OB comprehensive final review

The nurse has completed breastfeeding discharge instructions and determines the mother understands the instructions when she makes which statement(s)? Select all that apply.

"Any drugs I take may pass through to my baby though breast milk" "babies should have 6-8 wet diapers a day after the first 3 days of life" "I have the phone number for the lactation consultant if I have questions" Explanation: Maternal intake will need to increase approximately 500 calories/day while breastfeeding. It is true that many drugs taken by the mother cross through breast milk. When any medication is taken by the breastfeeding mom, the medication should be determined to be safe with the OB's or pediatrician's office. Infants who have six to eight wet diapers per day have had an adequate intake of breast milk. If there are fewer, the mother should try to increase the frequency of the infant's feedings. Within the first 24 to 72 hours of life, there will be fewer wet diapers as the mother's milk has not come in yet. Prior to discharge, clients should know how to access community resources to support breastfeeding. After a mother's breast milk is in at about the third day after birth, the infant should be satisfied for approximately 1½ to 3 hours after feeding. There is a need for more frequent feedings with breastfed infants than bottle-fed as the fat content in the breast milk is lower.

The mother of a neonate expresses concern about how she'll continue to breastfeed when she returns to work in 6 weeks. Which response by the nurse is best?

"you can plan from now to continue breastfeeding after you go back to work. You can pump your breasts in the morning and in the evening and put the milk in a bottle to store in the fridge" Explanation: Breastfeeding should continue for at least 6 months after birth whenever possible for maximum benefits. Breast milk can be pumped at before and during work to give to the neonate at the day-care center. Pumping will also support continuous mother's milk production.

Which behavior should cause the nurse to suspect that a client's labor is moving quickly and that the physician should be notified?

An increased sense of rectal pressure explanation: An increased sense of rectal pressure indicates that the client is moving into the second stage of labor. The nurse should be able to discern that information by the client's behavior.

A client is breastfeeding her newborn infant. The client's nipples are red and bruised, and a small crack is visible on the right nipple. Which intervention should the nurse do next?

Assist the client to have the infant create a correct latch to the breast Explanation: A good latch will be comfortable and should not cause redness, bruising, or cracks. Therefore, the nurse should intervene with the most probable cause of this complication; an incorrect latch. Whether a newborn has a cleft palate, a well-developed/strong suck reflex, or whether the mother has sensitive nipples, there should not be redness and ecchymosis to the areola.

What interval should the nurse use when assessing the frequency of contractions of a multiparous client in active labor admitted to the birthing area?

Beginning of one contraction to the beginning of the next Explanation: To assess the frequency of the client's contractions, the nurse should assess the interval from the beginning of one contraction to the beginning of the next contraction.

The nurse caring for a multigravida in active labor observes a variable fetal heart rate deceleration pattern. What should the nurse do first?

Change the client's position Explanation: A variable deceleration pattern of the fetal heart rate is usually due to cord compression. This may be a result of the cord around the presenting part, a short cord, or the maternal position. Tx involved changes maternal position. If this does not resolve the variable heart rate pattern, the primary care provider or nurse midwife should be notified

The nurse is beginning a shift caring for a group of postpartum clients. Which client should the nurse see first?

Client reports she has pain in the left calf Explanation: The priority problem that the nurse should address first is the client who is having pain in the calf, as this may indicate that the client has thrombophlebitis and has a potential risk for thromboembolism.

Which practice should a nurse recommend to a client who has had a cesarean birth?

Coughing and deep breathing exercises Explanation: As for any postoperative client this client needs to be taught coughing and deep-breathing exercises to keep the alveoli open and prevent infection.

The nurse is explaining to a primigravida in labor that her baby is in a breech presentation, with the baby's presenting part in a left, sacrum, posterior (LSP) position. Which illustration should the nurse use to help the client understand how her baby is positioned?

Figure showing baby in breech, feet towards cervix Explanation: The figure shows the client's baby is a breech presentation with the baby facing the pelvis on the left, the sacrum as the presenting part, and the presenting part (sacrum) is posterior in the pelvis

A client preparing for discharge with her first baby states that she does not know how to bathe her infant. The nurse demonstrates how to bathe the newborn. What is the best method to reinforce the teaching?

Have the client return demonstrate how to bathe the infant Explanation: The nurse should show the woman how to bathe the infant and evaluate understanding by having her return demonstrate the skill.After the client return demonstrates the skill, the nurse can also recommend the newborn care classes, ask if there are further questions and recommend the hospital newborn care booklet.

The nurse is to draw a blood sample for glucose testing from a term neonate during the first hour after birth. The nurse should obtain the blood sample from the neonate's foot near which area?

Heel stick on the sides of the heel, not the middle. Explanation: In a neonate, the lateral aspect of the heel is the most appropriate site for obtaining a blood specimen. Using this area prevents damage to the calcaneus bone, which is located in the middle of the heel. The middle of the heel is to be avoided because of the increased risk for damaging the calcaneus bone located there. The middle of the foot contains the medial plantar nerve and the medial plantar artery, which could be injured if this site is selected. Using the base of the big toe as the site for specimen collection would cause a great deal of discomfort for the neonate; therefore, it is not the preferred site

A new father indicates he feels left out of the new family relationship since he is not able to bond the same way as the breastfeeding mother. What is the most appropriate response by the nurse?

Holding, talking to and playing with the infant will facilitate bonding between baby and Dad Explanation: Time for bonding with their newborns is a frequent concern for fathers of breastfed babies. It is common for fathers to express concern about having less intimate contact time. These feelings are normal, but they do not go away in a few days. The father of the baby has to dedicate time to spend with the infant where he can talk to, hold, cuddle, and/or play with the infant. These strategies provide the infant with the contact and stimulation to establish a close bond between them. Bonding occurs from the moment of birth and continues in various ways between mother, father, and infant. Infants recognize and respond to touch, light, and voice immediately after birth. Bonding between both parents is equally important and one does not take priority over the other

A nurse assesses a client's vaginal discharge on the first postpartum day and describes it in the progress note (shown above). Which terms best identifies the discharge?

Lochia rubra Explanation: For the first 3 days after birth, the discharge is called lochia rubra. It consists almost entirely of blood, with only small particles of decidua and mucus. Lochia alba is a creamy white or colorless discharge that occurs 10 to 14 days postpartum. Lochia serosa is a pink or brownish discharge that occurs 4 to 14 days postpartum. The term lochia alone is not a correct description of the discharge.

