terbutaline 4. Pitocin 5. Magnesium sulfate 6. Misoprostil
1, 2, 4, 6 Pitocin, Methergine, Misoprostil, and Hemabate are all used to manage PPH. Terbutaline and magnesium sulfate are tocolytics; relaxation of the uterus causes or worsens PPH.
A nurse is caring for a pregnant client who is 32 weeks gestation with mild preeclampsia. The nurse should be alert to which manifestations that indicate worsening of the condition? Select all that apply. 1. Visual problems 2. Severe headache 3. Decreased platelets 4. Elevated serum creatinine 5. Lower abdominal discomfort 6. Elevated CPK
1. Visual problems 2. Severe headache 3. Decreased platelets 4. Elevated serum creatinine
The nurse is caring for a grieving family after the death of their newborn to severe sepsis. Which of the following statements is therapeutic? Select all that apply. 1. It is a blessing for you that this happened when you were only 30 weeks pregnant. 2. I know you will miss Ariana and no one will ever take her place in your heart. 3. You are healthy and can attempt to conceive again within 3 months. 4. You are so lucky to have an angel in heaven waiting for you. 5. I know this is painful for you, and I am here to help you through this if you would like to talk about it. 6. I miscarried 3 times. I know it is very hard to deal with the pain of losing a child.
2, 5 Facilitating the grieving process begins with therapeutic communication. Saying that no one can ever take the place of the infant that died validates their loss of a unique individual. The nurse should not diminish the pain that the parents are experiencing by giving false reassurances, trying to provide explanations for the unexplainable, or comparing the nurse's loss to that of the grieving family.
With regard to hemolytic diseases of the newborn, nurses should be aware that: 1. Rh incompatibility matters only when an Rh-negative offspring is born to an Rh-positive mother. 2. The indirect Coombs' test is performed on the mother before birth; the direct Coombs' test is performed on the cord blood after birth. 3. ABO incompatibility is more likely than Rh incompatibility to precipitate significant anemia. 4. Exchange transfusions frequently are required in the treatment of hemolytic disorders.
2. The indirect Coombs' test is performed on the mother before birth; the direct Coombs' test is performed on the cord blood after birth. An indirect Coombs' test may be performed on the mother a few times during pregnancy. Only the Rh-positive offspring of an Rh-negative mother is at risk. ABO incompatibility is more common than Rh incompatibility but causes less severe problems; significant anemia, for instance, is rare with ABO. Exchange transfers are needed infrequently because of the decrease in the incidence of severe hemolytic disease in newborns from Rh incompatibility.
The nurse is preparing to administer an injection of Vitamin K to a newborn. In preparing to administer the injection, the nurse should select which of the following injection sites? 1. The gluteus maximus muscle. 2. The lateral aspect of the middle third of the vastus lateralis muscle. 3. The lower aspect of the rectus femoris muscle. 4. The medial aspect of the deltoid muscle.
2. The lateral aspect of the middle third of the vastus lateralis muscle. The preferred injection site for an intramuscular injection in the newborn is the lateral aspect of the vastus lateralis muscle in the thigh. This site is preferred because it is free of major blood vessels and nerves and is large enough to absorb the medication. The gluteus, rectus femoris, and deltoid muscle sites are not recommended for intramuscular injection in the newborn due to risk of nerve damage or tissue trauma.
A pregnant woman experiencing nausea and vomiting should: Drink a glass of water with a fat-free carbohydrate before getting out of bed in the morning. Eat small, frequent meals (every 2 to 3 hours). Limit fluid intake throughout the day. Increase her intake of high-fat foods to keep the stomach full and coated.
Eat small, frequent meals (every 2 to 3 hours). Eating small, frequent meals is a correct suggestion for a woman experiencing nausea and vomiting. A pregnant woman experiencing nausea and vomiting should avoid consuming fluids early in the day or when nauseated, but should compensate by drinking fluids at other times. A pregnant woman experiencing nausea and vomiting should reduce her intake of fried and other fatty foods.
Sally who is a G1 P0000 comes in to the OB clinic at 16 weeks and 3 days gestation. She is concerned because she has not felt the baby move. The nurse's best response would be? The baby's movements can usually be felt at 20 weeks for the first time mom. The baby's movements can usually be felt by 14 weeks by the first time mom. It varies greatly for every woman depending on the size of the baby You will not feel the baby move until the 3rd trimester.
The baby's movements can usually be felt at 20 weeks for the first time mom.
Signs that precede labor include (Select all that apply): a. Lightening. b. Exhaustion. c. Bloody show. d. Rupture of membranes. e. Decreased fetal movement.
a. Lightening. c. Bloody show. d. Rupture of membranes.
