OB Exam 2

Risk factors for hyperbilirubinemia

- Fetal-maternal blood group incompatibility - prematurity - previously affected sibling - cephalohematomas - bruising - trauma from instrumented delivery - delayed meconium passage

Common problems for preterm newborns

- Respiratory distress syndrome - problems coordinating suck, swallow and breathing - hypothermia - hypoglycemia - hyperbilirubinemia - problems r/t immaturity of body systems (respiratory system is last to mature -> lack of surfactant)

What does APGAR stand for?

- Appearance (color): pink; partial credit if hands and feet are pale - Pulse (heart rate): goal is >100 - Grimace (reflex): does newborn withdraw/respond to stimulus? - Activity (muscle tone): flexed position - Respiratory (effort): good, strong cry

2 ways to monitor hyperbilurubinemia

- Transcutaneously: plotted in a graph based on gestational age (bilirubin levels will change over time as liver matures) - Serum levels: checked if transcutaneous levels are concerning

Management of Neonatal Sepsis

- abx therapy - broad spectrum to start (Amp/Gent) - circulatory & respiratory support - nutrition - prevention - hand washing - oral care - turning

If suspecting sepsis, what do you anticipate the provider will order in terms of labs?

- blood: CBC, blood culutre possibly - CSF for culture - urine for culture

4 ways newborns can lose heat

- conduction: transfer of heat from direct contact - convection: flow of heat to cooler surrounding air or air over body - evaporation: loss of heat when liquid if converted to vapor - radiation: loss of body heat to cooler, solid surfaces that are in proximity but not in direct contact

Name at least 4 assessment findings for Neonatal Sepsis

- lethargy - decreased tone - feeding difficulties including weak suck, poor feeding - abdominal distention - temp instability - respiratory distress including tachypnea, nasal flaring, chest retractions, grunting, cyanosis, apnea accompanied by bradycardia - hypotension

Clinical manifestations of hypoglycemia in newborn

- lethargy - tachycardia - respiratory distress - jitters - drowsiness - poor feeding and sucking - temp instability - hypotonia

RN implications when taking care of a newborn under phototherapy?

- monitoring body temp - monitoring fluid & electrolytes - intake and output/adequate feeds - eye protection - skin integrity

Nursing management for preterm infants

- oxyegation - thermal regulation - nutrtion & fluid balance - infection prevention - appropriate stimulation - pain management - growth and development - kangaroo care (skin to skin contact with mom) Parental support: - high-risk status - possible prenatal loss - discharge preparation - criteria must be met - breathing without apnea spells - gaining weight

4 circulatory changes at birth that must happen include

- oxygen exchange from placenta to pulmonary gas exchange - increased pulmonary blood flow - closure of foramen ovale - closure of ductus venosus & ductus arteriosus

Common problems for post-term newborns

- polycythemia - meconium aspiration - neonatal respiratory problems - LGA at birth -> difficult delivery, cephalopelvic disproportion, potential birth injury

What is the difference b/t acrocyanosis and cyanosis?

Acrocyanosis - bluish discoloration found only in hands, feet, and area around lips (normal finding in babies) Central Cyanosis - bluish discoloration on lips, tongue, head or torso should be promptly evaluated

What is Necrotrizing enterocolitis (NEC)

An inflammatory disease of GO mucosa d/t ischemia -> necrosis and perforation of bowel primarily seen in premature newborns

Early onset sepsis vs Late onset sepsis

Early - 3 days from mom (most common) Late - 1st week (pathogens that are acquired postnatally)

Fetal and Maternal risk factors for Neonatal Sepsis?

Fetal: - prematurity - low birth weight - admission to NICU Maternal: - prolonged ROM (18+ hours) - chorioamnionitis - vaginal colonization by group-B Streptococcus

Explain Jaundice Types

Physiologic: (normal) appears during 3rd-4th day of life & then rapidly declines over 1st week, breastfeeding can cause jaundice & cure it as it encourages passage of meconium Pathologic: appears within first 24 hours after birth & is associated with Rh, ABO; s/s are lethargy, poor suck, hypotonic, seizures possible

Physical characteristics of Post-Term Newborns compared to Preterm Newborns?

Post-Term Newborns: ("old person appearance") - dry, peeling skin - absence of vernix and languo - meconium stains - wrinkles Preterm Newborns: - thin skin - less brown fat - thin extremities - hypotonia - vernix - languo

What is RDS and who does it affect?

RDS is d/t lung immaturity & lack of surfactant in lungs Most infants affected are preterm (< 37 weeks) Babies born to diabetic mothers also at high risk b/c hyperglycemia can affect surfactant production

What is transient tachypnea of newborn and who does it usually affect?

Self-limiting condition resulting from delayed clearance of fetal lung liquid that usually resolves by 72 hours of delivery Who it affects: - born by c-section - newborns who are near term or full term

Why give vitamin K to newborn?

Shoudl be given within 1 hour of delivery as an IM (vastus lateralis) injection to prevent hemorrhagic disease Vit. K is produced in GI tract by bacteria & stimulates liver to synthesize coagulation factors II, VII, IX, and X Breastmilk & formula cause GI tracts to be colonized with bacteria. By day 8 of life, newborn is able to produce vit. K

Nursing management for TTN vs RDS

TTN: - supportive care - adequate oxygenation - minimize stimulation 0 maintain neutral temp - withhold oral feedings until tachypnea resolves RDS: - surfactant administration

A nurse is performing a vaginal examination of a woman in the early stages of labor. The woman has been at 2 cm dilated for the past 2 hours, but effacement has progressed steadily. Which statement by the nurse would best encourage the client regarding her progress? a) "You are still 2 cm dilated, but the cervix is thinning out nicely." b) "There has been no further dilation (dilatation); effacement is progressing." c) "You haven't dilated any further, but hang in there; it will happen eventually." d) Don't mention anything to the client yet; wait for further dilation (dilatation) to occur.

a) "You are still 2 cm dilated, but the cervix is thinning out nicely."

The nurse prepares to administer vitamin K into which muscle site?

Vastus lateralis

When is a newborn considered hypoglycemic?

When blood sugar is < 50 (40-45)

What medication would the nurse administer to a client experiencing uterine atony and bleeding leading to postpartum hemorrhage? a) Oxytocin b) Magnesium sulfate c) Domperidone d) Calcium gluconate

a) Oxytocin Rationale: Oxytocin causes the uterus to contract to improve uterine tone and reduce bleeding. Magnesium sulfate is administered to clients with preeclampsia or eclampsia or hypertension problems. Domperidone is used to increase lactation in women. Calcium gluconate is an antagonist used in clients experiencing side effects of magnesium sulfate.

What is the best way for the nurse to assess the newborn's heartbeat? a) auscultating the apical pulse for 60 seconds b) auscultating the apical pulse for 30 seconds and multiplying by 2 c) palpating the brachial pulse for 60 seconds d) palpating the femoral pulse for 30 seconds and multiplying by 2

a) auscultating the apical pulse for 60 seconds

When monitoring a postpartum client 2 hours after birth, the nurse notices heavy bleeding with large clots. Which response is most appropriate initially? a) massaging the fundus firmly b) performing bimanual compressions c) administering ergonovine d) notifying the primary care provider

a) massaging the fundus firmly Rationale: Initial management of excessive postpartum bleeding is firm massage of the fundus and administration of oxytocin. Bimanual compression is performed by a primary health care provider. Ergonovine maleate should be used only if the bleeding does not respond to massage and oxytocin. The primary health care provider should be notified if the client does not respond to fundal massage, but other measures can be taken in the meantime.