A multigravid client in active labor at 39 weeks' gestation has a history of smoking one to two packs of cigarettes daily. Which problem is the nurse most likely to find during the infant's assessment?

Low birth weight Explanation: Neonates born to mothers who smoke tend to have lower-than-average birth weights. Neonates born to mothers who smoke also are at higher risk for stillbirth, sudden infant death syndrome, bronchitis, allergies, delayed growth and development, and polycythemia.

During the assessment, the nurse observes a gray pigmented nevus on the neonate's buttocks. The nurse documents this as which finding?

Mongolian spot Explanation: Mongolian spots are gray, blue, or black marks that are found most frequently on the sacral area but also may be on the buttocks, arms, shoulders, or other areas. No treatment is necessary because these usually fade or disappear during the first few years of life.Harlequin's sign, manifested as one side of the body turning a deep red color, occurs when blood vessels on one side of the body constrict while those on the other side of the body dilate. The observance of Harlequin's sign should be documented and reported.Port-wine stains, flat purple-red sharply demarcated areas, or hemangiomas, dark red color lesions, or vascular tumors, are nevi flammeus and do not disappear with time.Cafe au lait spots are flat, patchy, light brown areas.

When preparing a teaching plan for a client who is to receive a rubella vaccine during the postpartum period, the nurse should include which information?

Pregnancy should be avoided for 4 weeks after the immunization Explanation: After administration of rubella vaccine, the client should be instructed to avoid pregnancy for at least 4 weeks to prevent the possibility of the vaccine's teratogenic effects to the fetus.

During labor, a client greatly relies on her partner for support. They previously attended childbirth education classes, and now he's working with her on comfort measures. Which nursing dx is appropriate for this couple?

Readiness for enhanced family coping related to participation in pregnancy and delivery Explanation: The client and her partner are working together for a common goal. He's offering support, and they're sharing the experience of childbirth, making Readiness for enhanced family coping related to participation in pregnancy and delivery and appropriate nursing diagnosis

The nurse is caring for a client on her second postpartum day. The nurse should expect the client's lochia to be

Red and moderate Explanation: During the first 3 days, the lochia will be red (lochia rubra) with moderate flow. Note, however, that the client shouldn't be soaking more than one pad every hour. A continuous flow of moderately clotted blood from the vagina isn't normal and should be reported. Clots may indicate retained pieces of placenta. Lochia changes to pink or brown (lochia serosa) after 3 to 10 days. By day 10, the lochia should be white (lochia alba) and continue for several weeks.

A multiparous client, 28 hours after cesarean birth, who is breastfeeding has severe cramps or afterpains. The nurse explains that these are caused by which factor?

Release of oxytocin during the breastfeeding session Explanation: Breastfeeding stimulates oxytocin secretion, which causes the uterine muscles to contract. These contractions account for the discomfort associated with afterpains.

The nurse is explaining to a client why she can have only fluids while in labor. Which client statement indicates that the teaching has been effective?

The digestive process is normally slow during labor Explanation: Recommendations for food and fluid intake during labor vary widely in the literature and in clinical practice. Because gastric emptying is slower in pregnancy and labor and the potential for nausea and vomiting (common late in the first stage of labor) poses a risk for aspiration of stomach contents, clients are often limited to clear fluids or ice chips.

A multiparous client whose fundus is firm and midline at the umbilicus 8 hours after a vaginal birth tells the nurse that when she ambulated to the bathroom after sleeping for 4 hours, her dark red lochia seemed heavier. Which information would the nurse include when explaining to the client about the increased lochia on ambulation?

The increased lochia occurs from lochia pooling in the vaginal vault Explanation: Lochia can be expected to increase when the client first ambulates. Lochia tends to pool in the uterus and vagina when the client is recumbent and flows out when the client arises. If the client had reported that her lochia was bright red, the nurse would suspect bleeding. In this situation, the client would be put back in bed and the HCP would be notified. Early postpartum hemorrhage occurs during the first 24 hours, but typically the fundus is soft or "boggy." The client's fundus here is firm and midline. Late postpartal hemorrhage, occurring after the first 24 hours, is usually caused by retained placental fragments or abnormal involution of the placental site.

The nurse is instructing the mother of a newborn about administering erythromycin ointment. Which statement made by the mother demonstrates that the instruction was effective?

This is placed in both eyes to prevent infection Explanation: Erythromycin ointment is placed the eyes to prevent infection in the eyes from exposure during birth.

The cervix of a 15-year-old primigravid client admitted to the labor area is 2 cm dilated and 50% effaced. Her membranes are intact, and contractions are occurring every 5 to 6 minutes. Which intervention should the nurse recommend at this time?

Walking around in the hallway Explanation: Most authorities suggest that a woman in an early stage of labor should be allowed to walk if she wishes as long as no complications are present. Birthing centers and single-room maternity units allow women considerable latitude without much supervision at this stage of labor. Gravity and walking can assist the process of labor in some clients. If the client becomes tired, she can rest in bed in the left lateral recumbent position or sit in a comfortable chair. Resting in the left lateral recumbent position improves circulation to the fetus.

When assessing a postterm neonate, what is considered a normal finding?

Wrinkled, peeling skin Explanation: A common finding for postmature neonates is wrinkled, peeling skin.

The health care provider (HCP) has prescribed prostaglandin gel to be administered vaginally to a newly admitted primigravid client. Which finding indicates that the client has had a therapeutic response to the medication?

softening of the cervix and beginning effacement Explanation: Prostaglandin gel may be used for cervical ripening before the induction of labor with oxytocin. It is usually administered by catheter or suppository, or by vaginal insertion. Two to three doses are usually needed to begin the softening process. Common adverse effects include nausea, vomiting, fever and diarrhea. Continuous FHR monitoring and close monitoring of maternal vitals are necessary to detect subtle changes or adverse effects.

When teaching parents of a neonate the proper position for the neonate's sleep, a nurse stresses the importance of placing the neonate on his back to reduce the risk of

Sudden infant death syndrome (SIDS) Explanation: The supine position is recommended to reduce the risk of SIDS in infancy. The risk of aspiration is slightly increased with supine positioning. Although suffocation is less likely if the neonate is supine, the primary intervention for reducing suffocation risk is removing blankets and pillows from the crib.