Which meal would provide the most absorbable iron? a. Toasted cheese sandwich, celery sticks, tomato slices, and a grape drink b. Oatmeal, whole wheat toast, jelly, and low-fat milk c. Black bean soup, wheat crackers, orange sections, and prunes d. Red beans and rice, cornbread, mixed greens, and decaffeinated tea
c. Black bean soup, wheat crackers, orange sections, and prunes Food sources that are rich in iron include liver, meats, whole grain or enriched breads and cereals, deep green leafy vegetables, legumes, and dried fruits. Dairy products and celery are not sources of iron.
A woman has come to the clinic for preconception counseling because she wants to start trying to get pregnant in 3 months. She can expect the following advice: "Lose weight so that you can gain more during pregnancy." "Discontinue all contraception now." "Make sure that you include adequate folic acid in your diet." "You may take any medications you have been taking regularly."
"Make sure that you include adequate folic acid in your diet." A healthy diet before conception is the best way to ensure that adequate nutrients are available for the developing fetus. A woman's folate or folic acid intake is of particular concern in the periconception period. Neural tube defects are more common in infants of women with a poor folic acid intake. Depending on the type of contraception used, discontinuing all contraception may not be an accurate statement. Losing weight is not appropriate advice. Depending on the type of medication the woman is taking, continuing its use may not be an accurate statement.
The nurse is gathering information for a nutritional assessment for a woman with pre-existing diabetes who just learned that she is pregnant. The woman tells the nurse that she uses herbal therapies and natural food supplements. Which of the following statements by the nurse is appropriate? "Please discuss these supplements and therapies with your healthcare provider before continuing their use." "Herbal formulations are subject to Food and Drug Administration premarket testing, so these substances are safe for you and your baby." "These substances have been found useful for prevention of complications of diabetes." "Complementary and alternative therapies are healthy choices for your diabetes."
"Please discuss these supplements and therapies with your healthcare provider before continuing their use."
Pain should be assessed regularly in all newborn infants. If the infant is displaying physiologic or behavioral cues indicating pain, measures should be taken to manage the pain. Examples of nonpharmacologic pain management techniques include (choose all that apply): 1. Swaddling 2. Sucrose 3. Acetaminophen 4. Non-nutritive sucking 5. Skin-to-skin contact with the mother.
1, 2, 4, 5. Swaddling, nonnutritive sucking, skin-to-skin contact with the mother, and sucrose are all appropriate nonpharmacologic techniques used to manage pain in neonates. Acetaminophen is a pharmacologic method of treating pain.
The nurse is caring for a large for gestational age newborn. His mother was diagnosed with gestational diabetes late in her pregnancy. The nurse should be alert for signs of hypoglycemia. Which of the following assessment findings is consistent with possible hypoglycemia? Select all that apply 1. Cyanosis 2. Temperature instability 3. Extreme hunger 4. Abdominal distention 5. Jitteriness and tremors 6. Poor feeding
1, 2, 5, 6 Signs of hypoglycemia include poor feeding, temperature instability, cyanosis, apnea, hypotonia, and tremors and jitteriness. Seizures may occur in severe hypoglycemia. Abdominal distention is not found in infant hypoglycemia.
Which of the following is an example of perinatal loss? Select all that apply. 1. Stillbirth at 39 weeks gestation. 2. Birth of an infant with Down syndrome. 3. Miscarriage at 6 weeks gestation. 4. Medically induced abortion at 10 weeks. 5. Sudden infant death syndrome at 3 weeks of age.
1, 3, 4, 5 Each of these may be a perinatal loss which can result in parental grief.
What nursing interventions should the nurse take when working with parents who experienced the death of their fetus? Select all that apply. 1. Identify the parents' perceptions and feelings about the baby's death. 2. Call a chaplain to visit the parents in the hospital. 3. Clean and wrap the baby in a clean blanket for parental viewing and holding. 4. Encourage the parents to avoid viewing the fetus. 5. Provide the parents with mementos such as locks of hair, footprints, and identification bands. 6. Refer the parents to appropriate community support groups.
1, 3, 5, 6 Allowing the parents quiet time to hold and view the baby and preparing the baby for viewing by cleaning the body and wrapping in a clean blanket will help the parents to realize the reality of their loss. The nurse should identify the parents' perceptions about the baby's death to correct misperceptions and alleviate guilt. Providing mementos supports the grieving process. Appropriate community support groups can facilitate grieving. The parents should be asked if they wish to receive spiritual support.
A new mother recalls from prenatal class that she should try to feed her newborn daughter when she exhibits feeding readiness cues rather than waiting until her infant is crying frantically. On the basis of this information, this woman should feed her infant about every 2.5 to 3 hours when she: Select all that apply 1. Makes sucking motions. 2. Has hiccups. 3. Stretches her legs out straight. 4. Makes sucking motions. 5. Waves her arms in the air. 6. Begins rooting. 7. Initiates hand-to-mouth motions.
1, 4, 6, 7 Sucking motions, rooting, mouthing, and hand-to-mouth motions are examples of feeding-readiness cues. Waving the arms in the air, hiccupping, and stretching the legs out straight are not typical feeding-readiness cues.