A nurse is assessing the following antenatal clients. Which client is at highest risk for having a multiple gestation? a) the 41-year-old client who conceived by in vitro fertilization b) the 38-year-old client whose spouse is a triplet c) the 19-year-old client diagnosed with polycystic ovary syndrome d) the 27-year-old client who gave birth to twins 2 years ago

a) the 41-year-old client who conceived by in vitro fertilization Rationale: The nurse should assess infertility treatment as a contributor to the increased probability of multiple gestations. Multiple gestations do not occur with an adolescent birth; instead, chances of multiple gestations are known to increase due to the increasing number of women giving birth at older ages.

A client who gave birth vaginally 16 hours ago states she does not need to void at this time. The nurse reviews the documentation and finds that the client has not voided for 7 hours. Which response by the nurse is indicated? a) "If you don't attempt to void, I'll need to catheterize you." b) "It's not uncommon after birth for you to have a full bladder even though you can't sense the fullness." c) "I'll contact your primary care provider." d) "I'll check on you in a few hours."

b) "It's not uncommon after birth for you to have a full bladder even though you can't sense the fullness." Rationale: After a vaginal birth, the client should be encouraged to void every 4 to 6 hours. As a result of anesthesia and trauma, the client may be unable to sense the filling bladder. It is premature to catheterize the client without allowing her to attempt to void first. There is no need to contact the primary care provider at this time, because the client is demonstrating common adaptations in the early postpartum period. Allowing the client's bladder to fill for another 2 to 3 hours might cause overdistention.

After teaching a review class to a group of perinatal nurses about various methods for cervical ripening, the nurse determines that the teaching was successful when the group identifies which method as surgical? a) breast stimulation b) amniotomy c) laminaria d) prostaglandin

b) amniotomy Rationale: Amniotomy is considered a surgical method of cervical ripening. Breast stimulation is considered a nonpharmacologic method for ripening the cervix. Laminaria is a hygroscopic dilator that mechanically causes cervical ripening. Prostaglandins are pharmacologic methods for cervical ripening.

A pregnant client is admitted to a maternity clinic for birth. Which assessment finding indicates that the client's fetus is in the transverse lie position? a) Long axis of fetus is at 60° to that of client. b) Long axis of fetus is parallel to that of client. c) Long axis of fetus is perpendicular to that of client. d) Long axis of fetus is at 45° to that of client.

c) Long axis of fetus is perpendicular to that of client.

What is Direct Coombs test and an Indirect Coombs test?

Direct Coombs test - looks for maternal antibodies attached to the newborn's RBCs (typically done for Rh- moms with Rh+ newborns Indirect Coombs test- looks for antibodies in mom's bloodstream (9doesn't tell us if newborn is affected, but helps assume that if antibodies are present then newborn is affected)

A nurse is providing care to a postpartum woman who gave birth about 2 days ago. The client asks the nurse, "I haven't moved my bowels yet. Is this a problem?" Which response by the nurse would be most appropriate? a) "It might take up to a week for your bowels to return to their normal pattern." b) "I'll get a laxative prescribed so that you can move your bowels." c) "That's unusual. Are you making sure to eat enough?" d) "Let me call your health care provider about this problem."

a) "It might take up to a week for your bowels to return to their normal pattern." Rationale: Spontaneous bowel movements may not occur for 1 to 3 days after giving birth because of a decrease in muscle tone in the intestines as a result of elevated progesterone levels. Normal patterns of bowel elimination usually return within a week after birth. The nurse should assess the client's abdomen for bowel sounds and ascertain if the woman is passing gas. Obtaining an order for a laxative may be appropriate, but this response does not address the client's concern. Telling the client that it is unusual is inaccurate and could cause the client additional anxiety. Notifying the health care provider is not necessary, and this statement could add to the client's current concern.

The postpartum nurse is providing instructions to a client after birth of a healthy newborn. Which time frame should the nurse relay to the client regarding the return of bowel function? a) 3 days postpartum b) 7 days postpartum c) on the day of birth d) within 2 weeks postpartum

a) 3 days postpartum Rationale: After birth, the nurse should auscultate client's abdomen in all 4 quadrants. Normal bowel elimination usually returns 2-3 days postpartum. Surgery, anesthesia, and use of opioids and pain control agents also contribute to longer period of altered bowel functions

The nurse has completed assessing the blood glucose levels of several infants who are 24 hours old. Which result should the nurse prioritize for intervention? a) 30 mg/dL (1.67 mmol/L) b) 53 mg/dL (2.94 mmol/L) c) 70 mg/dL (3.89 mmol/L) d) 90 mg/dL (5.00 mmol/L)

a) 30 mg/dL (1.67 mmol/L) Rationale: Blood glucose levels less than 50 mg/dL (2.77 mmol/L) is indicative of hypoglycemia in a newborn infant and should be further evaluated and/or treated depending on the individual situation.

A nurse in the maternity triage unit is caring for a client with a suspected ectopic pregnancy. Which nursing intervention should the nurse perform first? a) Assess the client's vital signs. b) Administer oxygen to the client. c) Obtain a surgical consent from the client. d) Provide emotional support to the client and significant other.

a) Assess the client's vital signs. Rationale: A suspected ectopic pregnancy can put the client at risk for hypovolemic shock. The assessment of vital signs should be performed first, followed by any procedures to maintain the ABCs. Providing emotional support would also occur, as would obtaining a surgical consent, if needed, but these are not first steps.

The nurse is caring for a newborn who has a large surface area to body mass ratio. What action will the nurse take to help this newborn regulate temperature? a) Assure the newborn has a cap on the head and is kept covered. b) Maintain accurate intake and output and monitor for dehydration. c) Educate the parents to rinse the newborn skin well after using soap. d) Monitor the newborn's skin for changes related to fluid loss, such as turgor.

a) Assure the newborn has a cap on the head and is kept covered. Rationale: Newborns have a large surface area to body mass ratio and are particularly susceptible to heat loss. The nurse will assure the newborn wears a cap on the head and is kept covered to avoid heat loss. The nurse would monitor intake and output but not related to temperature regulation. The skin of the newborn should be dried well after any liquid is noted (urine, cleansing wipes, etc.) to prevent temperature loss but not specifically because of the large surface area. The newborn's skin needs to be monitored but not specifically for temperature regulation.

A nurse is caring for a postpartum client diagnosed with von Willebrand disease. What should be the nurse's priority for this client? a) Check the lochia. b) Assess the temperature. c) Monitor the pain level. d) Assess the fundal height.

a) Check the lochia. Rationale: The nurse should assess the client for prolonged bleeding time. von Willebrand disease is a congenital bleeding disorder, inherited as an autosomal dominant trait, that is characterized by a prolonged bleeding time, a deficiency of von Willebrand factor, and impairment of platelet adhesion. A fever of 100.4° F (38° C) after the first 24 hours following birth and pain indicate infection. A client with a postpartum fundal height that is higher than expected may have subinvolution of the uterus.

A client's membranes rupture. The nurse observes the fetal heart rate drop from 156 to 110. The nurse inspects the client's perineum and sees a loop of umbilical cord. What is the nurse's priority concern in this situation? a) Decreased fetal oxygenation b) Increased risk for infection c) Increased risk for placental abruption d) Decreased strength of uterine contractions

a) Decreased fetal oxygenation Rationale: When there is a cord prolapse the cord becomes compressed, blood flow is interrupted, and there is decreased oxygen available to the fetus resulting in fetal distress. There is a slight increased risk for postbirth infection, but it is not the priority at this time. A cord prolapse does not increase the risk for placental abruption nor does it decrease the strength of uterine contractions

A pregnant woman is being evaluated for HELLP. The nurse reviews the client's diagnostic test results. An elevation in which result would the nurse interpret as helping to confirm this diagnosis? a) LDH b) white blood cells c) hematocrit d) platelet count

a) LDH Rationale: HELLP (hemolysis, elevated liver enzymes, low platelet count) syndrome is a variant of the preeclampsia/eclampsia syndrome. The diagnosis is based on laboratory test results, including: low hematocrit, elevated LDH, elevated AST, elevated ALT, elevated BUN, elevated bilirubin level, elevated uric acid and creatinine levels, and low platelet count. White blood cell counts are not used to evaluate for HELLP.