What assessment data of a laboring woman would require further intervention by the nurse?

maternal heart rate 125 bpm explanation: All data are normal except for the maternal heart rate of 125 beats/minute. Normal maternal heart rate is 60-100 beats/minute. The elevated heart rate is a possible signal of developing complications.

After the nurse explains about the second stage of labor, which client statement would indicate to the nurse that the client understands the information discussed?

"I should try to push with each contraction" Explanation: The second stage of labor begins with complete cervical dilation and ends with birth. During this time, the client is encouraged to push with each contraction.

The nurse is caring for a newborn that has been prescribed naloxone hydrochloride. The newborn weighs 2.5 kg. The order states to give 0.1 mg/kg now. How many milligrams will the nurse administer to the newborn? Record your answer using two decimal places.

0.25 Explanation: 2.5 kg × 0.1 mg = 0.25 mg

While performing continuous electronic monitoring of a client in labor, the nurse should document which information about uterine contractions? You Selected:

Duration, frequency, and intensity Explanation: The nurse should document the duration, frequency, and intensity of uterine contractions.

The client who is breastfeeding asks the nurse if she should supplement breastfeeding with formula feeding. The nurse bases the response on which principle?

Formula feeding should be avoided to prevent interfering with the breast milk supply Explanation: Bottle supplements tend to cause a decrease in the breast milk supply and demand for breastfeeding. Unless medically necessary, bottle supplements should be avoided until breastfeeding is well established

During the immediate postpartum period after giving birth to twins, the client experiences uterine atony. What should the nurse do first?

Gently massage the fundus Explanation: Uterine atony means that the uterus is not firm because it is not contracting. First, the nurse should gently massage the uterus in an effort to help contract the uterus and make it firm. Clients with multiple gestation, polyhydramnios, prolonged labor, or large-for-gestational-age fetus are more prone to uterine atony.

After a lengthy labor, a primigravid client gives birth to a healthy newborn boy with a moderate amount of skull molding. What information would the nurse include when explaining to the parents about this condition?

It usually lasts a day or two before resolving Explanation: Molding occurs with vaginal births and is commonly seen in newborns. This is especially true with primigravid clients experiencing a lengthy labor process. Parents need to be reassured that it is not permanent and that it typically lasts a day or two before resolving. Molding rarely is present if the fetus is in a breech or brow presentation. Surgical intervention is not necessary.

A client tells the nurse that she wants to continue breast-feeding her toddler in addition to breast-feeding her neonate. The client's partner doesn't want her to continue breast-feeding the toddler fearing it will harm the neonate. Despite much discussion, the couple continues to disagree. Which health team member should the nurse consult to counsel the couple about breast-feeding issues?

Lactation consultant Explanation: A lactation consultant can best address the client's breast-feeding issues. The social worker could help the couple see each other's viewpoint but has no breast-feeding training. The physician and home health nurse don't have specialized breast-feeding education.

On a client's first postpartum day, nursing assessment reveals vital signs within normal limits, a boggy uterus, and saturation of the perineal pad with lochia rubra. Which nursing intervention takes highest priority?

Massage the uterus gently Explanation: If a postpartum client has a boggy (relaxed) uterus, the nurse should first massage her uterus gently to stimulate contraction (involution). The nurse should reassess the client 15 minutes later to ensure that massage was effective. If the uterus doesn't respond to massage, the nurse should administer oxytocin as ordered. The nurse should notify the physician or nurse-midwife if the client's uterus remains boggy after massage and oxytocin administration or if assessment reveals a rapid, thready pulse or decreased blood pressure.

A nurse is assessing a client on the second postpartum day. Upon palpation, the nurse discovers that the fundus is deviated to the right. To further investigate this finding, what should the nurse ask the client?

"Have you voided recently?" Explanation: The fundus should be palpated in the abdomen 2 days postpartum. The nurse should ask the client if she has voided recently because a full bladder may cause the fundus to deviate to the right or left.

A nurse demonstrates infant bathing to a primiparous client. Which statement by the client indicates a need for additional teaching?

"I have all kinds of pretty, scented soaps and lotions to bathe the baby with" Explanation: The client requires additional teaching if she states that she'll use scented soaps to bathe the infant. Scented and medicated soaps and lotions aren't recommended for infants because they may alter the skin pH, making the skin less able to fight infection. Bathing the infant in a warm room, sponge-bathing the infant until the cord area heals, and washing the eyes and face first are appropriate activities and indicate an understanding of teaching regarding infant bathing.

After the birth of a viable neonate, a 20-year-old primiparous client comments to her mother and the nurse about the baby. Which comment would the nurse interpret as a possible sign of potential maternal-infant bonding problems?

"I think my mother should give him the first feeding" Explanation: Avoidance, hostility, or low-key (passive) behavior toward the baby may be a cue to potential bonding problems. The nurse should encourage the client to give the baby the first feeding to begin the bonding process. Expressions of disappointment with the baby's gender may also signal problems with maternal-infant bonding

A client is exclusively breastfeeding her 1-week-old infant and is concerned about her baby taking enough milk per day. The client tells the nurse that the infant has six wet diapers per day. Which response by the nurse is most appropriate?

"That many wet diapers indicates your infant is adequately hydrated" Explanation: t is true that the baby may feed frequently and sleep well between feeds but these alone are not significant indicators of adequate feeding and hydration. The best indicator for adequate hydration with breastfed babies is if the baby is having six to eight heavy, wet diapers per day from day four onwards. The infant's sleeping pattern and the feeling of the breasts are not good indicators of the infant's nutritional intake.

While the nurse is assessing the fundus of a multiparous client who gave birth 24 hours ago, the client asks, "What can I do to get rid of these stretch marks?" Which response would be most appropriate?

"They usually fade to a silvery-white color over a period of time" Explanation: Stretch marks, or striae gravidarum, are caused by stretching of the tissues, particularly over the abdomen. After birth, the tissues atrophy, leaving silver scars. These skin pigmentations will not disappear completely. The striae gravidarum may reappear as pink streaks if the client becomes pregnant again. Special creams are not warranted because they are not helpful and may be expensive. Weight loss does not make the marks disappear. Striae gravidarum tend to run in families.

