OB exam #4

The client with insulin-dependent type 2 diabetes and an HbA1c of 5.0% is planning to become pregnant soon. What anticipatory guidance should the nurse provide this client? 1. Insulin needs decrease in the first trimester and usually begin to rise late in the first trimester as glucose use and glycogen storage by the woman and fetus increase. 2. The risk of ketoacidosis decreases during the length of the pregnancy. 3. Vascular disease that accompanies diabetes slows progression. 4. The baby is likely to have a congenital abnormality because of the diabetes.

1 Explanation: 1. Insulin needs decrease in the first trimester and usually begin to rise late in the first trimester as glucose use and glycogen storage by the woman and fetus increase.

A client with diabetes is receiving preconception counseling. The nurse will emphasize that during the first trimester, the woman should be prepared for which of the following? 1. The need for less insulin than she normally uses 2. Blood testing for anemia 3. Assessment for respiratory complications 4. Assessment for contagious conditions

1 Explanation: 1. Women with diabetes often require less insulin during the first trimester.

The nurse has written the nursing diagnosis Injury, Risk for for a diabetic pregnant client. Interventions for this diagnosis include which of the following? Note: Credit will be given only if all correct and no incorrect choices are selected. Select all that apply. 1. Assessment of fetal heart tones 2. Perform oxytocin challenge test, if ordered 3. Refer the client to a diabetes support group 4. Assist with the biophysical profile assessment 5. Develop an appropriate teaching plan

1, 2, 4 Explanation: 1. Reassuring fetal heart rate variability and accelerations are interpreted as adequate placental oxygenation. 2. The nurse would perform oxytocin challenge test (OCT)/contraction stress test (CST) and non-stress tests as determined by physician. 4. The nurse assists the physician in performing a biophysical profile assessment.

MATCHING Because most pregnant women continue their usual activities, trauma remains a common complication during pregnancy. Approximately 1 in 12 pregnancies in the United States are complicated by trauma each year. As a result of the physiologic alterations that accompany pregnancy, special considerations for the mother and fetus are necessary when trauma occurs. Match the maternal system adaptation in pregnancy with the clinical response to trauma. a. Increased oxygen consumption b. Increased heart rate c. Decreased gastric motility d. Displacement of abdominal viscera e. Increase in clotting factors 1. Decreased placental perfusion in the supine position 2. Increased risk of thrombus formation 3. Altered pain referral 4. Increased risk of acidosis 5. Increased risk of aspiration

1. ANS: B DIF: Cognitive Level: Apply REF: p. 732 TOP: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity NOT: Immediate priorities for the stabilization of the pregnant woman after trauma should be identical to that of the nonpregnant client after trauma. Fetal survival depends on maternal survival, and stabilization of the mother improves the chance of fetal well-being. Trauma may affect a number of systems within the body, and being aware of normal system alterations in the pregnant woman is important for the nurse who is caring for this client. Care should be adapted according to the body system that has been injured. The effects of trauma on pregnancy are also influenced by the length of gestation, type and severity of the injuries, and the degree of disruption of uterine and fetal physiologic features. 2. ANS: E DIF: Cognitive Level: Apply REF: p. 732 TOP: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity NOT: Immediate priorities for the stabilization of the pregnant woman after trauma should be identical to that of the nonpregnant client after trauma. Fetal survival depends on maternal survival, and stabilization of the mother improves the chance of fetal well-being. Trauma may affect a number of systems within the body, and being aware of normal system alterations in the pregnant woman is important for the nurse who is caring for this client. Care should be adapted according to the body system that has been injured. The effects of trauma on pregnancy are also influenced by the length of gestation, type and severity of the injuries, and the degree of disruption of uterine and fetal physiologic features. 3. ANS: D DIF: Cognitive Level: Apply REF: p. 732 TOP: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity NOT: Immediate priorities for the stabilization of the pregnant woman after trauma should be identical to that of the nonpregnant client after trauma. Fetal survival depends on maternal survival, and stabilization of the mother improves the chance of fetal well-being. Trauma may affect a number of systems within the body, and being aware of normal system alterations in the pregnant woman is important for the nurse who is caring for this client. Care should be adapted according to the body system that has been injured. The effects of trauma on pregnancy are also influenced by the length of gestation, type and severity of the injuries, and the degree of disruption of uterine and fetal physiologic features. 4. ANS: A DIF: Cognitive Level: Apply REF: p. 732 TOP: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity NOT: Immediate priorities for the stabilization of the pregnant woman after trauma should be identical to that of the nonpregnant client after trauma. Fetal survival depends on maternal survival, and stabilization of the mother improves the chance of fetal well-being. Trauma may affect a number of systems within the body, and being aware of normal system alterations in the pregnant woman is important for the nurse who is caring for this client. Care should be adapted according to the body system that has been injured. The effects of trauma on pregnancy are also influenced by the length of gestation, type and severity of the injuries, and the degree of disruption of uterine and fetal physiologic features. 5. ANS: C DIF: Cognitive Level: Apply REF: p. 732 TOP: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity NOT: Immediate priorities for the stabilization of the pregnant woman after trauma should be identical to that of the nonpregnant client after trauma. Fetal survival depends on maternal survival, and stabilization of the mother improves the chance of fetal well-being. Trauma may affect a number of systems within the body, and being aware of normal system alterations in the pregnant woman is important for the nurse who is caring for this client. Care should be adapted according to the body system that has been injured. The effects of trauma on pregnancy are also influenced by the length of gestation, type and severity of the injuries, and the degree of disruption of uterine and fetal physiologic features.

A newly diagnosed insulin-dependent type 1 diabetic with good blood sugar control is at 20 weeks gestation. She asks the nurse how her diabetes will affect her baby. What would the best explanation include? 1. Your baby could be smaller than average at birth. 2. Your baby will probably be larger than average at birth. 3. As long as you control your blood sugar, your baby will not be affected at all. 4. Your baby might have high blood sugar for several days.

2 Explanation: 2. Characteristically, infants of mothers with diabetes are large for gestational age (LGA) as a result of high levels of fetal insulin production stimulated by the high levels of glucose crossing the placenta from the mother. Sustained fetal hyperinsulinism and hyperglycemia ultimately lead to excessive growth, called macrosomia, and deposition of fat.

A 26-year-old client is 28 weeks pregnant. She has developed gestational diabetes. She is following a program of regular exercise, which includes walking, bicycling, and swimming. What instructions should be included in a teaching plan for this client? 1. Exercise either just before meals or wait until 2 hours after a meal. 2. Carry hard candy (or other simple sugar) when exercising. 3. If your blood sugar is 120 mg/dL, eat 20 g of carbohydrate. 4. If your blood sugar is more than 120 mg/dL, drink a glass of whole milk.

2 Explanation: 2. The nurse should advise her to carry a simple sugar such as hard candy because of the possibility of exercise-induced hypoglycemia.