A woman at 34 weeks' gestation presents to labor and delivery with vaginal bleeding. Which finding from the obstetric examination would lead to a diagnosis of placental abruption (abruptio placentae)? a) Onset of vaginal bleeding was sudden and painful b) Fetus is in a breech position c) Sonogram shows the placenta covering the cervical os d) Uterus is soft between contractions

a) Onset of vaginal bleeding was sudden and painful Rationale: Sudden onset of abdominal pain and vaginal bleeding with a rigid uterus that does not relax are signs of a placental abruption (abruptio placentae). The other findings are consistent with a diagnosis of placenta previa.

A nurse is providing care to a client who has been diagnosed with a common benign form of gestational trophoblastic disease. The nurse identifies this as: a) hydatidiform mole. b) ectopic pregnancy. c) placenta accrete. d) hydramnios.

a) hydatidiform mole. Rationale: Gestational trophoblastic disease comprises a spectrum of neoplastic disorders that originate in the placenta. The two most common types are hydatidiform mole (partial or complete) and choriocarcinoma. Hydatidiform mole is a benign neoplasm of the chorion in which the chorionic villi degenerate and become transparent vesicles containing clear, viscid fluid. Ectopic pregnancy, placenta accreta, and hydramnios fall into different categories of potential pregnancy complications.

A postpartum client is having difficulty stopping her urine stream. Which should the nurse do next? a) Determine if the client is emptying her bladder. b) Ask the client when she last urinated. c) Perform an "in and out" catheter on the client. d) Educate the client on how to perform Kegel exercises.

d) Educate the client on how to perform Kegel exercises. Rationale: Clients should begin Kegel exercises on the first postpartum day to increase the strength of the perineal floor muscles. Priority for this client would be to educate her how to perform Kegel exercises as strengthening these muscles will allow her to stop her urine stream.

A woman has been progressing through labor uneventfully until the occurrence of an intense contraction, when she then develops signs of umbilical cord compression. The health care provider can feel a portion of the cord in the vagina. Which emergency intervention should the nurse implement? Select all that apply. a) Place a gloved hand in vagina and put upward pressure on presenting part to keep it off the cord. b) Position the woman in a knee-chest position. c) Locate and insert a vacuum suction catheter into vagina and push infant back into uterus. d) Apply oxygen mask at 10 L/min. e) Administer terbutaline, a tocolytic, as prescribed.

a) Place a gloved hand in vagina and put upward pressure on presenting part to keep it off the cord. b) Position the woman in a knee-chest position. d) Apply oxygen mask at 10 L/min. e) Administer terbutaline, a tocolytic, as prescribed. Rationale: A prolapsed cord is always an emergency situation because the pressure of the fetal head against the cord at the pelvic brim leads to cord compression and decreased oxygenation to the fetus. Management is aimed at relieving pressure on the cord. This may be done by placing a gloved hand in the vagina and manually elevating the fetal head off the cord, or by placing the woman in a knee-chest or Trendelenburg position to cause the fetal head to fall back from the cord. Administering oxygen at 10 L/min by face mask to the woman is also helpful to improve oxygenation to the fetus. A tocolytic (like terbutaline) agent may be prescribed to reduce uterine activity and pressure on the fetus. Asking the woman to bear down is contraindicated at this time.

A woman in labor suddenly reports sharp fundal pain accompanied by slight dark red vaginal bleeding. The nurse should prepare to assist with which situation? a) Premature separation of the placenta b) Preterm labor that was undiagnosed c) Placenta previa obstructing the cervix d) Possible fetal death or injury

a) Premature separation of the placenta Rationale: Premature separation of the placenta begins with sharp fundal pain, usually followed by dark red vaginal bleeding. Placenta previa usually produces painless bright red bleeding. Preterm labor contractions are more often described as cramping. Possible fetal death or injury does not present with sharp fundal pain. It is usually painless.

The nurse has been asked to present information to a group of civic leaders concerning women's health issues. In preparing the information, the nurse includes what goal from Healthy People 2030 related to women in labor? a) Reduce the rate of cesarean births among low-risk women. b) Encourage women with previous cesareans to always have a cesarean. c) Ensure care during labor includes immunizations. d) Ensure all couples receive preconception genetic counseling.

a) Reduce the rate of cesarean births among low-risk women. Rationale: Healthy People 2030 includes one goal related to cesarean births in the United States, "Reduce cesarean births among low-risk women with no prior births." Immunizations and genetic counseling are not associated with women in labor.

A woman experiences an amniotic fluid embolism as the placenta is delivered. The nurse's first action would be to: a) administer oxygen by mask. b) increase her intravenous fluid infusion rate. c) put firm pressure on the fundus of her uterus. d) tell the woman to take short, catchy breaths.

a) administer oxygen by mask. Rationale: An amniotic embolism quickly becomes a pulmonary embolism. The woman needs oxygen to compensate for the sudden blockage of blood flow through her lungs.

The nurse is monitoring a client who is in the active stage of labor. The nurse documents that the client is experiencing labor dystocia. The nurse determines that which risk factors in the client's hx placed her at risk for this complication? SATA a) age 54 years old b) body mass index of 28 c) previous difficulty w/ fertility d) administration of oxytocin for induction e) potassium level of 3.6 mEq/L (3.6 mmol/L)

a) age 54 years old b) body mass index of 28 c) previous difficulty w/ fertility Rationale: risk factors include advanced maternal age, overweight (BMI of 28 is overweight), previous difficulty with infertility, malpresentation of fetus, electrolyte imbalances, cephalopelvic disproportion, uterine abnormalities, administration of analgesic early in labor, use of epidural analgesic d: oxytocin alone is not a risk factor but risks exists only if uterine hyperstimulation occurs e: potassium level is a normal finding

The nurse is planning care for a postpartum client who had a vaginal delivery 2 hours ago. The client required an episiotomy. and has several hemorroids. What is the priority nursing consideration for this client? a) client pain level b) inadequate urinary output c) client perception of body changes d) potential for imbalanced body fluid volume

a) client pain level Rationale: Most clients have some degree of discomfort during the immediate postpartum period. There are no data in the question that indicate inadequate urinary output, presence of client perception of body changes, and potential for imbalanced body fluid volume

The nurse is teaching the parents of a newborn who was born with a high type of imperforate anus the care the newborn will need at home after surgery. The parents need to be aware that the newborn will require which measure temporarily? a) colostomy b) intravenous fluids c) nasal cannula for oxygen d) nasogastric tube

a) colostomy Rationale: Surgical intervention is needed for both high and low types of imperforated anus. Surgery for a high type of defect involves a colostomy in the newborn period, with corrective surgery performed in stages to allow for growth. The newborn will require intravenous fluids, nasogastric tube attached to low suction, and oxygen in the immediate postoperative period. Once bowel function has become established, these should no longer be needed.

A nurse is assessing a newborn for jaundice. The nurse would first notice jaundice at which area? a) face b) trunk c) legs d) arms

a) face Rationale: Neonatal jaundice first becomes visible in the face and forehead. Identification is aided by pressure on the skin, since blanching reveals the underlying color. Jaundice then gradually becomes visible on the trunk and extremities.