During a phone follow-up conversation with a woman who is 4 days' postpartum, the woman tells the nurse, "I don't know what's wrong. I love my son, but I feel so let down. I seem to cry for no reason!" The nurse would recognize that the woman is experiencing: 1. Postpartum (PP) blues. 2. Infant attachment disorder. 3. Postpartum depression (PPD). 4. Taking-in.
1. Postpartum (PP) blues. During the PP blues women are emotionally labile, often crying easily and for no apparent reason. This lability seems to peak around the fifth PP day. The taking-in phase is the period after birth when the mother focuses on her own psychologic needs. Typically this period lasts 24 hours. PPD is an intense, pervasive sadness marked by severe, labile mood swings; it is more serious and persistent than the PP blues. Crying is not a maladaptive attachment response; it indicates PP blues.
A woman who is 14 weeks pregnant tells the nurse that she always had a glass of wine with dinner before she became pregnant. She has abstained during her first trimester and would like to know if it is safe for her to have a drink with dinner now. The nurse would tell her: 1. "Because no one knows how much or how little alcohol it takes to cause fetal problems, the best course is to abstain throughout your pregnancy." 2. "Since you're in your second trimester, you can drink 2-3 drinks per week." 3. "Since you're in your second trimester, there's no problem with having one drink with dinner." 4. "One drink every night is too much. One drink three times a week should be fine."
1. "Because no one knows how much or how little alcohol it takes to cause fetal problems, the best course is to abstain throughout your pregnancy." "Because no one knows how much or how little alcohol it takes to cause fetal problems, the best course is to abstain throughout your pregnancy" is an accurate statement. A safe level of alcohol consumption during pregnancy has not yet been established. Although the consumption of occasional alcoholic beverages may not be harmful to the mother or her developing fetus, complete abstinence is strongly advised.
A woman who is 32 weeks pregnant is informed by the nurse that a danger sign of pregnancy could be: 1. A decrease in the pattern of fetal movement. 2. Heart palpitations. 3. Constipation 4. Edema in the ankles and feet at the end of the day.
1. A decrease in the pattern of fetal movement. A decreased amount of fetal movement may indicate fetal jeopardy. Constipation, heart palpitations, and ankle and foot edema are normal discomforts of pregnancy that occur in the second and third trimesters.
An RH-negative woman (2-2-0-0-2) has just given birth to an RH-positive baby boy. The direct and indirect Coombs' test results are both negative. The nurse: 1. Administers RhoGAM intramuscularly to the mother within 72 hours of birth. 2. Prepares to administer RhoGAM to the newborn within 24 hours of his birth. 3. Recognizes that RhoGAM is not needed because the Coombs' test results are negative. 4. Observes the newborn closely for signs of pathologic jaundice.
1. Administers RhoGAM intramuscularly to the mother within 72 hours of birth. RhoGAM should be administered to the mother within 72 hours of birth to prevent formation of antibodies. It would not be given if antibodies have already formed as indicated by a positive Coombs' test. Pathologic jaundice is unlikely because Coombs' test results indicate that antibodies have not been formed to destroy the newborn's RBC's.
Neonatal hyperbilirubinemia should be considered pathologic if which of the following criteria are met? Select all that apply. 1. Clinically evident jaundice within the first 24 hours of life. 2. Clinical jaundice persisting for more than 7 days in a term newborn. 3. An increase in serum bilirubin concentration by more than 0.1 mg/dL per hour. 4. Total serum bilirubin concentration exceeding the 95th percentile on the nomogram.
1. Clinically evident jaundice within the first 24 hours of life. 4. Total serum bilirubin concentration exceeding the 95th percentile on the nomogram. The primary cause of pathologic hyperbilirubinemia is hemolytic disease of the newborn. Newborns of Rh-negative and O blood type mothers are carefully assessed for blood type status, appearance of jaundice, and levels of serum bilirubin. Physiologic jaundice is typically due to the newborn's increased red blood cell mass, shorter red cell lifespan, slower uptake of bilirubin by the liver, lack of intestinal bacteria, and/or poorly established hydration from initial breastfeeding.
A 9 pound, 6 ounce newborn is delivered to a diabetic mother who has indicated that she wishes to breastfeed. The initial blood glucose reading is 32 mg/dL. The most appropriate action by the nurse at this time is: 1. Encourage breastfeeding. 2. Give oral glucose water. 3. Advise the mother that the baby should be bottle fed for the initial feeding. 4. Begin IV dextrose solution D10W.
1. Encourage breastfeeding. Adequate caloric intake by early breastfeeding or formula feeding is usually sufficient to prevent severe hypoglycemia and to meet the recommended fluid and caloric needs of the neonate. If breastfeeding is the mother's choice, the baby should not be supplemented with formula unless infant is not breastfeeding well. IV dextrose is used if glucose 20 mg/dL and baby is symptomatic and unable to tolerate oral feeds.