A diabetic client goes into labor at 36 weeks gestation. Provided that tests for fetal lung maturity are successful, the nurse will anticipate which of the following interventions? Note: Credit will be given only if all correct and no incorrect choices are selected. Select all that apply. 1. Administration of tocolytic therapy 2. Beta-sympathomimetic administration 3. Allowance of labor to progress 4. Hourly blood glucose monitoring 5. Cesarean birth may be indicated if evidence of reassuring fetal status exists

3, 4 Explanation: 3. There will be no attempt to stop the labor, as this can compromise the mother and fetus. 4. To reduce incidence of congenital anomalies and other problems in the newborn, the woman should be euglycemic (have normal blood glucose) throughout the pregnancy.

A 26-year-old client is 26 weeks pregnant. Her previous births include two large-for-gestational-age babies and one unexplained stillbirth. Which tests would the nurse anticipate as being most definitive in diagnosing gestational diabetes? 1. A 50g, 1-hour glucose screening test 2. A single fasting glucose level 3. A 100g, 1-hour glucose tolerance test 4. A 100g, 3-hour glucose tolerance test

4 Explanation: 4. Gestational diabetes is diagnosed if two or more of the following values are met or exceeded after taking the 100 g, 3-hour OGTT: Fasting: 95 mg/dL; 1 hour: 180 mg/dL; 2 hours: 155 mg/dL; 3 hours: 140 mg/dL.

The client has just been diagnosed as diabetic. The nurse knows teaching was effective when the client makes which statement? 1. Ketones in my urine mean that my body is using the glucose appropriately. 2. I should be urinating frequently and in large amounts to get rid of the extra sugar. 3. My pancreas is making enough insulin, but my body isnt using it correctly. 4. I might be hungry frequently because the sugar isnt getting into the tissues the way it should.

4 Explanation: 4. The client who understands the disease process is aware that if the body is not getting the glucose it needs, the message of hunger will be sent to the brain.

11. Which neurologic condition would require preconception counseling, if at all possible? a. Eclampsia b. Bell palsy c. Epilepsy d. Multiple sclerosis

: C Women with epilepsy should receive preconception counseling, if at all possible. Achieving seizure control before becoming pregnant is a desirable state. Medication should also be carefully reviewed. Eclampsia may sometimes be confused with epilepsy, and Bell palsy is a form of facial paralysis; preconception counseling for either condition is not essential to care. Multiple sclerosis is a patchy demyelination of the spinal cord that does not affect the normal course of pregnancy or birth. DIF: Cognitive Level: Understand REF: p. 725 TOP: Nursing Process: Planning

8. Since the gene for cystic fibrosis was identified in 1989, data can be collected for the purposes of genetic counseling for couples regarding carrier status. According to the most recent statistics, how often does cystic fibrosis occur in Caucasian live births? a. 1 in 100 b. 1 in 1000 c. 1 in 2000 d. 1 in 3200

: D Cystic fibrosis occurs in approximately 1 in 3200 Caucasian live births. 1 in 100, 1 in 1000, and 1 in 2000 occurrences of cystic fibrosis in live births are all too frequent rates. DIF: Cognitive Level: Remember REF: p. 722 TOP: Nursing Process: Assessment

Screening at 24 weeks of gestation reveals that a pregnant woman has gestational diabetes mellitus (GDM). In planning her care, the nurse and the client mutually agree that an expected outcome is to prevent injury to the fetus as a result of GDM. This fetus is at the greatest risk for which condition? a. Macrosomia b. Congenital anomalies of the central nervous system c. Preterm birth d. Low birth weight

A Poor glycemic control later in pregnancy increases the rate of fetal macrosomia. Poor glycemic control during the preconception time frame and into the early weeks of the pregnancy is associated with congenital anomalies. Preterm labor or birth is more likely to occur with severe diabetes and is the greatest risk in women with pregestational diabetes. Increased weight, or macrosomia, is the greatest risk factor for this fetus.

The most important nursing action in preventing neonatal infection is: A. Good handwashing B. Isolation of infected infants C. Separate gown technique D. Standard Precautions

A A. Correct: Virtually all controlled clinical trials have demonstrated that effective handwashing is responsible for the prevention of nosocomial infection in nursery units. B. Incorrect: Measures to be taken include Standard Precautions, careful and thorough cleaning, frequent replacement of used equipment, and disposal of excrement and linens in an appropriate manner. Overcrowding must be avoided in nurseries. However, the most important nursing action for preventing neonatal infection is effective handwashing. C. Incorrect: Measures to be taken include Standard Precautions, careful and thorough cleaning, frequent replacement of used equipment, and disposal of excrement and linens in an appropriate manner. Overcrowding must be avoided in nurseries. However, the most important nursing action for preventing neonatal infection is effective handwashing. D. Incorrect: Measures to be taken include Standard Precautions, careful and thorough cleaning, frequent replacement of used equipment, and disposal of excrement and linens in an appropriate manner. Overcrowding must be avoided in nurseries. However, the most important nursing action for preventing neonatal infection is effective handwashing. p. 1002

Many common drugs of abuse cause significant physiologic and behavioral problems in infants who are breastfed by mothers currently using (choose all that apply): A. Amphetamine B. Heroin C. Nicotine D. PCP E. Morphine

A, B, C, D These drugs of abuse are contraindicated during breastfeeding because of the reported effects on the infant. Morphine is a medication that often is used to treat neonatal abstinence syndrome. p. 1019

Medications used to manage postpartum hemorrhage (PPH) include (Select all that apply): a. Pitocin. b. Methergine. c.Terbutaline. d. Hemabate. e. Magnesium sulfate.

A, B, D Pitocin, Methergine, and Hemabate are all used to manage PPH. Terbutaline and magnesium sulfate are tocolytics; relaxation of the uterus causes or worsens PPH.

Diabetes refers to a group of metabolic diseases characterized by hyperglycemia resulting from defects in insulin action, insulin secretion, or both. Over time, diabetes causes significant changes in the microvascular and macrovascular circulations. What do these complications include? (Select all that apply.) a. Atherosclerosis b. Retinopathy c. Intrauterine fetal death (IUFD) d. Nephropathy e. Neuropathy f. Autonomic neuropathy

A, B, D, E These structural changes will most likely affect a variety of systems, including the heart, eyes, kidneys, and nerves. IUFD (stillbirth) remains a major complication of diabetes in pregnancy; however, this is a fetal complication.

Possible alternative and complementary therapies for postpartum depression (PPD) for breastfeeding mothers include (Select all that apply): a. Acupressure. b. Aromatherapy. c. St. John's wort. d. Wine consumption. e. Yoga.

A, B, E Possible alternative/complementary therapies for postpartum depression include acupuncture, acupressure, aromatherapy, therapeutic touch, massage, relaxation techniques, reflexology, and yoga. St. John's wort has not been proven to be safe for women who are breastfeeding. Women who are breastfeeding and/or have a history of PPD should not consume alcohol.