A client at 35 weeks' gestation is now in stable condition after being admitted for vaginal bleeding. Which assessment should the nurse prioritize? a) fetal heart tones b) signs of shock c) infection d) uterine stabilization

a) fetal heart tones Rationale: When a client is admitted for vaginal bleeding and is stable, the next priority assessment is to determine if the fetus is viable. The other options are not a higher priority than fetal heart tones.

Shoulder dystocia is a true medical emergency that can cause fetal demise because the baby cannot be born. Stuck in the birth canal, the infant cannot take its first breath. Which maneuver is first attempted to deliver an infant with shoulder dystocia? a) McDonald maneuver b) McGeorge maneuver c) McRoberts maneuver d) McRonald maneuver

c) McRoberts maneuver

An obese woman with diabetes has just given birth to a term, large-for-gestational-age (LGA) newborn. Which condition should the nurse most expect to find in this infant? a) hypoglycemia b) hyperglycemia c) hypotension d) hypertension

a) hypoglycemia Rationale: LGA infants also need to be carefully assessed for hypoglycemia in the early hours of life because large infants require large amounts of nutritional stores to sustain their weight. If the mother had diabetes that was poorly controlled (the cause of the large size), the infant would have had an increased blood glucose level in utero to match the mother's; this caused the infant to produce elevated levels of insulin. After birth, these increased insulin levels will continue for up to 24 hours of life, possibly causing rebound hypoglycemia.

The nurse is teaching a prenatal class on the difference between true and false labor contractions. The nurse determines the session is successful when the class correctly chooses which factor as an indication of true labor contraction? a) increase even if relaxing and taking a shower b) remain irregular with the same intensity c) subside when walking around and use the lateral position d) cause discomfort over the top of uterus

a) increase even if relaxing and taking a shower Rationale: True labor contractions do not stop; they continue and strengthen, as well as increase in frequency. If the contractions subside while taking a shower or relaxing, then they are not labor contractions. The discomfort over the top of the uterus is normal for full term pregnancy.

A nurse is conducting a class for nurses working in the postpartum unit about ways to reduce the risk of postpartum infections. The nurse determines that the teaching was effective when the group identifies which preventive measure as essential? a) meticulous handwashing b) use of clean gloves for invasive procedures c) unlimited visitation from family and friends d) fluid intake limitations

a) meticulous handwashing

Two weeks after giving birth, a woman is feeling sad, hopeless, and guilty because she cannot take care of the infant and partner. The woman is tired but cannot sleep and has isolated herself from family and friends. The nurse recognizes that this client is exhibiting signs of: a) postpartum depression. b) lack of partner support. c) maladjustment to parenting. d) postpartum blues.

a) postpartum depression. Rationale: Feeling sad; coping poorly; being overwhelmed; being fatigued, but unable to sleep; and withdrawing for social interactions are signs of postpartum depression. Signs of postpartum blues are similar, but less severe and seen within the first week after birth. It is normal for new mothers to feel overwhelmed and unable to care for her partner, as she did prior to the pregnancy. There is no evidence of lack of partner support in this situation.

The nurse in a labor room is preparing to care for a client with hypertonic uterine contractions. The nurse is told that the client is experiencing uncoordinated contractions that are erratic in their frequency, duration, and intensity. What is the priority nursing action? a) provide pain relief measures b) prepare the client for an amniotomy c) promote ambulation every 30 minutes d) monitor the oxytocin infusion closely

a) provide pain relief measures Rationale: hypertonic contractions are painful, occur frequently, and are uncoordinated. Management of hypertonic labor depends on the cause. Relief of pain is the primary intervention to promote a normal labor pattern. Amniotomy and oxytocin infusion are not treatments of hypertonic contractions (but can be used for hypotonic contractions). A client with hypertonic contractions would not be encouraged to ambulate, we'd want them to rest

A nurse is caring for a client who has been administered an epidural block. Which should the nurse assess next? a) respiratory rate b) temperature d) pulse c) uterine contractions

a) respiratory rate Rationale: The nurse must monitor for respiratory depression. Monitoring the client's respiratory rate will be the best indicator of respiratory depression.

A newborn girl who was born at 38 weeks' gestation weighs 2000 g and is below the 10th percentile in weight. The nurse recognizes that this girl will be placed in which classification? a) term, small-for-gestational-age, and low-birth-weight infant b) term, small-for-gestational-age, and very-low-birth-weight infant c) late preterm and appropriate for gestational age d) late preterm, large-for-gestational-age, and low-birth-weight infant

a) term, small-for-gestational-age, and low-birth-weight infant Rationale: Infants born before term (before the beginning of the 38th week of pregnancy) are classified as preterm infants, regardless of their birth weight. Term infants are those born after the beginning of week 38 and before week 42 of pregnancy. Infants who fall between the 10th and 90th percentiles of weight for their gestational age, whether they are preterm, term, or postterm, are considered appropriate for gestational age (AGA). Infants who fall below the 10th percentile of weight for their age are considered small-for-gestational-age (SGA). Those who fall above the 90th percentile in weight are considered large-for-gestational-age (LGA). Still another term used is low-birth-weight (LBW; one weighing under 2500 g at birth). Those weighing 1000 to 1500 g are very-low-birth-weight (VLBW). Those born weighing 500 to 1000 g are considered extremely-low-birth-weight infants (ELBW).

A client who is 8 weeks' pregnant comes to the emergency department reporting abdominal pain and spotting. The client also reports breast tenderness and fatigue. Additional assessment suggests a possible ectopic pregnancy and diagnostic evaluation is scheduled. The nurse would prepare the client for which test(s) to aid in confirming this diagnosis? Select all that apply. a) transvaginal ultrasound b) beta-human chorionic gonadotropin (hCG) level c) urine for protein d) platelet level e) complete blood count

a) transvaginal ultrasound b) beta-human chorionic gonadotropin (hCG) level Rationale: The use of transvaginal ultrasound to visualize the misplaced pregnancy and low levels of serum beta-hCG assist in diagnosing an ectopic pregnancy. The ultrasound determines whether the pregnancy is intrauterine, assesses the size of the uterus, and provides evidence of fetal viability. The visualization of an adnexal mass and the absence of an intrauterine gestational sac are diagnostic of ectopic pregnancy. In a normal intrauterine pregnancy, beta-hCG levels typically double every 2 to 4 days until peak values are reached 60 to 90 days after conception. Concentrations of hCG decrease after 10 to 11 weeks and reach a plateau at low levels by 100 to 130 days. Therefore, low beta-hCG levels are suggestive of an ectopic pregnancy. Urine for protein, platelet level, and complete blood count would provide no information about an ectopic pregnancy.

A nurse is assessing a newborn infant following circumcision and notes that the circumcised area is red with a small amount of bloody drainage. Which of the following nursing actions would be most appropriate? a. Document the findings b. Contact the physician c. Circle the amount of bloody drainage on the dressing and reassess in 30 minutes d. Reinforce the dressing

a. Document the findings Rationale: Close observation of the circumcision site during the first few hours is necessary to determine if there is a complication. A yellow exudate may be noted after 24 hours, and this is a part of normal healing. This should not be washed away because it serves a protective function. The nurse would expect that the area would be red with a small amount of bloody drainage. Because the findings identified in the question are normal, the nurse would document the assessment. Additionally, document if the infant is voiding after the procedure to ascertain that the urethra is not occluded. Instruct the parents to keep the site free from feces and covered in petrolatum until healing is complete. If the infant cries constantly and if there is redness or tenderness due to pain, it should be reported to the physician.