A client has just given birth to her first child, a healthy, full-term girl. The client is Rho(D)-negative and her neonate is Rh-positive. What intervention will be performed to reduce the risk of Rh incompatibility?

Administration of RH0(D) immune globulin IM to the mother within 72 hours Explanation: When a mother is Rho(D)-negative and a neonate is Rh-positive, the mother forms antibodies against the D antigen. Most of the antibodies develop within the first 72 hours after she has given birth as a result of the exchange of maternal and fetal blood during birth. If the mother becomes pregnant again, she'll have a high antibody D level that may destroy fetal blood cells during the second pregnancy. However, if the mother receives an injection of Rho(D) immune globulin within 72 hours, no antibodies will be formed. Rho(D) immune globulin may also be given to the mother during pregnancy if the neonate is Rh-positive. The neonate isn't given Rho(D) immune globulin.

A male neonate underwent circumcision. What nursing intervention is part of the initial care of a circumcised neonate?

Apply petroleum gauze to the site for 24 hours explanation: Petroleum gauze is applied to a circumcision site for the first 24 hours to prevent the skin edges from sticking to the diaper. Alcohol is contraindicated for circumcision care. Diapers are changed frequently, not as needed, to inspect the site. Neonates are initially kept in the prone position.

The nurse is assessing a postpartum client who gave birth 6 hours earlier. The nurse notes the fundus to be deviated to the left side of the umbilicus. Which action by the nurse is best?

Assist the client to the bathroom to void and reassess the fundus Explanation: When the fundus is elevated and to the side, the client's bladder is full. Having the client void and reassessing the fundus would be the appropriate intervention.

For a primigravid client with the fetal presenting part at -1 station, what would be the nurse's priority immediately after a spontaneous rupture of the membranes?

Check the FHR Explanation: Immediately after a spontaneous rupture of the membranes, the nurse should listen to the FHR to detect bradycardia. With the fetus at -1 station, the cord may prolapse as amniotic fluid rushes out. FHR should be monitored because it will indicate if cord prolapse or cord compression has occurred. The color, amount and odor of amniotic fluid should be noted.

Which action should a nurse perform immediately following the birth of a neonate?

Drying the neonate to stabilize the neonate's temperature explanation: The nurse's first action after birth is to dry the neonate and stabilize his temperature. Aspiration of the neonate's nose and mouth occurs at the time of delivery. Promoting parental bonding and identifying the neonate are appropriate after the neonate has been dried.

The nurse who is assessing the position, presentation, and lie of the fetus of a 9-month-pregnant client performs what action?

Leopold's maneuvers Explanation: Fetal position refers to the relationship of the fetus's presenting part to the mother's pelvis. Fetal posture refers to "attitude." Presentation refers to the part of the fetus at the cervical os. Lie refers to the relationship of the fetal long axis to that of the mother's long axis. The nurse assesses for these through Leopold's maneuvers, a series of four palpations of the uterus and fetus through the abdominal wall.

When the nurse accidentally bumps the bassinet, the neonate throws out its arms, hands opened, and begins to cry. The nurse interprets this reaction as indicative of which reflex?

Moro Reflex Explanation: The Moro, or startle, reflex occurs when the neonate responds to stimuli by extending the arms, hands open, and then moving the arms in an embracing motion. The Moro reflex, present at birth, disappears at about age 3 months.The Babinski reflex is elicited by stroking the neonate's foot resulting in the fanning of the toes. This reflex is normal in the neonate until approximately 3 months of age.The grasping reflex is demonstrated when the neonate grasps an object placed in the hand.The tonic neck reflex (or fencing reflex) is demonstrated when the neonate, lying supine, turns the head to one side.

The nurse is assisting a client who just received an epidural during the first stage of labor. Which medication does the nurse know may be needed at this time?

Oxytocin Explanation: An epidural can slow contractions, thus many clients will need to have oxytocin to maintain contraction strength.

When caring for a neonate, what is the most important step the nurse can take to prevent and control infection?

Practice meticulous hand washing Explanation: To prevent and control infection, the nurse should practice meticulous hand washing, scrubbing for 3 minutes before entering the nursery, washing frequently during caregiving activities, and scrubbing for 1 minute after providing care.

The nurse is caring for a client in labor. The nurse notes variable decelerations on the fetal monitor strip. What is the nurse's priority intervention?

Repositioning the client to the other side Explanation: Variable decelerations are caused by umbilical cord compression. These can occur with or without a contraction. Positioning the client on her side would provide optimal oxygenation to the fetus.

A nurse is instructing the client to do Kegel exercises. What should the nurse tell the client to do to perform these pelvic floor exercises?

Stop the flow of urine while urinating Explanation: By stopping urine flow during urination, the pelvic floor muscles are contracted. Tightening the leg or stomach muscles doesn't contract the pubococcygeus muscle. Pelvic squats don't tighten the pelvic floor muscles.

A multigravida with a history of cesarean birth due to fetal distress is admitted for a trial labor and possible vaginal birth. After several hours of active labor, the primary care provider prescribes nalbuphine. The nurse evaluates the drug as effective when the client makes which statement?

The contractions don't seem as painful as before Explanation: Nalbuphine, a synthetic agonist-antagonist similar to butorphanol and pentazocine, is used for analgesia during labor. Thus, the statement about the contractions seeming less painful indicates that the drug is effective. The client should not experience numbness or anesthesia from this drug.

A nurse is performing a psychosocial assessment on a first-time mother and her neonate. Which behavior indicates a need for further evaluation?

The mother makes little eye contact with the neonate Explanation: Behaviors that indicate a positive mother-neonate interaction include making eye contact with the neonate, talking to the neonate in a soothing tone, holding the neonate close, and paying more attention to the neonate than to the observer. Therefore, a client who makes little eye contact with the neonate requires further evaluation.

The nurse is caring for a client in labor. The client states, "I feel like I need to push." A sterile vaginal exam reveals that the client is dilated to 8 cm . What is the nurse's best response?

Your cervix is not fully dilated. Let's keep breathing through the pressure Explanation: Pushing (bearing down) before the cervix is completely dilated may cause edema, tissue damage, and may impede fetal descent.

The third stage of labor ends

after the delivery of the placenta explanation: The definition of the third stage of labor is the delivery of the placenta. The first stage of labor ends with complete cervical dilation and effacement. The second stage of labor ends with the birth of the neonate. The fourth stage of labor includes the first 4 hours after birth.