A serious but uncommon complication of undiagnosed or partially treated hyperthyroidism is a thyroid storm, which may occur in response to stress such as infection, birth, or surgery. What are the signs and symptoms of this emergency disorder? (Select all that apply.) a. Fever b. Hypothermia c. Restlessness d. Bradycardia e. Hypertension

A, C Fever, restlessness, tachycardia, vomiting, hypotension, and stupor are symptoms of a thyroid storm. Fever, not hypothermia; tachycardia, not bradycardia; and hypotension, not hypertension, are symptoms of thyroid storm.

The corrected age of an infant who was born at 25 1/7 weeks and is preparing for discharge 124 days past delivery is ______________.

ANS: 42 6/7 weeks The age of a preterm newborn is corrected by adding the gestational age and the postnatal age. For example, an infant born at 32 weeks of gestation 4 weeks ago would now be considered 36 weeks of age. (32 + 4 = 36).

23. A client at 39 weeks of gestation has been admitted for an external version. Which intervention would the nurse anticipate the provider to order? a. Tocolytic drug b. Contraction stress test (CST) c. Local anesthetic d. Foley catheter

ANS: A A tocolytic drug will relax the uterus before and during the version, thus making manipulation easier. CST is used to determine the fetal response to stress. A local anesthetic is not used with external version. Although the bladder should be emptied, catheterization is not necessary. DIF: Cognitive Level: Apply REF: p. 779 TOP: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity

4. A woman in preterm labor at 30 weeks of gestation receives two 12-mg intramuscular (IM) doses of betamethasone. What is the purpose of this pharmacologic intervention? a. To stimulate fetal surfactant production b. To reduce maternal and fetal tachycardia associated with ritodrine administration c. To suppress uterine contractions d. To maintain adequate maternal respiratory effort and ventilation during magnesium sulfate therapy

ANS: A Antenatal glucocorticoids administered as IM injections to the mother accelerate fetal lung maturity. Propranolol (Inderal) is given to reduce the effects of ritodrine administration. Betamethasone has no effect on uterine contractions. Calcium gluconate is given to reverse the respiratory depressive effects of magnesium sulfate therapy. DIF: Cognitive Level: Understand REF: p. 769 TOP: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity

25. Which nursing intervention should be immediately performed after the forceps-assisted birth of an infant? a. Assessing the infant for signs of trauma b. Administering prophylactic antibiotic agents to the infant c. Applying a cold pack to the infant's scalp d. Measuring the circumference of the infant's head

ANS: A The infant should be assessed for bruising or abrasions at the site of application, facial palsy, and subdural hematoma. Prophylactic antibiotics are not necessary with a forceps delivery. A cold pack would place the infant at risk for cold stress and is contraindicated. Measuring the circumference of the head is part of the initial nursing assessment. DIF: Cognitive Level: Apply REF: p. 788 TOP: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

Which risk factors are associated with NEC (Necrotizing enterocolitis)? (Select all that apply.) a.Polycythemia b.Anemia c.Congenital heart disease d.Bronchopulmonary dysphasia e.Retinopathy

ANS: A, B, C Risk factors for NEC include asphyxia, RDS, umbilical artery catheterization, exchange transfusion, early enteral feedings, patent ductus arteriosus (PDA), congenital heart disease, polycythemia, anemia, shock, and gastrointestinal infection. Bronchopulmonary dysphasia and retinopathy are not associated with NEC

2. What are the complications and risks associated with cesarean births? (Select all that apply.) a. Pulmonary edema b. Wound dehiscence c. Hemorrhage d. Urinary tract infections e. Fetal injuries

ANS: A, B, C, D, E Pulmonary edema, wound dehiscence, hemorrhage, urinary tract infections, and fetal injuries are possible complications and risks associated with cesarean births. DIF: Cognitive Level: Understand REF: p. 790 TOP: Nursing Process: Evaluation MSC: Client Needs: Physiologic Integrity

2. Screening questions for alcohol and drug abuse should be included in the overall assessment during the first prenatal visit for all women. The 4 Ps Plus is a screening tool specifically designed to identify the need for a more in-depth assessment. Which are the correct components of the 4 Ps Plus? (Select all that apply.) a. Parents b. Partner c. Present d. Past e. Pregnancy

ANS: A, B, D, E The nurse who is screening the client using the 4 Ps Plus would use the following format: Parents: "Did either of your parents have a problem with alcohol or drugs?" Partner: "Does your partner have a problem with alcohol or drugs?" Past: "Have you ever had any beer, wine, or liquor?" Pregnancy: "In the month before you knew you were pregnant, how many cigarettes did you smoke? How much beer, wine, or liquor did you drink?" Present: Is not a component of the 4 Ps Plus. DIF: Cognitive Level: Apply REF: p. 753 TOP: Nursing Process: Assessment MSC: Client Needs: Psychologic Integrity

4. The induction of labor is considered an acceptable obstetric procedure if it is in the best interest to deliver the fetus. The charge nurse on the labor and delivery unit is often asked to schedule clients for this procedure and therefore must be cognizant of the specific conditions appropriate for labor induction. What are appropriate indications for induction? (Select all that apply?) a. Rupture of membranes at or near term b. Convenience of the woman or her physician c. Chorioamnionitis (inflammation of the amniotic sac) d. Postterm pregnancy e. Fetal death

ANS: A, C, D, E The conditions listed are all acceptable indications for induction. Other conditions include intrauterine growth restriction (IUGR), maternal-fetal blood incompatibility, hypertension, and placental abruption. Elective inductions for the convenience of the woman or her provider are not recommended; however, they have become commonplace. Factors such as rapid labors and living a long distance from a health care facility may be valid reasons in such a circumstance. Elective delivery should not occur before 39 weeks of completed gestation. DIF: Cognitive Level: Apply REF: p. 790 TOP: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity

17. The nurse is teaching a client with preterm premature rupture of membranes (PPROM) regarding self-care activities. Which activities should the nurse include in her teaching? a. Report a temperature higher than 40° C. b. Tampons are safe to use to absorb the leaking amniotic fluid. c. Do not engage in sexual activity. d. Taking frequent tub baths is safe.

ANS: C Sexual activity should be avoided because it may induce preterm labor. A temperature higher than 38° C should be reported. To prevent the risk of infection, tub baths should be avoided and nothing should be inserted into the vagina. Further, foul-smelling vaginal fluid, which may be a sign of infection, should be reported. DIF: Cognitive Level: Apply REF: p. 762 TOP: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance

5. Indications for a primary cesarean birth are often nonrecurring. Therefore, a woman who has had a cesarean birth with a low transverse scar may be a candidate for vaginal birth after cesarean (VBAC). Which clients would beless likely to have a successful VBAC? (Select all that apply.) a. Lengthy interpregnancy interval b. African-American race c. Delivery at a rural hospital d. Estimated fetal weight <4000 g e. Maternal obesity (BMI >30)

ANS: B, C, E Indications for a low success rate for a VBAC delivery include a short interpregnancy interval, non-Caucasian race, gestational age longer than 40 weeks, maternal obesity, preeclampsia, fetal weight greater than 4000 g, and delivery at a rural or private hospital. DIF: Cognitive Level: Understand REF: p. 794 TOP: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

12. Which statement related to cephalopelvic disproportion (CPD) is the least accurate? a. CPD can be related to either fetal size or fetal position. b. The fetus cannot be born vaginally. c. CPD can be accurately predicted. d. Causes of CPD may have maternal or fetal origins.