A radiant warmer will be used to help a newborn stabilize her termperature. The nurse implementing this care should: 1. Undress and dry the infant before placing her under the warmer. 2. Assess her rectal temperature every hour until her temperature stabilizes. 3. Place the thermistor probe on the left side of her chest just below her nipple. 4. Bundle the infant well to assist in warming.
1. Undress and dry the infant before placing her under the warmer. The infant should be dry and undressed, wearing only a diaper under the radiant warmer. The probe should be placed in the right upper quadrant of the abdomen below the intercostal margin, never over a rib. Axillary, not rectal, temperature should be taken every hour.
A first-time mother is concerned about the type of medications she will receive during labor. She is in a fair amount of pain and is nauseous. In addition, she appears to be very anxious. You explain that opioid analgesics often are used with sedatives because: 1. "Administering these drugs together may help to prevent complications during your labor and birth." 2. "Sedatives help the opioid work better, and they also will help relax you and relieve your nausea." 3. "They work better together so you can sleep until you have the baby." 4. "This is what the doctor has ordered for you."
2. "Sedatives help the opioid work better, and they also will help relax you and relieve your nausea." Sedatives can be used to reduce the nausea and vomiting that often accompany opioid use. In addition, some ataractics reduce anxiety and apprehension and potentiate the opioid analgesic affects. A potentiator may cause the two drugs to work together more effectively, but it does not ensure maternal or fetal complications. Sedation may be a related effect of some ataractics, but it is not the goal. Furthermore, a woman is unlikely to be able to sleep through transitional labor and birth. "This is what the doctor has ordered for you" may be true, but it is not an acceptable comment for the nurse to make.
While assessing the newborn, the nurse should be aware that the average expected apical pulse range of a full-term, quiet, alert newborn is: 1. 150 to 180 beats/min. 2. 120 to 160 beats/min. 3. 80 to 100 beats/min. 4. 100 to 120 beats/min.
2. 120 to 160 beats/min. The average infant heart rate while awake is 120 to 160 beats/min. The newborn's heart rate may be about 85 to 100 beats/min while sleeping. The infant's heart rate typically is a bit higher when alert but quiet. A heart rate of 150 to 180 beats/min is typical when the infant cries.
Which woman is most likely to experience strong afterpains? 1. A woman who experienced oligohydramnios 2. A woman who is a gravida 4, para 4-0-0-4 3. A woman whose infant weighed 5 pounds, 3 ounces 4. A woman who is bottle-feeding her infant
2. A woman who is a gravida 4, para 4-0-0-4 Afterpains are more common in multiparous women. Afterpains are more noticeable with births in which the uterus was greatly distended, as in a woman who experienced polyhydramnios or a woman who delivered a large infant. Breastfeeding may cause afterpains to intensify.
A mother expresses fear about changing her infant's diaper after he is circumcised. What does the woman need to be taught to take care of the infant when she gets home? 1. Cleanse the penis with prepackaged diaper wipes every 3 to 4 hours. 2. Cleanse the penis gently with water and put petroleum jelly around the glans after each diaper change. 3. Apply constant, firm pressure by squeezing the penis with the fingers for at least 5 minutes if bleeding occurs 4. Wash off the yellow exudate that forms on the glans at least once every day to prevent infection.
2. Cleanse the penis gently with water and put petroleum jelly around the glans after each diaper change. Cleansing the penis gently with water and putting petroleum jelly around the glans after each diaper change is appropriate when caring for an infant who has had a circumcision. With each diaper change, the penis should be washed off with warm water to remove any urine or feces. If bleeding occurs, the nurse should apply gentle pressure to the site of the bleeding with a sterile gauze square. Yellow exudates cover the glans penis in 24 hours after the circumcision. This is part of normal healing and not an infective process. The exudates should not be removed.
The nurse observes that a 15-year-old mother seems to ignore her newborn. A strategy that the nurse can use to facilitate mother-infant attachment in this mother is to: 1. Explain to the mother she needs to mature to facilitate mother-infant attachment. 2. Show the mother how the infant initiates interaction and pays attention to her. 3. Arrange for the mother to watch a video on parent-infant interaction. 4. Demonstrate for the mother different positions for holding her infant while feeding.
2. Show the mother how the infant initiates interaction and pays attention to her. Pointing out the responsiveness of the infant is a positive strategy for facilitating parent-infant attachment. Telling the mother that she needs more maturity to parent may be perceived as derogatory and is not appropriate. Educating the young mother in infant care is important, but pointing out the responsiveness of her baby is a better tool for facilitating mother-infant attachment. Videos are an educational tool that can demonstrate parent-infant attachment, but encouraging the mother to recognize the infant's responsiveness is more appropriate.