The heart rate of a newly born neonate is regular at 142 bpm. What should the nurse do next?

document this as a normal neonatal finding Explanation: Normally, a neonate's heart rate should be between 120 and 160 bpm shortly after birth. The nurse should document this as a normal neonatal finding. The HCP does not need to be notified. Assessing for cyanosis is a routine assessment at birth, but with the neonate's heart rate at 142 bpm, cyanosis should be minimal and typically located in the hands and feet. Heart rate assessments are performed routinely according to facility protocol. For example, the heart rate is assessed soon after birth, every 15 minutes for 1 hour, every 30 minutes for 1 hour, and then every 4 hours.

After instructing the client in techniques of pushing to use during the second stage of labor, the nurse determines that the client needs further instructions when she says she will need to do which action?

hold breath throughout the length of the contraction Explanation: The client should use exhale breathing (inhaling several deep breaths, holding the breath for 5 to 6 seconds, and exhaling slowly every 5 to 6 seconds through pursed lips while continuing to hold the breath) while pushing to avoid the adverse physiologic effects of the Valsalva maneuver, occurring with prolonged breath holding during pushing. The Valsalva maneuver also can be avoided by exhaling continuously while pushing.

After giving birth to a viable term male neonate vaginally under epidural anesthesia, a primiparous client asks the nurse, "Why are my baby's breasts so swollen?" The nurse responds to the client stating that slight breast engorgement in term neonates is due to which factor?

maternal hormonal influences explanation: Slight breast engorgement in term neonates is related to the maternal hormone elevations that occur during pregnancy.

A postpartum client calls the nurse and reports " I had a baby 1 week ago and am still having a pink discharge." Which is the nurse's best response?

"This is called lochia serosa and is a normal finding for approx 3-10 days" Explanation: Lochia rubra is red in color and occurs from the 1st to the 3rd postpartum day. It is composed of blood, fragments of decidua, and mucus. Lochia serosa is pink in color and occurs from the 3rd through the 10th day and is composed of blood, mucus, and invading leukocytes. Lochia alba is white in color and occurs the 10th through the 14th postpartum day and is composed largely of mucus with a high leukocyte count.

A postpartum client tells the nurse that she and her partner had an argument about continuing breastfeeding before the partner left for work in the morning. The partner was up all night, not able to sleep with the baby crying, and wants the client to give the baby formula. What is the most appropriate immediate response from the nurse?

"What are your feelings about breastfeeding?" Explanation: This response further explores the client's feelings in order to assist her at the time of the nurse's visit. The other responses do not validate her feelings or they take ownership of the situation away from the client and do not build capacity within the family.

A nurse is about to give a full-term neonate their first bath. How should the nurse proceed?

Bathe the neonate only after vital signs have stabilized Explanation: To guard against heat loss, the nurse should bathe the neonate only after vital signs have stabilized. To avoid altering the skin pH, the nurse should use only mild soap and water. Scrubbing should be avoided because it may cause abrasions through which microorganisms can enter. The nurse should wash the neonate from head to feet.

A client has given birth to a preterm neonate. The client tells the nurse that she wants to breast-feed her neonate. The nurse should explain to the mother that

Breast milk contains antibodies that help protect her neonate Explanation: Studies have proven that breast milk provides preterm neonates with better protection from infections such as necrotizing enterocolitis because of the antibodies contained in the milk. Commercial formula doesn't provide any better nutrition than breast milk. Breast milk feedings can be started as soon as the neonate is stable. The neonate is more likely to develop infections when fed formula rather than breast milk.

While assisting a primiparous client with her first breastfeeding session, the nurse should instruct the mother to perform which action in order to stimulate the neonate to open the mouth and grasp the nipple?

Brush the neonate's lips lightly with the nipple Explanation: Lightly brushing the neonate's lips with the nipple causes the neonate to open the mouth and begin sucking. The neonate should be taught to open the mouth and grasp the nipple on his or her own. The neonate should not be forced to nurse.

A client is admitted to the labor area for induction with IV oxytocin because she is 42 weeks pregnant. What should the nurse include in the induction teaching plan for this client?

Continuous FHR monitoring will be implemented Explanation: Uteroplacental insufficiency is associated with a postterm fetus; therefore, it is recommended that the FHR and contraction pattern be monitored throughout the labor and birth process. In addition, IV oxytocin, which is frequently used for induction of labor, may result in hyperstimulation of the uterus. Therefore, monitoring the client is critical.

A multigravid client at term is admitted to the hospital for a trial labor and possible vaginal birth. She has a history of previous cesarean birth because of fetal distress. When the client is 4 cm dilated, she receives nalbuphine intravenously. While monitoring the fetal heart rate, the nurse observes minimal variability and a rate of 120 bpm. The nurse should explain to the client that the decreased variability is most likely caused by which factor?

Effects of analgesic medication Explanation: Decreased variability may be seen in various conditions. However, it is most commonly caused by analgesic administration. Other factors that can cause decreased variability include anesthesia, deep fetal sleep, anencephaly, prematurity, hypoxia, tachycardia, brain damage and arrhythmias.

A 32-year old primigravida at 39 week's gestation is admitted to the hospital in active labor. While the nurse performs Leopold's maneuvers, the client asks why these maneuvers are being done. The nurse explains the major purpose of these maneuvers is to determine which factor?

Fetal presentation Explanation: Leopold's maneuvers, four techniques of abdominal palpation performed between contractions and after the client empties her bladder, assist in identifying fetal presentation and position. Leopold's maneuvers are often performed before initial auscultation of the FHR.

The client gives birth to a neonate who is given a score of 9 at 5 minutes on the Apgar rating system. How does the nurse interpret the neonate's physical condition?

Good Explanation: The Apgar rating system evaluates the neonate on the basis of heart rate, respiratory effort, muscle tone, reflex irritability, and color at 1- and 5-minute intervals after birth. The neonate receives a score between 0 and 10. The higher the score, the better the neonate's condition. Scores between 7 and 10 indicate good status. An Apgar score between 4 and 6 indicates fair condition with a possible need for oxygen, suction, and stimulation.An Apgar score between 0 and 3 is indicative of poor neonatal status and a need for resuscitation. This status is also sometimes referred to as critical.