ANS: C Unfortunately, accurately predicting CPD is not possible. Although CPD is often related to excessive fetal size (macrosomia), malposition of the fetal presenting part is the problem in many cases, not true CPD. When CPD is present, the fetus cannot fit through the maternal pelvis to be born vaginally. CPD may be related to either fetal origins such as macrosomia or malposition or maternal origins such as a too small or malformed pelvis. DIF: Cognitive Level: Understand REF: p. 775 TOP: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance

6. A woman is having her first child. She has been in labor for 15 hours. A vaginal examination performed 2 hours earlier revealed the cervix to be dilated to 5 cm and 100% effaced, and the presenting part of the fetus was at station 0; however, another vaginal examination performed 5 minutes ago indicated no changes. What abnormal labor pattern is associated with this description? a. Prolonged latent phase b. Protracted active phase c. Secondary arrest d. Protracted descent

ANS: C With a secondary arrest of the active phase, the progress of labor has stopped. This client has not had any anticipated cervical change, indicating an arrest of labor. In the nulliparous woman, a prolonged latent phase typically lasts longer than 20 hours. A protracted active phase, the first or second stage of labor, is prolonged (slow dilation). With a protracted descent, the fetus fails to descend at an anticipated rate during the deceleration phase and second stage of labor. DIF: Cognitive Level: Analyze REF: p. 774 TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

MULTIPLE RESPONSE 1. Reports have linked third trimester use of selective serotonin uptake inhibitors (SSRIs) with a constellation of neonatal signs. The nurse is about to perform an assessment on the infant of a mother with a history of a mood disorder. Which signs and symptoms in the neonate may be the result of maternal SSRI use? (Select all that apply.) a. Hypotonia b. Hyperglycemia c. Shivering d. Fever e. Irritability

ANS: C, D, E Neonatal signs of maternal SSRI use include continuous crying, irritability, jitteriness, shivering, fever, hypertonia, respiratory distress, feeding difficulty, hypoglycemia, and seizures. The onset of signs and symptoms ranges from several hours to several days after birth, but the signs generally resolve within 2 weeks. DIF: Cognitive Level: Apply REF: p. 742 TOP: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

When evaluating the preterm infant, the nurse understands that compared with the term infant, what information is important for the nurse to understand? a.Few blood vessels visible through the skin b.More subcutaneous fat c.Well-developed flexor muscles d.Greater surface area in proportion to weight

ANS: D Preterm infants have greater surface area in proportion to their weight. More subcutaneous fat and well-developed muscles are indications of a more mature infant.

3. In evaluating the effectiveness of magnesium sulfate for the treatment of preterm labor, which finding alerts the nurse to possible side effects? a. Urine output of 160 ml in 4 hours b. DTRs 2+ and no clonus c. Respiratory rate (RR) of 16 breaths per minute d. Serum magnesium level of 10 mg/dl

ANS: D The therapeutic range for magnesium sulfate management is 4 to 7.5 mg/dl. A serum magnesium level of 10 mg/dl could lead to signs and symptoms of magnesium toxicity, including oliguria and respiratory distress. Urine output of 160 ml in 4 hours, DTRs of 2+, and a RR of 16 breaths per minute are all normal findings. DIF: Cognitive Level: Apply REF: p. 767 TOP: Nursing Process: Evaluation MSC: Client Needs: Physiologic Integrity

An 18-year-old client who has reached 16 weeks of gestation was recently diagnosed with pregestational diabetes. She attends her centering appointment accompanied by one of her girlfriends. This young woman appears more concerned about how her pregnancy will affect her social life than her recent diagnosis of diabetes. A number of nursing diagnoses are applicable to assist in planning adequate care. What is the most appropriate diagnosis at this time? a. Risk for injury, to the fetus related to birth trauma b. Deficient knowledge, related to diabetic pregnancy management c. Deficient knowledge, related to insulin administration d. Risk for injury, to the mother related to hypoglycemia or hyperglycemia

B Before a treatment plan is developed or goals for the outcome of care are outlined, this client must come to an understanding of diabetes and the potential effects on her pregnancy. She appears more concerned about changes to her social life than adopting a new self-care regimen. Risk for injury to the fetus related to either placental insufficiency or birth trauma may come later in the pregnancy. At this time, the client is having difficulty acknowledging the adjustments that she needs to make to her lifestyle to care for herself during pregnancy. The client may not yet be on insulin. Insulin requirements increase with gestation. The importance of glycemic control must be part of health teaching for this client. However, she has not yet acknowledged that changes to her lifestyle need to be made and may not participate in the plan of care until understanding takes place.

A new mother with a thyroid disorder has come for a lactation follow-up appointment. Which thyroid disorder is a contraindication for breastfeeding? a. Hyperthyroidism b. PKU c. Hypothyroidism d. Thyroid storm

B PKU is a cause of mental retardation in infants; mothers with PKU pass on phenylalanine and therefore should elect not to breastfeed. A woman with either hyperthyroidism or hypothyroidism would have no particular reason not to breastfeed. A thyroid storm is a complication of hyperthyroidism and is not a contraindication to breastfeeding.

The nurse would conclude that grieving parents had progressed to the reorganization/recovery phase during a follow-up visit a year later if: a. The parents say they feel no pain. b. The parents are discussing sex and a future pregnancy, even if they have not sorted out their feelings yet. c. The parents have abandoned those moments of bittersweet grief. d. The parents' questions have progressed from "Why?" to "Why us?"

B. The parents are discussing sex and a future Many couples have conflicting feelings about sexuality and future pregnancies. A little pain is always present, certainly past the first year, when recovery begins to peak. Bittersweet grief describes the brief grief response that occurs with reminders of a loss, often on anniversary dates. Most couples never abandon it. Recovery is ongoing. Typically a couple's search for meaning progresses from "Why?" in the acute phase to "Why me?" in the intense phase to "What does this loss mean to my life?" in the reorganizational phase.

Which preexisting factor is known to increase the risk of GDM? a. Underweight before pregnancy b. Maternal age younger than 25 years c. Previous birth of large infant d. Previous diagnosis of type 2 diabetes mellitus

C A previous birth of a large infant suggests GDM. Obesity (body mass index [BMI] of 30 or greater) creates a higher risk for gestational diabetes. A woman younger than 25 years is not generally at risk for GDM. The person with type 2 diabetes mellitus already has diabetes and thus will continue to have it after pregnancy. Insulin may be required during pregnancy because oral hypoglycemia drugs are contraindicated during pregnancy.