A nurse is assessing a newborn five minutes after birth and notes: HR 110 bpm; a good, strong cry; well flexed extremities; grimacing when slapped on the sole of the foot; and normal pigment in most of the body, with blue hands and feet. What Apgar score will the nurse document for this infant? a) 6 b) 8 d) 9 e) 7

b) 8 Rationale: The heart rate of 110 bpm, the strong cry, and the muscles of the extremities being well flexed each indicate a score of 2 in the heart rate, respiratory effort, and muscle tone areas, respectively. The grimace in response to a slap to the sole of the foot and the blue at the extremities each indicate a score of 1 for the reflex irritability and color areas, respectively. Thus, the total Apgar score for this infant is 8 (2 + 2 + 2 + 1 + 1 = 8).

A 29-year-old postpartum client is receiving anticoagulant therapy for deep venous thrombophlebitis. The nurse should include which instruction in her discharge teaching? a) Avoid iron replacement therapy. b) Avoid over-the-counter (OTC) salicylates. c) Wear knee-high stockings when possible. d) Shortness of breath is a common adverse effect of the medication.

b) Avoid over-the-counter (OTC) salicylates. Rationale: Discharge teaching should include informing the client to avoid OTC salicylates, which may potentiate the effects of anticoagulant therapy. Iron will not affect anticoagulation therapy. Restrictive clothing should be avoided to prevent the recurrence of thrombophlebitis. Shortness of breath should be reported immediately because it may be a symptom of pulmonary embolism.

A nurse is caring for a preterm newborn born at 29 weeks' gestation. Which nursing diagnosis would have the highest priority? a) Grieving related to the loss of "a healthy full-term newborn" b) Ineffective thermoregulation related to decreased amount of subcutaneous fat c) Risk for injury related to the very thin epidermis layer of skin d) Imbalanced nutrition: Less than body requirements related to the premature digestive system

b) Ineffective thermoregulation related to decreased amount of subcutaneous fat Rationale: In the condition of hypothermia, newborns typically metabolize brown fat. This requires the newborn to use glucose and oxygen. A premature infant is at risk for respiratory distress and hypoglycemia. The hypoglycemia can increase the infant's need for glucose and oxygen, which, in turn, could cause more severe disease or further complications. The other diagnoses are appropriate but not the highest priority.

A woman presents at Labor and Delivery very upset. She reports that she has not felt her baby moving for the last 6 hours. The nurse listens for a fetal heart rate and cannot find a heartbeat. An ultrasound confirms fetal death and labor induction is started. What intervention by the nurse would be appropriate for this mother at this time? a) Explain to her that there was probably something wrong with the infant and that is why it died. b) Offer to take pictures and footprints of the infant once it is delivered. c) Call the hospital chaplain to talk to the parents. d) Recommend that she not hold the infant after it is delivered so as to not upset her more.

b) Offer to take pictures and footprints of the infant once it is delivered.

The nurse is giving an educational presentation to the local Le Leche league chapter. One woman asks about risk factors for mastitis. Which condition would the nurse most likely include in the response? a) Use of breast pumps b) Pierced nipple c) Complete emptying of the breast d) Frequent feeding

b) Pierced nipple Rationale: Certain risk factors contribute to the development of mastitis. These include inadequate or incomplete breast emptying during feeding or lack of frequent feeding leading to milk stasis; engorgement; clogged milk ducts; cracked or bleeding nipples; nipple piercing; and use of plastic-backed breast pads.

The nurse is admitting a client in labor. The nurse determines that the fetus is in a transverse lie by performing Leopold maneuvers. What intervention should the nurse provide for the client? a) Administer an analgesic to the client. b) Prepare the client for a cesarean birth. c) Prepare for a precipitous vaginal birth. d) Prepare to assist the care provider with an amniotomy.

b) Prepare the client for a cesarean birth. Rationale: If a transverse lie persists, the fetus cannot be born vaginally. Thus, the nurse will prepare the client for a caesarean birth. There is no indication the client will have precipitous labor. Amniotomy, artificial rupture of the membranes, is not indicated when preparing from a caesarean birth. The nurse would not administer analgesic before surgery unless prescribed by the health care provider.

A preterm infant will be hospitalized for an extended time. Assuming the infant's condition is improving, which environment would the nurse feel is most suitable for the child? a) Keep the environment free of color to reduce eye straining. b) Provide a mobile the child can see no matter how he or she is turned. c) Place the infant's Isolette near the window so the child can see outside. d) Bring the child's open bassinet near the desk area so the infant sees people.

b) Provide a mobile the child can see no matter how he or she is turned. Rationale: Preterm infants are able to focus at short distances before they can see well at long distances. A mobile offers short-distance stimulation.

A newborn's primary method of heat production is through nonshivering thermogenesis. This process oxidizes which substance in response to cold exposure? a) white fat b) brown fat c) muscles d) nerves

b) brown fat Rationale: The newborn's primary method of heat production is through nonshivering thermogenesis, a process in which brown fat (adipose tissue) is oxidized in response to cold exposure. The brown color is derived from the fat's rich supply of blood vessels and nerve endings.

The nurse is performing an assessment on a client who has just been told that a pregnancy test is positive. Which assessment finding indicates that the client is at risk for preterm labor? a) client is a 35 year old primigravida b) client has a history of cardiac disease c) client's hemoglobin level is 13.5 g/dL (135 mmol/L) d) client is a 20 year old primigravida of average weight and height

b) client has a history of cardiac disease Rationale: Factors associated w/ preterm labor include hx of medical conditions, present * past obstetric problems, social and environmental factors, and substance abuse, multifetal pregnancy (contributes to overdistention of uterus), anemia (decreases oxygen supply to uterus), age younger than 18 years or first pregnancy at age older than 40 years a, c, and d are similar and are normal findings

A nurse is monitoring a client with PROM who is in labor and observes meconium in the amniotic fluid. What does the observation of meconium indicate? a) cord compression b) fetal distress related to hypoxia c) infection d) central nervous system (CNS) involvement

b) fetal distress related to hypoxia Rationale: When meconium is present in the amniotic fluid, it typically indicates fetal distress related to hypoxia. Meconium stains the fluid yellow to greenish brown, depending on the amount present. A decreased amount of amniotic fluid reduces the cushioning effect, thereby making cord compression a possibility. A foul odor of amniotic fluid indicates infection. Meconium in the amniotic fluid does not indicate CNS involvement.

A client has been admitted with placental abruption (abruptio placentae). She has lost 1,200 ml of blood, is normotensive, and ultrasound indicates approximately 30% separation. The nurse documents this as which classification of abruptio placentae? a) grade 1 b) grade 2 c) grade 3 d) grade 4

b) grade 2 Rationale: The classifications for placental abruption (abruptio placentae) are: grade 1 (mild) - minimal bleeding (less than 500 ml), 10% to 20% separation, tender uterus, no coagulopathy, signs of shock or fetal distress; grade 2 (moderate) - moderate bleeding (1,000 to 1,500 ml), 20% to 50% separation, continuous abdominal pain, mild shock, normal maternal blood pressure, maternal tachycardia; grade 3 (severe) - absent to moderate bleeding (more than 1,500 ml), more than 50% separation, profound shock, dark vaginal bleeding, agonizing abdominal pain, decreased blood pressure, significant tachycardia, and development of disseminated intravascular coagulopathy. There is no grade 4.