A primiparous client, 48 hours after a vaginal birth, is to be discharged with a prescription for vitamins with iron because she is anemic. To maximize absorption of the iron, the nurse instructs the client to take the medication with which liquid?

Orange Juice Explanation: Iron is best absorbed in an acid environment or with vitamin C. For maximum iron absorption, the client should take the medication with orange juice or a vitamin C supplement. Herbal tea has no effect on iron absorption. Milk decreases iron absorption. Grape juice is not acidic and therefore would have no effect on iron absorption.

A primiparous client who is beginning to breastfeed her neonate asks the nurse, "Is it important for my baby to get colostrum?" When instructing the client, the nurse would explain that colostrum provides the neonate with which factor?

Passive immunity from maternal antibodies Explanation: Colostrum is a thin, watery, yellow fluid composed of protein, sugar, fat, water, minerals, vitamins, and maternal antibodies (e.g., immunoglobulin A). It is important for the neonate to receive colostrum for passive immunity. Colostrum is lower in fat and lactose than mature breast milk. Colostrum does not contain vitamin K. The neonate will produce vitamin K once a feeding pattern is established. Colostrum may speed, rather than delay, the passage of meconium.

A nurse notices repetitive late decelerations on the fetal heart monitor. What is the best initial actions by the nurse?

Reposition the client, apply oxygen, and increase IV fluids Explanation: Late decelerations on a FHR monitor indicate uteroplacental insufficiency. Interventions to improve perfusion include repositioning the client, oxygen and IV fluids.

After circumcision with a Plastibell, the nurse should instruct the neonate's mother to cleanse the circumcision site with which agent?

Warm water explanation: After circumcision with a Plastibell, the most commonly recommended procedure is to clean the circumcision site with warm water with each diaper change. Other treatments are necessary only if complications, such as an infection, develop. Antibacterial soap or diluted hydrogen peroxide may cause pain and is not recommended. Povidone-iodine solution may cause stinging and burning, and therefore its use is not recommended.

A new mother is concerned because her breast-feeding neonate wants to "nurse all the time." Which response best indicates the normal neonate's breast-feeding behavior?

"Breast milk is ideal for your baby, so his stomach will digest it quickly, requiring more feedings" Explanation: Breast milk is the ideal food for a neonate. As a result, the neonate will digest and use all of the nutrients in each feeding quickly. Coaching the mother must include relaying this information to allay maternal concerns about producing an adequate supply of milk.

A 25-year-old woman who is in the first stage of labor receives a continuous lumbar epidural block when the cervix is 6 cm dilated. After administration of this anesthesia, which assessment would be most important?

Fetal heart rate Explanation: The anesthetic used for the epidural block may cause relaxation of maternal blood vessels, leading to lower maternal blood pressure. The decrease in maternal blood pressure causes oxygenated blood to move more slowly to the fetus, commonly leading to a lower fetal heart rate and hypoxia. A major complication is a decreased fetal heart rate. Thus, assessment of fetal heart rate is most important.

The nurse is caring for a client in labor. How would the nurse report the frequency of each contraction?

Measuring the length of time from start of one contraction to the start of the next Explanation: To determine the frequency of contractions, the nurse should time one contraction to the next by the beginning of one contraction and ending at the beginning of the next.

On the second postpartum day, a client tells the nurse she feels anxious and tearful. Which assessment finding is most consistent with the client's statement?

Postpartum "blues" Explanation: ostpartum "blues" are a normal, expected finding 2 days postpartum. About 50% to 70% of postpartum clients experience transient depression during the first 7 to 10 days after giving birth. Postpartum depression and postpartum psychosis aren't seen until later than the second day postpartum. A statement by the client about not being able to care for her neonate or herself would indicate poor coping skills.

A client in labor received an epidural for pain management. Before receiving the epidural, the client's blood pressure was 124/76 mm Hg. Ten minutes after receiving the epidural, the client's blood pressure is 98/56 mm Hg, and the mother is vomiting. Before calling the health care provider (HCP), what should the nurse do?

Turn the client to her side Explanation: The nurse should turn the client to the side to reduce pressure on the abdominal aorta.

A nurse is teaching a client how to perform perineal care to reduce the risk of puerperal infection. Which activity indicates that the client understands proper perineal care?

Using a peri bottle to clean the perineum after each voiding or BM Explanation: Cleaning with a peri bottle (squirt or spray bottle) should be performed after each voiding or bowel movement. The perineum should be cleaned from front to back, to avoid contamination from the rectal area. To keep the perineum clean, perineal pads must be changed when they are soiled. Water from the peri bottle isn't sterile and should never be directed into the vagina.

The nurse is preparing to administer vitamin K intramuscularly to a term neonate of a primipara who has just given birth. After explaining the purpose of the drug to the mother, which statement by the mother indicates effective teaching?

Vitamin K will help my baby's blood to clot properly Explanation: At birth, vitamin K-dependent blood clotting factors are significantly decreased, and there is a transitory deficiency in blood coagulation during the second and fifth days of life. As a preventive measure, 0.5 to 1 mg of vitamin K is administered to the newborn during the first day of life to aid in blood clotting.

For almost an hour after birth, a neonate was awake, alert, and startled and cried easily. Respirations rose to 70 breaths/minute, and heart rate on two occasions was 160 bpm. After sleeping quietly for about 2 hours, the neonate then awoke with a start, cried, extended, and flexed all four extremities, and then choked, gagged, and regurgitated some thick mucus. What should the nurse do next?

Change the neonate's position and aspirate mucus as necessary Explanation: After the first period of reactivity, beginning at birth and lasting about 30 minutes, the neonate falls asleep for 2 to 4 hours. The neonate then begins the second period of reactivity, which lasts 4 to 6 hours. This neonate's signs and symptoms, the appearance of regurgitating and choking on mucus, are normal for the neonate's age and common during the second period of reactivity. Thus, the nurse should change the neonate's position and aspirate mucus as necessary.

A nurse is caring for a woman who gave birth to her baby boy 2 hours ago. The nurse notes the woman's perineal pad contains some small clots and a moderate amount of lochia has accumulated under her buttocks. What is the first action the nurse should take at this time?