A first-time father is changing the diaper of his 1-day-old daughter. He asks the nurse, "What is this black, sticky stuff in her diaper?" The nurse's best response is: 1. "That's transitional stool, which is normal for a 1-day-old." 2. "Oh, don't worry about that. It's okay." 3. "That's meconium, which is your baby's first stool. It's normal." 4. "This could be a sign of internal bleeding.I will notify your baby's doctor immediately."
3. "That's meconium, which is your baby's first stool. It's normal." "That's meconium, which is your baby's first stool. It's normal" is an accurate statement and the most appropriate response. Transitional stool is greenish brown to yellowish brown and usually appears by the third day after initiation of feeding. "This could be a sign of internal bleeding" is not accurate. "Oh, don't worry about that. It's okay" is not an appropriate statement. It is belittling to the father and does not educate him about the normal stool patterns of his daughter.
A primipara asks the nurse why her baby is wearing a cap and is snugly wrapped in warm blankets after birth. What is the best response for the nurse to make? 1. "Babies feel more secure when they are snugly wrapped." 2. "Babies who are stressed by being too cold risk hypoxemia, acidemia, and death, so we take measures to keep them warm. 3. "Wrapping the baby and putting a cap on his head helps to prevent heat loss, which can be a problem for newborn babies." 4. "Are you concerned about your baby?"
3. "Wrapping the baby and putting a cap on his head helps to prevent heat loss, which can be a problem for newborn babies." The nurse provides clear and simple education about newborn care to new parents, including measures that are taken to prevent cold stress of the neonate.
A client is warm and asks for a fan in her room for her comfort. The nurse enters the room to assess the mother and her infant and finds the infant unwrapped in his crib with the fan blowing over him on "high." The nurse instructs the mother that the fan should not be directed toward the newborn and the newborn should be wrapped in a blanket. The mother asks why. The nurse's best response is: 1. "Your baby may lose heat by conduction, which means that he will lose heat from his body to the cooler ambient air. You should keep him wrapped and prevent cool air from blowing on him." 2. "Your baby may lose heat by evaporation, which means that he will lose heat from his body to the cooler ambient air. You should keep him wrapped and prevent cool air from blowing on him." 3. "Your baby may lose heat by convection, which means that he will lose heat from his body to the cooler ambient air. You should keep him wrapped and prevent cool air from blowing on him." 4. "Your baby will get cold stressed easily and needs to be bundled up at all times."
3. "Your baby may lose heat by convection, which means that he will lose heat from his body to the cooler ambient air. You should keep him wrapped and prevent cool air from blowing on him."
An infant is born in the breech position. Because Erb's palsy may be seen as a result of a difficult forceps or breech delivery, the nurse should assess the infant for: 1. Loss of grasp reflex on the affected side. 2. Inability to turn the head to the affected side. 3. A flaccid arm with the elbow extended. 4. A negative Moro reflex on the unaffected side.
3. A flaccid arm with the elbow extended. In Erb's Duchenne palsy, there is damage to spinal nerves C5 and C6, which causes paralysis of the arm. The grasp reflex will be intact because the fingers are not affected. If C8 is injured, paralysis of the hand results (Klumpke's). There is no difficulty with turning the head with Erb's palsy, and the negative Moro reflex would only occur on the affected side.
A multiparous woman has been in labor for 8 hours. Her membranes have just ruptured. The nurse's initial response would be to: 1. Prepare the woman for imminent birth. 2. Document the characteristics of the fluid. 3. Assess the fetal heart rate and pattern. 4. Notify the woman's primary health care provider.
3. Assess the fetal heart rate and pattern. The umbilical cord may prolapse when the membranes rupture. The fetal heart rate and pattern should be monitored closely for several minutes immediately after ROM to ascertain fetal well-being, and the findings should be documented. Rupture of membranes (ROM) may increase the intensity and frequency of the uterine contractions, but it does not indicate that birth is imminent. The nurse may notify the primary care provider after ROM occurs and the fetal well-being and response to ROM have been assessed. The nurse's priority is to assess fetal well-being. The nurse should document the characteristics of the amniotic fluid, but the initial response is to assess fetal well-being and the response to ROM.
The nurse assessing a newborn knows that the most critical physiologic change required of the newborn is: 1. Full function of the immune defense system at birth. 2. Closure of fetal shunts in the circulatory system. 3. Initiation and maintenance of respirations. 4. Maintenance of a stable temperature.
3. Initiation and maintenance of respirations. The most critical adjustment of a newborn at birth is the establishment of respirations. The cardiovascular system changes markedly after birth as a result of fetal respiration, which reduces pulmonary vascular resistance to the pulmonary blood flow and initiates a chain of cardiac changes that support the cardiovascular system. The infant relies on passive immunity received from the mother for the first 3 months of life. After the establishment of respirations, heat regulation is critical to newborn survival.