At 31 weeks' gestation, a 37-year-old client with a history of preterm birth reports cramps, vaginal pain, and low, dull backache accompanied by vaginal discharge and bleeding. Assessment reveals cervix 2.1 cm long; fetal fibronectin in cervical secretions, and cervix dilated 3 to 4 cm. Which interactions should the nurse prepare to assist with? a) bed rest and hydration at home b) hospitalization, tocolytic, and corticosteroids c) an emergency cesarean birth d) careful monitoring of fetal movement (kick) counts

b) hospitalization, tocolytic, and corticosteroids Rationale: At 31 weeks' gestation, the goal would be to maintain the pregnancy as long as possible if the client and fetus are tolerating the continuation of the pregnancy. Stopping the contractions and placing the client in the hospital allows for monitoring in a safe place if the client continues and gives birth. Administration of corticosteroids may help to develop the lungs and prepare for early preterm birth. Sending the client home is contraindicated in the scenario described. An emergency cesarean birth is not indicated at this time. Monitoring fetal movement (kick) counts is typically done with a postterm pregnancy.

What would be the physiologic basis for a placenta previa? a) a loose placental implantation b) low placental implantation c) a placenta with multiple lobes d) a uterus with a midseptum

b) low placental implantation Rationale: The cause of placenta previa is usually unknown, but for some reason the placenta is implanted low instead of high on the uterus.

The nurse is assessing the breast of a woman who is 1 month postpartum. The woman reports a painful area on one breast with a red area. The nurse notes a local area on one breast to be red and warm to touch. What should the nurse consider as the potential diagnosis? a) breast yeast b) mastitis c) plugged milk duct d) engorgement

b) mastitis Rationale: Mastitis usually occurs 2 to 3 weeks after birth and is noted to be unilateral. Mastitis needs to be assessed and treated with antibiotic therapy.

The nurse has created a plan of care for a client experiencing labor dystocia and includes several nursing actions in the plan of care. What is the priority nursing action? a) providing comfort measures b) monitoring the fetal heart rate c) changing the client's position frequently d) keeping the significant other informed of the progress of labor

b) monitoring the fetal heart rate Rationale: Priority is to monitor the fetal heart rate. Although a, c, and d are components of plan of care, the fetal status would be priority

A premature infant in the neonatal intensive care unit exhibits worsening respiratory distress and is noted to have abdominal distention, absent bowel sounds, and frequent diarrhea stools that are positive for hemoccult. What diagnosis would be most likely to correlate with the symptoms? a) garamycin-resistant bacteria b) necrotizing enterocolitis c) rotavirus infection d) respiratory distress syndrome

b) necrotizing enterocolitis Rationale: Observations for the development of NEC in the premature newborn may include feeding intolerance with abdominal distention, abdominal tenderness, and bloody or hemoccult-positive stools. Diarrhea is present with NEC and worsening of respiratory distress. Decreased or absent bowel sounds are noted. Rotavirus causes inflammation of a child's stomach and digestive tract, usually triggering vomiting, diarrhea, and fever and not seen in a preterm infant. Garamycin-resistant bacteria is usually seen in older adults.

The nurse is caring for a pregnant client with fallopian tube rupture. Which intervention is the priority for this client? a) Monitor the client's beta-hCG level. b) Monitor the mass with transvaginal ultrasound. c) Monitor the client's vital signs and bleeding. d) Monitor the fetal heart rate (FHR).

c) Monitor the client's vital signs and bleeding. Rationale: A nurse should closely monitor the client's vital signs and bleeding (peritoneal or vaginal) to identify hypovolemic shock that may occur with tubal rupture. Beta-hCG level is monitored to diagnose an ectopic pregnancy or impending spontaneous abortion (miscarriage). Monitoring the mass with transvaginal ultrasound and determining the size of the mass are done for diagnosing an ectopic pregnancy. Monitoring the FHR does not help to identify hypovolemic shock.

The nurse in a labor room is performing a vaginal assessment on a pregnant client in labor. The nurse notes the presence of the umbilical cord protruding from the vagina. What is the first nursing action with this finding? a) gently push the cord into the vagina b) place the client in Trendelenburg's position c) Find the closest telephone and page the primary health care provider stat d) call the delivery room to notify the staff that the client will be transported immediately

b) place the client in Trendelenburg's position Rationale: When cord prolapse occurs, prompt actions are taken to relieve cord compression and increase fetal oxygenation. The client should be positioned with the hips higher than head to shift the fetal presenting part toward the diaphragm. The nurse should push the call light to summon help & the other staff members should call the primary health care provider and notify the delivery room. If the cord is protruding from the vagina, no attempt should be made to replace it because to do so could traumatize it and reduce blood flow further. Also as a first action, the examiner should place a gloved hand into the vagina and hold the presenting part off the umbilical cord. Oxygen, 8-10 L/min, by face mask is administered to the client to increase fetal oxygenation

Which factor puts a multiparous client on her first postpartum day at risk for developing hemorrhage? a) hemoglobin level of 12 g/dl (120 g/L) b) uterine atony c) thrombophlebitis d) moderate amount of lochia rubra

b) uterine atony Rationale: Multiparous women typically experience a loss of uterine tone due to frequent distentions of the uterus from previous pregnancies. As a result, this client is also at higher risk for hemorrhage. Thrombophlebitis does not increase the risk of hemorrhage during the postpartum period. The hemoglobin level and lochia flow are within acceptable limits.

A nursing instructor asks a nursing student to describe the procedure for administering erythromycin ointment into the eyes of a neonate. The instructor determines that the student needs to research this procedure further if the student states: a. "I will cleanse the neonate's eyes before instilling ointment." b. "I will flush the eyes after instilling the ointment." c. "I will instill the eye ointment into each of the neonate's conjunctival sacs within one hour after birth." d. "Administration of the eye ointment may be delayed until an hour or so after birth so that eye contact and parent-infant attachment and bonding can occur."

b. "I will flush the eyes after instilling the ointment."

A nurse is working with the parents of a newborn girl. The parents have a 2-year-old boy at home. Which statement would the nurse include when teaching these parents? a) "Expect to see your 2-year-old become more independent when the baby gets home." b) "Talk to your 2-year-old about the baby when you're driving him to day care." c) "Ask your 2-year-old to pick out a special toy for his sister." d) "Have your 2-year-old stay at home while you're here in the hospital."

c) "Ask your 2-year-old to pick out a special toy for his sister." Rationale: The parents should encourage the sibling to participate in some of the decisions about the baby, such as names or toys. Typically siblings experience some regression with the birth of a new baby. The parents should talk to the sibling during relaxed family times. The parents should arrange for the sibling to come to the hospital to see the newborn.

The nurse provides education to a postterm pregnant client. What information will the nurse include to assist in early identification of potential problems? a) "Increase your fluid intake to prevent dehydration." b) "Be sure to measure 24-hour urine output daily." c) "Continue to monitor fetal movements daily." d) "Monitor your bowel movements for constipation."

c) "Continue to monitor fetal movements daily." Rationale: The nurse will teach the postterm client to monitor fetal movements (kick counts) daily to help determine if the fetus is experiencing distress. A 24-hour urine is needed for postterm clients; however, this is not collected daily. Although all pregnant clients should avoid dehydration, there is no indication this client needs to increase her fluid intake and this will not help identify potential problems. Monitoring bowel movements for constipation is not needed.

A client with a history of cervical insufficiency is seen for reports of pink-tinged discharge and pelvic pressure. The primary care provider decides to perform a cervical cerclage. The nurse teaches the client about the procedure. Which client response indicates that the teaching has been effective? a) "Staples are put in the cervix to prevent it from dilating." b) "The cervix is glued shut so no amniotic fluid can escape." c) "Purse-string sutures are placed in the cervix to prevent it from dilating." d) "A cervical cap is placed so no amniotic fluid can escape."

c) "Purse-string sutures are placed in the cervix to prevent it from dilating." Rationale: The cerclage, or purse string suture, is inserted into the cervix to prevent preterm cervical dilation (dilatation) and pregnancy loss. Staples, glue, or a cervical cap will not prevent the cervix from dilating.