Check fundus for position and consistency Explanation: While the greatest risk of postpartum hemorrhage is within the first hour following birth, a woman can develop an early postpartum hemorrhage anytime within the first 24 hours post-birth. As soon as the nurse notices an increased amount of lochia and clots, the fundus must be assessed for firmness and position. Normally, it should be firm, midline, and either just above or below the umbilicus. Massaging the fundus if it is not firm will assist with a uterine contraction to help decrease blood loss postpartum.

The nurse is caring for a client in labor. The client wishes to have a "nonmedicated" labor and birth. During the early stages of labor, the client becomes frustrated with the use of music and imagery. Which of the following would the nurse include in the client's plan of care? Select all that apply.

Offer use of a yoga ball Suggest a shower or bath Encourage ambulation Explanation: This client has asked for a nonmedicated labor and birth. As the client advocate, the nurse should offer nonmedicated interventions and options. Encouraging ambulation, suggesting shower or bath, or offering the use of a yoga ball are nonmedication interventions appropriate for this stage of labor. Offering an epidural or giving IV pain medication, does not support the client's choice of care.

How should a nurse assess a neonate's rooting reflex?

Stroke the neonate's cheek Explanation: The rooting reflex is elicited by stroking the neonate's cheek or stroking near the corner of the neonate's mouth. The neonate turns the head in the direction of the stroking, looking for food. This reflex disappears by 6 weeks. The palmar grasp reflex is elicited by placing an object in the palm of a neonate; the neonate's fingers close around it. This reflex disappears between ages 6 and 9 months. Babinski's reflex is elicited by stroking the neonate's foot, on the side of the sole, from the heel toward the toes. A neonate will fan his toes, producing a positive Babinski's reflex, until about age 3 months. The sucking reflex is seen when the neonate's lips are touched and lasts for about 6 months.

After teaching the client about bottle-feeding, which client statement indicates the need for additional teaching?

"Whole milk is an acceptable alternative formula once the baby is 4 months old" Explanation: Neither unmodified cow's milk nor whole milk is an acceptable alternative for newborn nutrition. The American Academy of Pediatrics and Canadian Pediatric Society recommend that infants be given breast milk or formula until 1 year of age. However, the American Academy of Pediatrics Committee on Nutrition has decreed that cow's milk could be substituted in the second 6 months of life, but only if the amount of milk calories does not exceed 65% of total calories and iron is replaced through solid foods. The protein content in cow's milk is too high, is poorly digested, and may cause gastrointestinal tract bleeding. Bottle-fed infants may gain as much as 1 oz (30 g)/day up to age 6 months.Iron-fortified formulas are recommended.Bottle-fed neonates may regain their birth weight by 10 to 14 days of age.

A primiparous client, who has just given birth to a healthy term neonate after 12 hours of labor, holds and looks at her neonate and begins to cry. The nurse interprets this behavior as a sign of which response?

A normal response to birth Explanation: Childbirth is a very emotional experience. An expression of happiness with tears is a normal reaction. Cultural factors, exhaustion, and anxieties over the new role can all affect maternal responses, so the nurse must be sensitive to the client's emotional expressions. There is no evidence to suggest that the mother is disappointed in the baby's gender, grieving over the end of the pregnancy, or a candidate for postpartum "blues." However, approximately 80% of postpartum clients experience transient postpartum blues several days after birth.

A woman gave birth to a term neonate a short time ago and has requests that a "special bracelet" be placed on the baby's wrist. What should the nurse do?

Apply the bracelet on the neonate's wrist as the mother requests Explanation: The nurse should abide by the mother's request and place the bracelet on the neonate. In some cultures, amulets and other special objects are viewed as good luck symbols. By allowing the bracelet, the nurse demonstrates culturally sensitive care, promoting trust.The neonate can wear the bracelet while with the mother or in the nursery.The bracelet can be used while the neonate is being bathed, or, if necessary and acceptable to the client, removed and replaced afterward.

A multigravid client is admitted at 4-cm dilation and is requesting pain medication. The nurse gives the client an opioid agonist-antagonist. Within 5 minutes, the client tells the nurse she feels like she needs to have a bowel movement. What should the nurse do first?

Complete a vaginal examination Explanation: The feeling of needing to have a BM is commonly caused by pressure on the receptors low in the perineum when the fetal head is creating pressure on them. This feeling usually indicates advances in fetal station and that the client may be close to birth. The nurse should respond initially to the client's signs and symptoms by completing a vaginal exam to validate current effacement, dilation and station. If the fetus is ready to be born, having the room ready for brith and having naloxone available are important. Naloxone completely or partially reverses the effects of natural and synthetic opioids, including resp depression.

The nurse from the nursery is bringing a newborn to a mother's room. The nurse took care of the mother yesterday and knows the mother and baby well. The nurse should implement which action to ensure the safest transition of the infant to the mother?

Complete the hospital identification procedure with mother and infant Explanation: The hospital identification procedures for mothers and infants need to be completed each time a newborn is returned to a family's room. It does not matter how well the nurse knows the mother and infant; this validation is a standard of care in an obstetrical setting. Assessing the mother's ability to ambulate, asking the mother if there is anything else she needs to care for the infant, and checking the crib to determine if there are enough supplies are important steps that are part of the process of transferring a baby to the mother, but identification verification is a safety measure that must occur first

During a home visit on the fourth postpartum day, a primiparous client tells the nurse that she has been experiencing breast engorgement. To relieve engorgement, the nurse teaches the client to use which intervention before nursing her baby?

Express a small amount of breast milk Explanation: Expressing a little milk before nursing, massaging the breasts gently, or taking a warm shower before feeding also may help to improve milk flow. Although various measures such as ice, heat, and massage may be tried to relieve breast engorgement, prevention of breast engorgement by frequent feedings is the method of choice. Applying ice to the nipples does not relieve breast engorgement. However, it may temporarily relieve the discomfort associated with breast engorgement. Using lanolin on the nipples does not relieve breast engorgement and is unnecessary. Use of lanolin may cause sensitivity and irritation. Having frequent breastfeeding sessions, rather than offering the neonate a small amount of formula, is the method of choice for preventing and relieving breast engorgement. In addition, offering the neonate small amounts of formula may result in nipple confusion.

When assessing the fetal heart rate tracing, a nurse becomes concerned about the fetal heart rate pattern. In response to the loss of variability, the nurse repositions the client to her left side and administers oxygen. These actions are likely to improve:

Fetal hypoxia Explanation: These actions, which will improve fetal hypoxia, increase the amount of maternal circulating oxygen by taking pressure created by the uterus off the aorta and improving blood flow.