Which statement regarding the laboratory test for glycosylated hemoglobin Alc is correct? a. The laboratory test for glycosylated hemoglobin Alc is performed for all pregnant women, not only those with or likely to have diabetes. b. This laboratory test is a snapshot of glucose control at the moment. c. This laboratory test measures the levels of hemoglobin Alc, which should remain at less than 7%. d. This laboratory test is performed on the womans urine, not her blood.

C Hemoglobin Alc levels greater than 7% indicate an elevated glucose level during the previous 4 to 6 weeks. This extra laboratory test is for diabetic women and defines glycemic control over the previous 4 to 6 weeks. Glycosylated hemoglobin level tests are performed on the blood.

During a prenatal visit, the nurse is explaining dietary management to a woman with pregestational diabetes. Which statement by the client reassures the nurse that teaching has been effective? a. I will need to eat 600 more calories per day because I am pregnant. b. I can continue with the same diet as before pregnancy as long as it is well balanced. c. Diet and insulin needs change during pregnancy. d. I will plan my diet based on the results of urine glucose testing.

C Diet and insulin needs change during the pregnancy in direct correlation to hormonal changes and energy needs. In the third trimester, insulin needs may double or even quadruple. The diet is individualized to allow for increased fetal and metabolic requirements, with consideration of such factors as prepregnancy weight and dietary habits, overall health, ethnic background, lifestyle, stage of pregnancy, knowledge of nutrition, and insulin therapy. Energy needs are usually calculated on the basis of 30 to 35 calories per kilogram of ideal body weight. Dietary management during a diabetic pregnancy must be based on blood, not urine, glucose changes.

To manage her diabetes appropriately and to ensure a good fetal outcome, how would the pregnant woman with diabetes alter her diet? a. Eat six small equal meals per day. b. Reduce the carbohydrates in her diet. c. Eat her meals and snacks on a fixed schedule. d. Increase her consumption of protein.

C Having a fixed meal schedule will provide the woman and the fetus with a steady blood sugar level, provide a good balance with insulin administration, and help prevent complications. Having a fixed meal schedule is more important than the equal division of food intake. Approximately 45% of the food eaten should be in the form of carbohydrates.

Near the end of the first week of life, an infant who has not been treated for any infection develops a copper-colored, maculopapular rash on the palms and around the mouth and anus. The newborn is showing signs of: A. Gonorrhea B. Herpes simplex virus infection C. Congenital syphilis D. HIV

C A. Incorrect: The rash is indicative of congenital syphilis. The lesions may extend over the trunk and extremities. B. Incorrect: The rash is indicative of congenital syphilis. The lesions may extend over the trunk and extremities. C. Correct: The rash is indicative of congenital syphilis. The lesions may extend over the trunk and extremities. D. Incorrect: The rash is indicative of congenital syphilis. The lesions may extend over the trunk and extremities. p. 1005

An infant was born 2 hours ago at 37 weeks of gestation, weighing 4.1 kg. The infant appears chubby with a flushed complexion and is very tremulous. The tremors are most likely the result of: A. Birth injury B. Hypocalcemia C. Hypoglycemia D. Seizures

C A. Incorrect: This infant is macrosomic and at risk for hypoglycemia. The description is indicative of a macrocosmic infant. The tremors are jitteriness that is associated with hypoglycemia. B. Incorrect: This infant is macrosomic and at risk for hypoglycemia. The description is indicative of a macrocosmic infant. The tremors are jitteriness that is associated with hypoglycemia. C. Correct: Hypoglycemia is common in the macrosomic infant. Signs of hypoglycemia include jitteriness, apnea, tachypnea, and cyanosis. D. Incorrect: This infant is macrosomic and at risk for hypoglycemia. The description is indicative of a macrocosmic infant. The tremors are jitteriness that is associated with hypoglycemia. p. 998

Hypothyroidism occurs in 2 to 3 pregnancies per 1000. Because severe hypothyroidism is associated with infertility and miscarriage, it is not often seen in pregnancy. Regardless of this fact, the nurse should be aware of the characteristic symptoms of hypothyroidism. Which do they include? (Select all that apply.) a. Hot flashes b. Weight loss c. Lethargy d. Decrease in exercise capacity e. Cold intolerance

C, D, E Symptoms include weight gain, lethargy, decrease in exercise capacity, and intolerance to cold. Other presentations might include constipation, hoarseness, hair loss, and dry skin. Thyroid supplements are used to treat hyperthyroidism in pregnancy.

When helping the mother, father, and other family members actualize the loss of the infant, nurses should: a. Use the words lost or gone rather than dead or died. b. Make sure that the family understands that it is important to name the baby. c. If the parents choose to visit with the baby, apply powder and lotion to the baby and wrap the infant in a pretty blanket. d. Set a firm time for ending the visit with the baby so the parents know when to let go.

C. If the parents choose to visit with the baby, apply powder, and lotion to the baby and wrap the infant in al pretty infant. Presenting the baby in a nice way stimulates the parents' senses and provides pleasant memories of their baby. Nurses must use dead and died to assist the bereaved in accepting reality. Although naming the baby can be helpful, it is important not to create the sense that parents have to name the baby. In fact, some cultural taboos and religious rules prohibit the naming of an infant who has died. Parents need different time periods with their baby to say goodbye. Nurses need to be careful not to rush the process.

What bacterial infection is definitely decreasing because of effective drug treatment? A. Escherichia coli infection B. Tuberculosis C. Candidiasis D. Group B streptococcal infection

D A. Incorrect: E. coli may be increasing, perhaps because of the increasing use of ampicillin (resulting in a more virulent E. coli resistant to the drug). Group B streptococcus has been beaten back by penicillin. B. Incorrect: Tuberculosis is increasing in the United States and in Canada. Group B streptococcus has been beaten back by penicillin. C. Incorrect: Candidiasis is a fairly benign fungal infection. Group B streptococcus has been beaten back by penicillin. D. Correct: Penicillin has significantly decreased the incidence of group B streptococcal infection. pp. 1010-1011

A woman with gestational diabetes has had little or no experience reading and interpreting glucose levels. The client shows the nurse her readings for the past few days. Which reading signals the nurse that the client may require an adjustment of insulin or carbohydrates? a. 75 mg/dl before lunch. This is low; better eat now. b. 115 mg/dl 1 hour after lunch. This is a little high; maybe eat a little less next time. c. 115 mg/dl 2 hours after lunch. This is too high; it is time for insulin. d. 50 mg/dl just after waking up from a nap. This is too low; maybe eat a snack before going to sleep.

D 50 mg/dl after waking from a nap is too low. During hours of sleep, glucose levels should not be less than 60 mg/dl. Snacks before sleeping can be helpful. The premeal acceptable range is 60 to 99 mg/dl. The readings 1 hour after a meal should be less than 129 mg/dl. Two hours after eating, the readings should be less than 120 mg/dl.