A nurse is applying ice packs to the perineal area of a client who has had a vaginal birth. Which intervention should the nurse perform to ensure that the client gets the optimum benefits of the procedure? a) Apply ice packs directly to the perineal area. b) Apply ice packs for 40 minutes continuously. c) Ensure ice pack is changed frequently. d) Use ice packs for a week after birth.

c) Ensure ice pack is changed frequently. Rationale: The nurse should ensure that the ice pack is changed frequently to promote good hygiene and to allow for periodic assessments. Ice packs are wrapped in a disposable covering or clean washcloth and then applied to the perineal area, not directly. The nurse should apply the ice pack for 20 minutes, not 40 minutes. Ice packs should be used for the first 24 hours, not for a week after birth.

A woman in labor is having very intense contractions with a resting uterine tone >20 mm Hg. The woman is screaming out every time she has a contraction. What is the highest priority fetal assessment the health care provider should focus on at this time? a) Monitor heart rate for tachycardia. b) Monitor fetal movements to ensure they are neurologically intact. c) Look for late decelerations on monitor, which is associated with fetal anoxia. d) Monitor fetal blood pressure for signs of shock (low BP, high FHR).

c) Look for late decelerations on monitor, which is associated with fetal anoxia. Rationale: A danger of hypertonic contractions is that the lack of relaxation between contractions may not allow optimal uterine artery filling; this can lead to fetal anoxia early in the latent phase of labor. Applying a uterine and a fetal external monitor will help identify that the resting phase between contractions is adequate and that the FHR is not showing late deceleration.

A 26-year-old primigravida has brought her doula to the birthing center for support during her labor and birth. The doula has been helping her through the past 16 hours of labor. The laboring woman is now 6 cm dilated. She continues to report severe pain in her back with each contraction. The client finds it comforting when her doula uses the ball of her hand to put counterpressure on her lower back. What is the likely cause of the woman's back pain? a) Breech presentation b) Fetal macrosomia c) Occiput posterior position d) Nongynecoid pelvis

c) Occiput posterior position Rationale: A labor complicated by occiput posterior position is usually prolonged and characterized by maternal perception of increased intensity of back discomfort. The lay term for this type of labor is "back labor."

A woman at 28 weeks' gestation has been hospitalized with moderate bleeding that is now stabilizing. The nurse performs a routine assessment and notes the client sleeping, lying on the back, and electronic fetal heart rate (FHR) monitor showing gradually increasing baseline with late decelerations. Which action will the nurse perform first? a) Administer oxygen to the client. b) Notify the health care provider. c) Reposition the client to left side. d) Increase the rate of IV fluids.

c) Reposition the client to left side. Rationale: The fetus is showing signs of fetal distress. The immediate treatment is putting the client in a side-lying position to ensure adequate perfusion to the fetus. After placing the client on the side, the nurse should re-assess the FHR and determine if oxygen, IV fluids, and calling the health care provider are needed.

A woman whose fetus is in the occiput posterior position is experiencing increased back pain. Which is the best way for the nurse to help alleviate this back pain? a) applying a heating pad to the back b) applying ice to the back c) applying counterpressure to the back d) performing acupuncture on the back

c) applying counterpressure to the back Rationale: Counterpressure applied to the lower back with a fisted hand sometimes helps the woman cope with "back labor" associated with occiput-posterior positioning. The others are not recommended or used techniques for a woman in labor with back pain.

To give birth to her infant, a woman is asked to push with contractions. Which pushing technique is the most effective and safest? a) lying supine with legs in lithotomy stirrups b) squatting while holding her breath c) head elevated, grasping knees, breathing out d) lying on side, arms grasped on abdomen

c) head elevated, grasping knees, breathing out Rationale: For the most effective pushing during the second stage of labor, a woman should wait to feel the urge to push even though a pelvic exam has revealed she is fully dilated. Pushing is usually best done from a semi-Fowler's position with legs raised against the abdomen, squatting, or on all fours rather than lying flat to allow gravity to aid the effort .Make sure the woman pushes with contractions and rests between them. She can use short pushes or long, sustained ones, whichever feels more comfortable. Holding the breath during a contraction could cause a Valsalva maneuver or temporarily impede blood return to her heart because of increased intrathoracic pressure, which could then also interfere with blood supply to the uterus. To prevent her from holding her breath during pushing, urge her to grunt or breathe out during a pushing effort (as tennis players do).

The nurse is assessing a client who is 6 hours postpartum after delivering a full-term healthy newborn. The client complains to the nurse of feelings of faintness and dizziness. Which nursing action is most appropriate? a) raise the head of the client's bed b) obtain hemoglobin and hematocrit levels c) instruct the client to request help when getting out of bed d) inform the nursery room nurse to avoid bringing the newborn to the client until the client's symptoms have subsided

c) instruct the client to request help when getting out of bed Rationale: orthostatic hypotension may be evident during the first 8 hours after birth. Feelings of faintness or dizziness are signs that caution the nurse to focus interventions on the client's safety. The nurse should advise the client to get help the first few times she gets out of bed. A is not a helpful action in this situation and would not relieve symptoms B requires a prescription D is unnecessary

The nurse is reviewing the primary health care provider's prescriptions for a client admitted for premature rupture of membranes. Gestational age of the fetus is determined to be 37 weeks. Which prescription should the nurse question? a) monitor fetal heart rate continuously b) monitor maternal vital signs c) perform a vaginal examination every shift d) administer an antibiotic per prescription and per agency protocol

c) perform a vaginal examination every shift Rationale: vaginal exams should not be done routinely on a client with premature ROM because of the risk of infection. The nurse would expect to monitor fetal heart rate, maternal vital signs, and administer an antibiotic

A nurse is preparing to administer a vitamin K injection to a newborn infant. The mother asks the nurse why her newborn infant needs the injection. The best response by the nurse would be: a. "Your infant needs vitamin K to develop immunity." b. "Vitamin K will protect your infant from having jaundice." c. "Newborn infants are deficient in vitamin K, and this injection prevents your infant from abnormal bleeding." d. "Newborn infants have sterile bowels, and vitamin K promotes the growth of bacteria in the bowel."

c. "Newborn infants are deficient in vitamin K, and this injection prevents your infant from abnormal bleeding."

When teaching umbilical cord care to a new mother, the nurse would include which information? a. Apply peroxide to the cord with each diaper change b. Cover the cord with petroleum jelly after bathing c. Keep the cord dry and open to air d. Wash the cord with soap and water each day during a tub bath

c. Keep the cord dry and open to air Rationale: helps reduce infection and hastens drying

A woman of 16 weeks' gestation telephones the nurse because she has passed some "berry-like" blood clots and now has continued dark brown vaginal bleeding. Which action would the nurse instruct the woman to do? a) "Maintain bed rest, and count the number of perineal pads used." b) "Come to the health care facility if uterine contractions begin." c) "Continue normal activity, but take the pulse every hour." d) "Come to the health facility with any vaginal material passed."

d) "Come to the health facility with any vaginal material passed." Rationale: This is a typical time in pregnancy for gestational trophoblastic disease to present. Asking the woman to bring any material passed vaginally would be important so the material can be assessed for this.