A collection of blood between the skull bone and its periosteum is known as a cephalhematoma. To reassure the new parents whose infant develops such a soft bulge, it is important that the nurse be aware that this condition: 1. Only happens as the result of a forceps or vacuum delivery. 2. Will gradually absorb over the first few months of life. 3. May occur with spontaneous vaginal birth. 4. Is present immediately after birth.
3. May occur with spontaneous vaginal birth. Bleeding may occur during a spontaneous vaginal delivery as a result of the pressure against the maternal bony pelvis. The soft, irreducible fullness does not pulsate or bulge when the infant cries. Low forceps and other difficult extractions may result in bleeding. However, these can also occur spontaneously. The swelling may appear unilaterally or bilaterally and is usually minimal or absent at birth. It increases over the first 2 to 3 days of life. Cephalhematomas disappear gradually over 2 to 3 weeks. A less common condition results in calcification of the hematoma, which may persist for months.
A new father wants to know what medication was put into his infant's eyes and why it is needed. The nurse explains to the father that the purpose of the Ilotycin ophthalmic ointment is to: 1. Moisten the infants eyes, which helps the infant see. 2. Prevent potentially harmful exudate from invading the tear ducts of the infant's eyes, leading to dry eyes. 3. Prevent gonorrheal and chlamydial infection of the infant's eyes potentially acquired from the birth canal. 4. Destroy an infectious exudate caused by Staphylococcus aureus that could make the infant blind.
3. Prevent gonorrheal and chlamydial infection of the infant's eyes potentially acquired from the birth canal The purpose of the Ilotycin ophthalmic ointment is to prevent gonorrheal and chlamydial infection of the infant's eyes potentially acquired from the birth canal. Prophylactic ophthalmic ointment is instilled in the eyes of all neonates to prevent gonorrheal or chlamydial infection. Prophylactic ophthalmic ointment is not instilled to prevent dry eyes. It is instilled to prevent gonorrheal or chlamydial infection. Prophylactic ophthalmic ointment has no bearing on vision other than to protect against infection that may lead to vision problems.
The normal term infant has little difficulty clearing its airway after birth. Most secretions are brought up to the oropharynx by the cough reflex. However, if the infant has excess secretions, the mouth and nasal passages can be cleared easily with a bulb syringe. When instructing parents on the correct use of this piece of equipment, it is important that the nurse teach them to: 1. Insert the compressed bulb into the center of the mouth. 2. Avoid suctioning the nares. 3. Suction the mouth first. 4. Remove the bulb syringe from the crib when finished.
3. Suction the mouth first. The mouth should be suctioned first to prevent the infant from inhaling pharyngeal secretions by gasping as the nares are suctioned. The nasal passages should be suctioned one nostril at a time. The mouth should always be suctioned first. After compression of the bulb it should be inserted into one side of the mouth. If it is inserted into the center of the mouth, the gag reflex is likely to be initiated. When the infant's cry no longer sounds as though it is through mucus or a bubble, suctioning can be stopped. The bulb syringe should remain in the crib so that it is easily accessible if needed again.
With regard to umbilical cord care, nurses should be aware that: 1. The cord clamp is removed at cord separation. 2. The cord stump should be cleaned with alcohol after each diaper change. 3. The stump can easily become infected. 4. nurse noting bleeding from the vessels of the cord should immediately call for assistance.
3. The stump can easily become infected. The cord stump is an excellent medium for bacterial growth. The nurse should first check the clamp (or tie) and apply a second one. If the bleeding does not stop, the nurse calls for assistance. The cord clamp is removed after 24 hours when it is dry. Alcohol should not be used and is not necessary for cord stump cleaning.
A newborn at 5 hours old wakes from a sound sleep and becomes very active. He exhibits the following signs when assessed. Which one would require further assessment? 1. Passage of large amount of thick, dark meconium. 2. Heart rate of 170 BPM with crying. 3. Two apneic episodes of 16 and 20 seconds in duration. 4. Increased mucous production.
3. Two apneic episodes of 16 and 20 seconds in duration. The newborn at 5 hours of age is in the second period of reactivity during which tachycardia, tachypnea, increased muscle tone, skin color changes, mucous production, passage of meconium occur. Although a neonate can experience periods of apnea up to 15 seconds duration, these should not exceed 15 seconds.
The perinatal nurse is caring for a woman in the immediate postbirth period. Assessment reveals that the woman is experiencing profuse bleeding. The most likely etiology for the bleeding is: 1. Vaginal hematoma. 2. Uterine inversion. 3. Uterine atony. 4. Vaginal laceration.
3. Uterine atony. Uterine atony is marked hypotonia of the uterus. It is the leading cause of postpartum hemorrhage. Uterine inversion may lead to hemorrhage, but it is not the most likely source of this client's bleeding. Furthermore, if the woman were experiencing a uterine inversion, it would be evidenced by the presence of a large, red, rounded mass protruding from the introitus. A vaginal hematoma may be associated with hemorrhage. However, the most likely clinical finding would be pain, not the presence of profuse bleeding. A vaginal laceration may cause hemorrhage, but it is more likely that profuse bleeding would result from uterine atony. A vaginal laceration should be suspected if vaginal bleeding continues in the presence of a firm, contracted uterine fundus.