Which physiologic alteration of pregnancy most significantly affects glucose metabolism? a. Pancreatic function in the islets of Langerhans is affected by pregnancy. b. Pregnant women use glucose at a more rapid rate than nonpregnant women. c. Pregnant women significantly increase their dietary intake. d. Placental hormones are antagonistic to insulin, thus resulting in insulin resistance.

D Placental hormones, estrogen, progesterone, and human placental lactogen (HPL) create insulin resistance. Insulin is also broken down more quickly by the enzyme placental insulinase. Pancreatic functioning is not affected by pregnancy. The glucose requirements differ because of the growing fetus. The pregnant woman should increase her intake by 200 calories a day.

A family is visiting two surviving triplets. The third triplet died 2 days ago. What action would indicate that the family had begun to grieve for the dead infant? a. They refer to the two live infants as twins. b. They ask about the dead triplet's current status. c. They bring in play clothes for all three infants. d. They refer to the dead infant in the past tense.

D. They refer to the dead infant in the past tense Accepting that the infant is dead (in the past tense of the word) demonstrates acceptance of the reality and that the family has begun to grieve. Referring to the two live infants as twins, asking about the dead infant's current status, and bringing clothing for all three infants indicate that the parents are still in denial.

____________________, a synthetic opiate, has been the therapy of choice for heroin addiction. It crosses the placenta, leading to significant neonatal abstinence syndrome after birth.

Methadone p. 1015

All infants born to mothers with diabetes are at some risk for complications. True or false?

True The degree of risk is influenced by the severity and duration of maternal disease. p. 996

Early postpartum hemorrhage is defined as a blood loss greater than: a. 500 mL in the first 24 hours after vaginal delivery. b. 750 mL in the first 24 hours after vaginal delivery. c. 1000 mL in the first 48 hours after cesarean delivery. d. 1500 mL in the first 48 hours after cesarean delivery.

a. 500 mL in the first 24 hours after vaginal delivery.

What PPH conditions are considered medical emergencies that require immediate treatment? a. Inversion of the uterus and hypovolemic shock b. Hypotonic uterus and coagulopathies c. Subinvolution of the uterus and idiopathic thrombocytopenic purpura d. Uterine atony and disseminated intravascular coagulation

a. Inversion of the uterus and hypovolemic shock Inversion of the uterus and hypovolemic shock are considered medical emergencies. Although hypotonic uterus and coagulopathies, subinvolution of the uterus and idiopathic thrombocytopenic purpura, and uterine atony and disseminated intravascular coagulation are serious conditions, they are not necessarily medical emergencies that requires immediate treatment.

The perinatal nurse caring for the postpartum woman understands that late postpartum hemorrhage (PPH) is most likely caused by: a. Subinvolution of the placental site. b. Defective vascularity of the decidua. c. Cervical lacerations. d. Coagulation disorders.

a. Subinvolution of the placental site. Late PPH may be the result of subinvolution of the uterus, pelvic infection, or retained placental fragments. Late PPH is not typically a result of defective vascularity of the decidua, cervical lacerations, or coagulation disorders.

The perinatal nurse is caring for a woman in the immediate postbirth period. Assessment reveals that the woman is experiencing profuse bleeding. The most likely etiology for the bleeding is: a. Uterine atony. b. Uterine inversion. c. Vaginal hematoma. d. Vaginal laceration.

a. Uterine atony. Uterine atony is marked hypotonia of the uterus. It is the leading cause of postpartum hemorrhage. Uterine inversion may lead to hemorrhage, but it is not the most likely source of this client's bleeding. Furthermore, if the woman were experiencing a uterine inversion, it would be evidenced by the presence of a large, red, rounded mass protruding from the introitus. A vaginal hematoma may be associated with hemorrhage. However, the most likely clinical finding would be pain, not the presence of profuse bleeding. A vaginal laceration may cause hemorrhage, but it is more likely that profuse bleeding would result from uterine atony. A vaginal laceration should be suspected if vaginal bleeding continues in the presence of a firm, contracted uterine fundus.

A newborn in the neonatal intensive care unit (NICU) is dying as a result of a massive infection. The parents speak to the neonatologist, who informs them of their son's prognosis. When the father sees his son, he says, "He looks just fine to me. I can't understand what all this is about." The most appropriate response by the nurse would be: a. "Didn't the doctor tell you about your son's problems?" b. "This must be a difficult time for you. Tell me how you're doing." c. To stand beside him quietly. d. "You'll have to face up to the fact that he is going to die sooner or later."

b. "This must be a difficult time for you. Tell me how you're doing." The grief phase can be very difficult, especially for fathers. Parents should be encouraged to share their feelings as the initial steps in the grieving process. This father is in a phase of acute distress and is "reaching out" to the nurse as a source of direction in his grieving process. Shifting the focus is not in the best interest of the parent. Nursing actions may help the parents actualize the loss of their infant through sharing and verbalization of feelings of grief. "You'll have to face up to the fact that he is going to die sooner or later" is dispassionate and inappropriate statement.

Which woman is at greatest risk for early postpartum hemorrhage (PPH)? a. A primiparous woman (G 2 P 1 0 0 1) being prepared for an emergency cesarean birth for fetal distress b. A woman with severe preeclampsia who is receiving magnesium sulfate and whose labor is being induced c. A multiparous woman (G 3 P 2 0 0 2) with an 8-hour labor d. A primigravida in spontaneous labor with preterm twins

b. A woman with severe who is receiving magnesium sulfate and whose labor is being induced. Magnesium sulfate administration during labor poses a risk for PPH. Magnesium acts as a smooth muscle relaxant, thereby contributing to uterine relaxation and atony. Although many causes and risk factors are associated with PPH, the primiparous woman being prepared for an emergency c-section, the multiparous woman with 8-hour labor, and the primigravida in spontaneous labor do not pose risk factors or causes of early PPH.

If nonsurgical treatment for late postpartum hemorrhage is ineffective, which surgical procedure is appropriate to correct the cause of this condition? a. Hysterectomy b. Laparoscopy c. Laparotomy d. D&C

d. D&C

A woman is diagnosed with having a stillborn. At first, she appears stunned by the news, cries a little, and then asks you to call her mother. The phase of bereavement the woman is experiencing is called: a. Anticipatory grief. b.Acute distress. c. Intense grief. d. Reorganization.

b. Acute distress. The immediate reaction to news of a perinatal loss or infant death encompasses a period of acute distress. Disbelief and denial can occur. However, parents also feel very sad and depressed. Intense outbursts of emotion and crying are normal. However, lack of affect, euphoria, and calmness may occur and may reflect numbness, denial, or personal ways of coping with stress. Anticipatory grief applies to the grief related to a potential loss of an infant. The parent grieves in preparation of the infant's possible death, although he or she clings to the hope that the child will survive. Intense grief occurs in the first few months after the death of the infant. This phase encompasses many different emotions, including loneliness, emptiness, yearning, guilt, anger, and fear. Reorganization occurs after a long and intense search for meaning. Parents are better able to function at work and home, experience a return of self-esteem and confidence, can cope with new challenges, and have placed the loss in perspective.