A client who is 5 cm dilated reports that she has the urge to push. Which is the appropriate response by the nurse?

Have client blow out breath to keep from pushing Explanation: The nurse should have the client who is 5 cm dilated and experiencing the urge to push to blow out her breath to keep from pushing. Encouraging the client to push with the next contraction would cause traumatic swelling of the cervix caused by the attempt to force the fetus through an incompletely dilated cervix.

A 31-year-old multigravid client at 39 weeks' gestation admitted to the hospital in active labor is receiving intravenous lactated Ringer's solution and a continuous epidural anesthetic. During the first hour after administration of the anesthetic, the nurse should monitor the client for which adverse reaction?

Hypotension Explanation: When a client receives an epidural anesthetic, sympathetic nerves are blocked along with the pain nerves, possibly resulting in vasodilation and hypotension. Other adverse effects include bladder distention, prolonged second stage of labor, nausea and vomiting, pruritis and delayed resp depression for up to 24 hours after administration

The nurse is teaching a G2P1 client about her upcoming labor. Which response would indicate to the nurse that further teaching is necessary?

I can wait until my contractions are every 2 minutes to contact the physician because my first labor was so long explanation: Although a woman having her second baby (gravida 2) may have a shorter labor than her first labor, she should still contact the HCP when the contractions are every 5 mins for at least 1 hour. Waiting until the contractions are every 2 mins is too late.

When dicussing the maternal attachment process in post-conference, which statement made by the student nurse best describes the anticipated actions in the taking-hold phase?

I can't stop kissing, hugging and caring for my new baby Explanation: Taking-hold behaviors, the third step in parent-neonate attachment, are best described by activities that involve tactile contact. These behaviors indicate that the parents have made significant strides toward taking care of their neonate. Meeting the mother's needs first, looking at the neonate, and talking about the neonate are typically associated with the taking-in period.

A pregnant client's partner coaches her with breathing and relaxation techniques as they were taught in birth preparation classes. When the client reaches 8 cm dilation, she screams out "I can't do this anymore!" Which suggestion would be most helpful for the client's partner?

Maintain direct eye contact and breathe with her Explanation: The transition of labor requires reinforcement of techniques learned during preparation for childbirth classes. It is best to use direct eye contact and breathe with the client when she loses control during the transition stage. This often helps her regain control. The client should be encouraged to focus on one contraction at a time at this point in labor.

What would be the priority when caring for a primigravid client whose cervix is dilated at 8 cm when the fetus is at 1+ station and the client has had no analgesia or anesthesia?

Offering encouragement and support Explanation: The client is in the transition phase of the first stage of labor. During this phase, the client needs encouragement and support because this is a difficult and painful time, when contractions are especially strong. Usually, the client finds it difficult to maintain self-control. Everything seems secondary to her as she progresses into the second stage of labor. Although ice chips may be given, typically the client does not desire sips of water. Labor is hard work. Generally, the client is perspiring and does not desire additional warmth. Frequent perineal cleansing is not necessary unless there is excessive amniotic fluid leaking.

A client has expressed her desire to give birth with minimal intervention. She is now moving into the active phase of labor. What intervention by the nurse would be the priority of care?

Offering support by reviewing the short-pant form of breathing explanation: By helping the client use the pant form of breathing, the nurse can help the client manage her contractions. This is appropriate because the client has expressed a desire to deliver with minimal intervention.

The nurse plans care for a neonate to prevent neonatal heat loss immediately after birth. What action should the nurse take to conserve heat and help the infant maintain a stable temperature?

Place the infant skin to skin with the mother Explanation: Thermoregulation of the neonate is a critical intervention for the nurse caring for neonates. The preferred method of thermoregulation for healthy term newborns is to place them skin to skin with the mother. Wrapping and placing a hat on the newborn is another way to conserve heat and prevent heat loss. With the neonate lying against a crib wall, heat transfers away from the infant to the cooler surface (conduction). If the neonate is wet, the warmer water on the surface of the neonate evaporates to the cooler air (evaporation). If the neonate is lying in an open crib with a diaper on, the body naturally loses heat to the surrounding cooler air as it radiates from the warm body to the cooler room (radiation).

A 25-year-old primiparous client who gave birth 2 hours ago has decided to breastfeed her neonate. Which instruction should the nurse address as the highest priority in the teaching plan about preventing nipple soreness?

Placing as much of the areola as possible into the baby's mouth Explanation: Several methods can be used to prevent nipple soreness. Placing as much of the areola as possible into the neonate's mouth is one method. This action prevents compression of the nipple between the neonate's gums, which can cause nipple soreness. Other methods include changing position with each feeding, avoiding breast engorgement, nursing more frequently, and feeding on demand. Plastic liners are not helpful because they prevent air circulation, thus promoting nipple soreness. Instead, air drying is recommended. Pulling the baby's mouth out smoothly after only 10 minutes may prevent the baby from getting the entire feeding and increases nipple soreness. Any breast milk remaining on the nipples should not be wiped off because the milk has healing properties

A client in early labor is connected to an external fetal monitor. The physician hasn't noted any restrictions on her chart. The client tells the nurse that she needs to go to the bathroom frequently and that her partner can help her. How should the nurse respond?

Please press the call button. I'll disconnect you from the monitor so you can get out of bed. Explanation: The nurse should instruct the client to use the call button when she needs to use the bathroom. The nurse will need to disconnect the fetal monitor and mark the strip to indicate the activity. If the client's partner disconnects and reconnects the monitor, the nurse can't determine if the readings are accurate.

A 24-year-old primigravid client who gives birth to a viable term neonate is prescribed to receive oxytocin intravenously after delivery of the placenta. Which of the following signs would indicate to the nurse that the placenta is about to be delivered?

The cord lengthens outside the vagina Explanation: The most reliable sign that the placenta has detached from the uterine wall is lengthening of the cord outside the vagina. Other signs include a sudden gush of (rather than a decrease in) vaginal blood. Usually, when placenta detachment occurs, the uterus becomes firmer and changes in shape from discoid to globular. This process takes about 5 minutes. If the placenta does not separate, manual removal may be necessary to prevent postpartum hemorrhage.