A woman is 3 months pregnant. At her prenatal visit she tells the nurse that she doesn't know what is happening; one minute she's happy that she is pregnant, and the next minute she cries for no reason. Which response by the nurse is most appropriate? 1. "Perhaps you really don't want to be pregnant." 2. "Have you talked to your husband about how you feel?" 3. "Don't worry about it; you'll feel better in a month or so." 4. "Hormonal changes during pregnancy commonly result in mood swings."
4. "Hormonal changes during pregnancy commonly result in mood swings." "Hormonal changes during pregnancy commonly result in mood swings" is an accurate statement and the most appropriate response by the nurse. "Don't worry about it; you'll feel better in a month or so" dismisses the client's concerns and is not the most appropriate response. Although women should be encouraged to share their feelings, "Have you talked to your husband about how you feel" is not the most appropriate response and does not provide the client with a rationale for the psychosocial dynamics of her pregnancy. "Perhaps you really don't want to be pregnant" is completely inappropriate and deleterious to the psychologic well-being of the woman. Hormonal and metabolic adaptations often cause mood swings in pregnancy. The woman's responses are normal. She should be reassured about her feelings.
Shortly following birth, a newborn is diagnosed as having Erb's palsy. The nurse is aware that this problem is caused by: 1. Nerve damage associated with fracture of the clavicle. 2. Pressure on the baby's head during vacuum delivery. 3. Emergency cesarean birth. 4. An injury to the brachial plexus nerve during birth.
4. An injury to the brachial plexus nerve during birth. Erb's brachial palsy occurs when the brachial plexus (the group of nerves that supplies the arms and hands) is injured. It is most common when there is difficulty delivering the baby's shoulder, called shoulder dystocia. The baby loses the ability to flex and rotate the arm. It is not caused by emergency cesarean birth or pressure on the baby's head during vacuum delivery.
A new mother wants to be sure that she is meeting her daughter's needs while feeding her commercially prepared infant formula. The nurse should evaluate the mother's knowledge about appropriate infant care. The mother meets her child's needs when she: 1. Warms the bottles using a microwave oven. 2. Refrigerates any leftover formula for the next feeding. 3. Adds rice cereal to her formula at 2 weeks of age to ensure adequate nutrition. 4. Burps her infant during and after the feeding as needed.
4. Burps her infant during and after the feeding as needed. Most infants swallow air when fed from a bottle and should be given a chance to burp several times during a feeding and after the feeding. Solid food should not be introduced to the infant for at least 4 to 6 months after birth. A microwave should never be used to warm any food to be given to an infant. The heat is not distributed evenly, which may pose a risk of burning the infant. Any formula left in the bottle after the feeding should be discarded because the infant's saliva has mixed with it.
The most common cause of pathologic hyperbilirubinemia is: 1. Poorly established hydration from initial breastfeeding. 2. Shorter red cell lifespan in the newborn. 3. Increased red blood cell mass in the newborn. 4. Hemolytic disease in the newborn.
4. Hemolytic disease in the newborn. The primary cause of pathologic hyperbilirubinemia is hemolytic disease of the newborn. Newborns of Rh-negative and O blood type mothers are carefully assessed for blood type status, appearance of jaundice, and levels of serum bilirubin. Physiologic jaundice is typically due to the newborn's increased red blood cell mass, shorter red cell lifespan, slower uptake of bilirubin by the liver, lack of intestinal bacteria, and/or poorly established hydration from initial breastfeeding.
The neonate of a diabetic mother will be screened for hypoglycemia by the nurse: 1. Observing for signs of hypoglycemia. 2. Beginning a glucose tolerance test. 3. Drawing blood for serum glucose. 4. Performing a heel stick using a glucose oxidase test strip.
4. Performing a heel stick using a glucose oxidase test strip. An infant of a diabetic mother will be screened for hypoglycemia by testing glucose level with a glucose oxidase test strip, not serum glucose testing. Glucose tolerance tests are not performed in newborns. Although the newborn should be observed for signs of hypoglycemia, an objective measure of glucose should also be performed.
A newborn is jaundiced and receiving phototherapy via ultraviolet bank lights. An appropriate nursing intervention when caring for an infant with hyperbilirubinemia and receiving phototherapy by this method would be to: 1. Change the newborn's position every 4 hours. 2. Limit the newborn's intake of milk to prevent nausea, vomiting, and diarrhea. 3. Apply an oil-based lotion to the newborn's skin to prevent dying and cracking. 4. Place eye shields over the newborn's closed eyes.