A woman delivered a 9-lb, 10-oz baby 1 hour ago. When you arrive to perform her 15-minute assessment, she tells you that she "feels all wet underneath." You discover that both pads are completely saturated and that she is lying in a 6-inch-diameter puddle of blood. What is your first action? a. Call for help. b.Assess the fundus for firmness. c.Take her blood pressure. d. Check the perineum for lacerations.

b. Assess the fundus for firmness.

The prevalence of urinary incontinence (UI) increases as women age, with more than one third of women in the United States suffering from some form of this disorder. The symptoms of mild to moderate UI can be successfully decreased by a number of strategies. Which of these should the nurse instruct the client to use first? a. Pelvic floor support devices b. Bladder training and pelvic muscle exercises c. Surgery d. Medications

b. Bladder training and pelvic muscle exercises Pelvic muscle exercises, known as Kegel exercises, along with bladder training can significantly decrease or entirely relieve stress incontinence in many women. Pelvic floor support devices, also known as pessaries, come in a variety of shapes and sizes. Pessaries may not be effective for all women and require scrupulous cleaning to prevent infection. Anterior and posterior repairs and even a hysterectomy may be performed. If surgical repair is performed, the nurse must focus her care on preventing infection and helping the woman avoid putting stress on the surgical site. Pharmacologic therapy includes serotonin-norepinephrine uptake inhibitors or vaginal estrogen therapy. These are not the first action a nurse should recommend.

A mother in late middle age who is certain she is not pregnant tells the nurse during an office visit that she has urinary problems and sensations of bearing down and of something in her vagina. The nurse would realize that the client most likely is suffering from: a. Pelvic relaxation. b. Cystoceles and/or rectoceles. c. Uterine displacement. d. Genital fistulas.

b. Cystoceles and/or rectoceles. Cystoceles are protrusions of the bladder downward into the vagina; rectoceles are herniations of the anterior rectal wall through a relaxed or ruptured vaginal fascia. Both can present as a bearing down sensation with urinary dysfunction. They occur more often in older women who have borne children.

A steady trickle of bright red blood from the vagina in the presence of a firm fundus suggests: a. Uterine atony. b. Lacerations of the genital tract. c. Perineal hematoma. d. Infection of the uterus.

b. Lacerations of the genital tract.

Which instructions should be included in the discharge teaching plan to assist the patient in recognizing early signs of complications? a. Palpate the fundus daily to ensure that it is soft. b. Notify the physician of any increase in the amount of lochia or a return to bright red bleeding. c. Report any decrease in the amount of brownish red lochia. d. The passage of clots as large as an orange can be expected.

b. Notify the physician of any increase in the amount of lochia or a return to bright red bleeding.

During a follow-up visit, if parents have progressed to the second stage or phase of grieving, the nurse should not expect to see: a. Guilt, particularly in the mother. b. Numbness or lack of response. c. Bitterness or irritability. d. Fear and anxiety, especially about getting pregnant again.

b. Numbness or lack of response The second phase of grieving encompasses a wide range of intense emotions, including guilt, anger, bitterness, fear, and anxiety. What the nurse would hope not to see is numbness or unresponsiveness, as if the parents were still in denial or shock.

A primary nursing responsibility when caring for a woman experiencing an obstetric hemorrhage associated with uterine atony is to: a. Establish venous access. b. Perform fundal massage. c. Prepare the woman for surgical intervention. d. Catheterize the bladder.

b. Perform fundal massage. The initial management of excessive postpartum bleeding is firm massage of the uterine fundus. Although establishing venous access may be a necessary intervention, the initial intervention would be fundal massage. The woman may need surgical intervention to treat her postpartum hemorrhage, but the initial nursing intervention would be to assess the uterus. After uterine massage the nurse may want to catheterize the client to eliminate any bladder distention that may be preventing the uterus from contracting properly.

The perinatal nurse assisting with establishing lactation is aware that acute mastitis can be minimized by: a. Washing the nipples and breasts with mild soap and water once a day. b. Using proper breastfeeding techniques. c. Wearing a nipple shield for the first few days of breastfeeding. d. Wearing a supportive bra 24 hours a day.

b. Using proper breastfeeding techniques. Almost all instances of acute mastitis can be avoided by proper breastfeeding technique to prevent cracked nipples. Washing the nipples and breasts daily is no longer indicated. In fact, this can cause tissue dryness and irritation, which can lead to tissue breakdown and infection. Wearing a nipple shield does not prevent mastitis. Wearing a supportive bra 24 hours a day may contribute to mastitis, especially if an underwire bra is worn, because it may put pressure on the upper, outer area of the breast, contributing to blocked ducts and mastitis.

Which options for saying goodbye would the nurse want to discuss with a woman who is diagnosed with having a stillborn girl? a. The nurse shouldn't discuss any options at this time; there is plenty of time after the baby is born. b. "Would you like a picture taken of your baby after birth?" c. "When your baby is born, would you like to see and hold her?" d. "What funeral home do you want notified after the baby is born?"

c. "When your baby is born, would you like to see and hold her?" Mothers and fathers may find it helpful to see the infant after delivery. The parents' wishes should be respected. Interventions and support from the nursing and medical staff after a prenatal loss are extremely important in the healing of the parents. Although this may be an intervention, the initial intervention should be related directly to the parents' wishes with regard to seeing or holding their dead infant. Although this information may be relevant, it is not the most appropriate option at this time. Burial arrangements can be discussed after the infant is born.

Despite popular belief, there is a rare type of hemophilia that affects women of childbearing age. von Willebrand disease is the most common of the hereditary bleeding disorders and can affect males and females alike. It results from a factor VIII deficiency and platelet dysfunction. Although factor VIII levels increase naturally during pregnancy, there is an increased risk for postpartum hemorrhage from birth until 4 weeks after delivery as levels of von Willebrand factor (vWf) and factor VIII decrease. The treatment that should be considered first for the client with von Willebrand disease who experiences a postpartum hemorrhage is: a. Cryoprecipitate. b.Factor VIII and vWf. c. Desmopressin d. Hemabate.

c. Desmopressin Desmopressin is the primary treatment of choice. This hormone can be administered orally, nasally, and intravenously. This medication promotes the release of factor VIII and vWf from storage. Cryoprecipitate may be used; however, because of the risk of possible donor viruses, other modalities are considered safer. Treatment with plasma products such as factor VIII and vWf are an acceptable option for this client. Because of the repeated exposure to donor blood products and possible viruses, this is not the initial treatment of choice. Although the administration of this prostaglandin is known to promote contraction of the uterus during postpartum hemorrhage, it is not effective for the client who presents with a bleeding disorder.