Fetal distress is occurring with a laboring patient. As the nurse prepares the client for a cesarean birth, what is the most important nursing action? a) slow the intravenous rate b) continue the oxytocin drip if infusing c) place the client in high Fowler's position d) administer oxygen, 8-10 L/min, via face mask

d) administer oxygen, 8-10 L/min, via face mask Rationale: oxygen is administered to optimize oxygenation of circulating blood A is wrong because intravenous infusion should be increased (per primary health care provider prescription) to increase maternal blood volume B is wrong because oxytocin stimulation of the uterus should be discontinued if fetal heart rate patterns change for any reason C is wrong because client is placed in lateral position with her legs raises to increase maternal blood volume and improve fetal perfusion

The nurse is required to assess a pregnant client who is reporting vaginal bleeding. Which nursing action is the priority? a) monitoring uterine contractility b) assessing signs of shock c) determining the amount of funneling d) assessing the amount and color of the bleeding

d) assessing the amount and color of the bleeding Rationale: When the woman arrives and is admitted, assessing her vital signs, the amount and color of the bleeding, and current pain rating on a scale of 1 to 10 are the priorities. Assessing the signs of shock, monitoring uterine contractility, and determining the amount of funneling are not priority assessments when a pregnant woman complaining of vaginal bleeding is admitted to the hospital.

Which nursing intervention is appropriate for prevention of a urinary tract infection (UTI) in the postpartum woman? a) increasing oral fluid intake b) increasing intravenous fluids c) screening for bacteriuria in the urine d) encouraging the woman to empty her bladder completely every 2 to 4 hours

d) encouraging the woman to empty her bladder completely every 2 to 4 hours Rationale: The nurse should advise the woman to urinate every 2 to 4 hours while awake to prevent overdistention and trauma to the bladder. Maintaining a good fluid intake is also important, but it is not necessary to increase fluids if the woman is consuming enough. Screening for bacteria in the urine would require a primary care provider's order and is not necessary as a prevention measure.

The nurse is monitoring the uterine contractions of a woman in labor. The nurse determines the woman is experiencing hypertonic uterine dysfunction based on which contraction finding? a) well coordinated. b) poor in quality. c) brief. d) erratic.

d) erratic. Rationale: Hypertonic contractions occur when the uterus never fully relaxes between contractions, making the contractions erratic and poorly coordinated because more than one uterine pacemaker is sending signals for contraction. Hypotonic uterine contractions are poor in quality, brief, and lack sufficient intensity to dilate and efface the cervix.

A woman at 8 weeks' gestation is admitted for ectopic pregnancy. She is asking why this has occurred. The nurse knows that which factor is a known risk factor for ectopic pregnancy? a) high number of pregnancies b) multiple gestation pregnancy c) use of oral contraceptives d) history of endometriosis

d) history of endometriosis Rationale: The nurse needs to complete a full history of the client to determine if she had any other risk factors for an ectopic pregnancy. Adhesions, scarring, and narrowing of the tubal lumen may block the zygote's progress to the uterus. Any condition or surgical procedure that can injure a fallopian tube increases the risk. Examples include salpingitis, infection of the fallopian tube, endometriosis, history of prior ectopic pregnancy, any type of tubal surgery, congenital malformation of the tube, and multiple abortions (elective terminations of pregnancy). Conditions that inhibit peristalsis of the tube can result in tubal pregnancy. A high number of pregnancies, multiple gestation pregnancy, and the use of oral contraceptives are not known risk factors for ectopic pregnancy.

The postpartum nurse is taking the vital signs of a client who delivered a healthy newborn 4 hours ago. The nurse notes that he client's temperature is 100.2 F. What is the priority nursing action? a) document the findings b) notify the obstetrician c) retake the temperature 15 minutes d) increase hydration by encouraging oral fluids

d) increase hydration by encouraging oral fluids Rationale: Client's temperature should be taken q4h while she is awake. Temperatures up to 100.4 F in first 24 hours after birth are often r/t dehydrating effects of labor. The appropriate action is to increase hydration which should bring the temperature to a normal reading

Which medication will the nurse anticipate the health care provider will prescribe as treatment for an unruptured ectopic pregnancy? a) oxytocin b) promethazine c) ondansetron d) methotrexate

d) methotrexate Rationale: Methotrexate, a folic acid antagonist that inhibits cell division in the developing embryo, is most commonly used to treat ectopic pregnancy. Oxytocin is used to stimulate uterine contractions and would be inappropriate for use with an ectopic pregnancy. Promethazine and ondansetron are antiemetics that may be used to treat hyperemesis gravidarum.

The nurse in a birthing room is monitoring a client with dysfunctional labor for signs of fetal or maternal compromise. Which assessment finding should alert the nurse to a compromise? a) maternal fatigue b) coordinated uterine contractions c) progressive changes in the cervix d) persistent non-reassuring fetal heart rate

d) persistent non-reassuring fetal heart rate Rationale: signs of fetal or maternal compromise include a persistent non-reassuring fetal heart rate, fetal acidosis, & passage of meconium Maternal fatigue and infection can occur if labor is prolonged but do not indicate if there's maternal or fetal compromise Coordinated uterine contractions and progressive changes in the cervix are reassuring pattern in labor

The nurse is admitting a client at 23 weeks' gestation in preparation for induction and delivery after it was determined the fetus had died secondary to trauma. When asked by the client to explain what went wrong, the nurse can point out which potential cause for this loss? a) genetic abnormality b) premature rupture of membranes c) preeclampsia d) placental abruption

d) placental abruption Rationale: The most common cause of fetal death after a trauma is placental abruption (abruptio placentae), where the placenta separates from the uterus, and the fetus is not able to survive. Genetic abnormalities typically cause spontaneous abortion (miscarriage) in the first trimester. Trauma does not cause preeclampsia (which is related to various issues in the mother) nor does trauma usually cause PROM.

A pregnant client is admitted to a maternity clinic after experiencing contractions. The assigned nurse observes that the client experiences pauses between contractions. The nurse knows that which event marks the importance of the pauses between contractions during labor? a) effacement and dilation (dilatation) of the cervix b) shortening of the upper uterine segment c) reduction in length of the cervical canal d) restoration of blood flow to uterus and placenta

d) restoration of blood flow to uterus and placenta Rationale: The pauses between contractions during labor are important because they allow the restoration of blood flow to the uterus and the placenta. Shortening of the upper uterine segment, reduction in length of the cervical canal, and effacement and dilation (dilatation) of the cervix are other processes that occur during uterine contractions.

The nurse instructs a new mother about safety considerations for the neonate. The nurse determines that the patient does not understand the instructions when she says: a. "All neonates should be in an approved car seat when in an automobile." b. "Pillows should not be used in the infant's crib." c. "Infants should never be left unattended on an unguarded surface." d. "I should wake the baby to feed every 3 to 4 hours."

d. "I should wake the baby to feed every 3 to 4 hours." Rationale: Newborns should be fed on demand rather than on a schedule. Teach families to count the number of wet and dirty diapers to monitor for adequate intake.

The home health nurse visits a family 2 weeks after hospital discharge. The nurse observes that the umbilical cord has dried and fallen off. The area appears healed with no drainage or erythema present. The mother can be instructed to: a. cover the umbilicus with a band-aid. b. continue to clean the stump with alcohol for one week. c. apply an antibiotic ointment to the stump. d. give him a bath in an infant tub now.

d. give him a bath in an infant tub now. Rationale: The baby's umbilical cord stump dries out and eventually falls off — usually within one to three weeks after birth. After the cord has fallen off, the navel will gradually heal. It's normal for the center to look red at the point of separation. Sponge baths are recommended for a few more days or tub baths will be fine.