4. Place eye shields over the newborn's closed eyes. The infant's eyes must be protected by an opaque mask to prevent overexposure to the light. Eye shields should cover the eyes completely but not occlude the nares. Lotions and ointments should not be applied to the infant because they absorb heat, and this can cause burns. The lights increase insensible water loss, placing the infant at risk for fluid loss and dehydration. Therefore it is important that the infant be adequately hydrated. The infant should be turned every 2 hours to expose all body surfaces to the light.
Nurses should be able to tell breastfeeding mothers that all of these are signs that the infant has latched on correctly to her breast except: 1. The baby's jaw glides smoothly with sucking. 2. She feels a firm tugging sensation on her nipples but not pinching or pain. 3. The baby sucks with cheeks rounded, not dimpled. 4. She hears a clicking or smacking sound.
4. She hears a clicking or smacking sound. The clicking or smacking sound may indicate that the baby is having difficulty keeping the tongue out over the lower gum ridge. The mother should hope to hear the sound of swallowing. The tugging sensation without pinching is a good sign. The clicking or smacking sound may indicate that the baby is having difficulty keeping the tongue out over the lower gum ridge. The mother should hope to hear the sound of swallowing. Rounded cheeks are a good sign. The clicking or smacking sound may indicate the baby is that having difficulty keeping the tongue out over the lower gum ridge. The mother should hope to hear the sound of swallowing. A smoothly gliding jaw is a good sign. The clicking or smacking sound may indicate that the baby is having difficulty keeping the tongue out over the lower gum ridge. The mother should hope to hear the sound of swallowing.
Bleeding disorders in late pregnancy include all of these except: 1. Placental abruption. 2. Placenta previa. 3. Uterine rupture. 4. Spontaneous abortion.
4. Spontaneous abortion. Spontaneous abortion is another name for miscarriage; by definition it occurs early in pregnancy. Placenta previa is a cause of bleeding disorders in later pregnancy. Abruptio placentae is a cause of bleeding disorders in later pregnancy. Uterne rupture is a cause of bleeding in later pregnancy.
The cheeselike, whitish substance that fuses with the epidermis and serves as a protective coating is called: 1. Acrocyanosis 2. Surfactant 3. Caput succedaneum 4. Vernix caseosa
4. Vernix caseosa This protection, vernix caseosa, is needed because the infant's skin is so thin. Surfactant is a protein that lines the alveoli of the infant's lungs. Caput succedaneum is the swelling of the tissue over the presenting part of the fetal head. Acrocyanosis is cyanosis of the hands and feet, resulting in a blue coloring.
During the first trimester, a woman can expect which of the following changes in her sexual desire? An increase, because of enlarging breasts A decrease, because of lack of partner interest in sexual activity. An increase, because of increased levels of androgenic hormones. A decrease, because of nausea and fatigue.
A decrease, because of nausea and fatigue.
At 1 minute after birth the nurse assesses the infant and notes: a heart rate of 80 beats/min, some flexion of extremities, a weak cry, grimacing, and a pink body but blue extremities. The nurse would calculate an Apgar score of: A. 7 B. 4 C. 6 D. 5
D. 5 Each of the five signs the nurse noted would score a 1 on the Apgar scale, for a total of 5.
A woman is giving birth to her third child in a setting that allows her husband and other two children to be actively involved in the process. The nurse caring for the woman must also consider the husband and family as patients and work to meet their needs. This type of setting is termed: Family-centered care Individualized care Structured care Birthing care
Family-centered care
Cardiovascular system changes occur during pregnancy. Which finding would be considered normal for a woman in her second trimester? Increased blood pressure Decreased red blood cell (RBC) production Increased pulse rate Less audible heart sounds (S1, S2)
Increased pulse rate Between 14 and 20 weeks of gestation, pulse increases about 10 -15 beats/min, which persists to term.
When caring for pregnant women, the nurse should keep in mind that violence during pregnancy: May be associated with complications of pregnancy such as bleeding. Affects more than 25% of pregnant women in the United States. Increases a pregnant woman's risk for preeclampsia. Has decreased in incidence as a result of better assessment techniques and record keeping.
May be associated with complications of pregnancy such as bleeding.
The family structure consisting of parents and their dependent children living together is known as a(n) Nuclear family Reconstituted family Alternative family Extended family
Nuclear family
A Hispanic woman has just given birth. The nurse caring for the woman should recognize that the woman may: Request that her newborn be supplemented with formula before her milk comes in. Remain on bed rest for 7 days after giving birth. Request a fan in her room to keep her infant cool. Ask to shower before breast feeding.
Request that her newborn be supplemented with formula before her milk comes in.
A gravida's fundal height is noted to be just above the pubic symphysis The nurse is aware that which of the following fetal changes is likely to be occurring at the same time in the pregnancy? Surfactant is sufficient in the fetal lungs for life outside the womb. Eyes begin to open and close. Respiratory movements begin The spinal column is completely formed.
The spinal column is completely formed. The column is formed by 8 weeks and since she is probably about 12 weeks gestation this is correct.