Anxiety disorders are the most common mental disorders that affect women. While providing care to the maternity patient, the nurse should be aware that one of these disorders is likely to be triggered by the process of labor and birth. This disorder is: a. Phobias. b. Panic disorder. c. Post-traumatic stress disorder (PTSD). d. Obsessive-compulsive disorder (OCD).

c. Post-traumatic stress disorder (PTSD).

A mother with mastitis is concerned about breastfeeding while she has an active infection. The nurse should explain that: a. The infant is protected from infection by immunoglobulins in the breast milk. b. The infant is not susceptible to the organisms that cause mastitis c. The organisms that cause mastitis are not passed to the milk. d. The organisms will be inactivated by gastric acid.

c. The organisms that cause mastitis are not passed to the milk.

After giving birth to a stillborn infant, the woman turns to the nurse and says, "I just finished painting the baby's room. Do you think that caused my baby to die?" The nurse's best response to this woman is: a. "That's an old wives' tale; lots of women are around paint during pregnancy, and this doesn't happen to them." b. "That's not likely. Paint is associated with elevated pediatric lead levels." c. Silence. d. "I can understand your need to find an answer to what caused this. What else are you thinking about?"

d. "I can understand your need to find an answer to what caused this. What else are you thinking about?" The statement, "I can understand your need to find an answer to what caused this. What else are you thinking about?" is very appropriate for the nurse. It demonstrates caring and compassion and allows the mother to vent her thoughts and feelings, which is therapeutic in the process of grieving. The nurse should resist the temptation to give advice or to use clichés in offering support to the bereaved. In addition, trying to give bereaved parents answers when no clear answers exist or trying to squelch their guilt feeling does not help the process of grief. Trying to give bereaved parents answers when no clear answers exist does not help the grief process. In addition, this response probably would increase the mother's feelings of guilt. One of the most important goals of the nurse is to validate the experience and feelings of the parents by encouraging them to tell their stories and listening with care. The nurse should encourage the mother to express her ideas.

A woman experienced a miscarriage at 10 weeks of gestation and had a dilation and curettage (D&C). She states that she is just fine and wants to go home as soon as possible. While you are assessing her responses to her loss, she tells you that she had purchased some baby things and had picked out a name. On the basis of your assessment of her responses, what nursing intervention would you use first? a. Ready her for discharge. b. Notify pastoral care to offer her a blessing. c. Ask her whether she would like to see what was obtained from her D&C. d. Ask her what name she had picked out for her baby.

d. Ask her what name she had picked out for her baby. One way of actualizing the loss is to allow parents to name the infant. The nurse should follow this client's cues and inquire about naming the infant. The client is looking for an opportunity to express her feelings of loss. The nurse should take this opportunity to offer support by allowing the woman to talk about her feelings. Furthermore, one way of actualizing the loss is to allow parents to name the infant. The nurse should follow this client's cues and inquire about naming the infant. Although it may be therapeutic to offer religious support, the nurse should take this opportunity to offer support by allowing the woman to talk about her feelings. Furthermore, one way of actualizing the loss is to allow parents to name the infant. Asking the woman if she would like to see what was obtained from her D&C is completely inappropriate.

The nurse caring for a family during a loss may notice that survival guilt sometimes is felt at the death of an infant by the child's: a. Siblings. b. Mother. c. Father. d. Grandparents.

d. Grandparents. Survival guilt sometimes is felt by grandparents, because they believe that the death upsets the natural order of things. They are angry that they are alive and their grandchild is not.

The most appropriate statement that the nurse can make to bereaved parents is: a. "You have an angel in heaven." b. "I understand how you must feel." c. "You're young and can have other children." d. "I'm sorry."

d. I'm sorry One of nurse's most important goals is to validate the experience and feelings of the parents by encouraging them to tell their stories and listening with care. At the very least, the nurse should acknowledge the loss with a simple but sincere comment such as, "I'm sorry." The initial impulse may be to reduce one's sense of helplessness and say or do something that you think will reduce their pain. Although such a response may seem supportive at the time, it can stifle the further expression of emotion. The nurse should resist the temptation to give advice or to use clichés when offering support to the bereaved. Saying, "You're young and can have other children" is not a therapeutic response for the nurse to make.

Which condition is a transient, self-limiting mood disorder that affects new mothers after childbirth? a. Postpartum depression b.Postpartum psychosis c. Postpartum bipolar disorder d. Postpartum blues

d. Postpartum blues

One of the first symptoms of puerperal infection to assess for in the postpartum woman is: a. Fatigue continuing for longer than 1 week. b. Pain with voiding. c. Profuse vaginal bleeding with ambulation. d. Temperature of 38° C (100.4° F) or higher on 2 successive days starting 24 hours after birth.

d. Temperature of 38° C (100.4° F) or higher on 2 successive days starting 24 hours after birth. Postpartum or puerperal infection is any clinical infection of the genital canal that occurs within 28 days after miscarriage, induced abortion, or childbirth. The definition used in the United States continues to be the presence of a fever of 38° C (100.4° F) or higher on 2 successive days of the first 10 postpartum days, starting 24 hours after birth. Fatigue would be a late finding associated with infection. Pain with voiding may indicate a urinary tract infection, but it is not typically one of the earlier symptoms of infection. Profuse lochia may be associated with endometritis, but it is not the first symptom associated with infection.

When caring for a postpartum woman experiencing hemorrhagic shock, the nurse recognizes that the most objective and least invasive assessment of adequate organ perfusion and oxygenation is: a. Absence of cyanosis in the buccal mucosa. b. Cool, dry skin c. Diminished restlessness. d. Urinary output of at least 30 mL/hr.

d. Urinary output of at least 30 mL/hr. Hemorrhage may result in hemorrhagic shock. Shock is an emergency situation in which the perfusion of body organs may become severely compromised and death may occur. The presence of adequate urinary output indicates adequate tissue perfusion. The assessment of the buccal mucosa for cyanosis can be subjective in nature. The presence of cool, pale, clammy skin would be an indicative finding associated with hemorrhagic shock. Hemorrhagic shock is associated with lethargy, not restlessness.

2. Which condition would require prophylaxis to prevent subacute bacterial endocarditis (SBE) both antepartum and intrapartum? a. Valvular heart disease b. Congestive heart disease c. Arrhythmias d. Postmyocardial infarction

: A Prophylaxis for intrapartum endocarditis and pulmonary infection may be provided for women who have mitral valve prolapse. Prophylaxis for intrapartum endocarditis is not indicated for a client with congestive heart disease, underlying arrhythmias, or postmyocardial infarction. DIF: Cognitive Level: Understand REF: p. 712 TOP: Nursing Process: Implementation

MULTIPLE RESPONSE 1. Which congenital anomalies can occur as a result of the use of antiepileptic drugs (AEDs) in pregnancy? (Select all that apply.) a. Cleft lip b. Congenital heart disease c. Neural tube defects d. Gastroschisis e. Diaphragmatic hernia

: A, B, C Congenital anomalies that can occur with AEDs include cleft lip or palate, congenital heart disease, urogenital defects, and neural tube defects. Carbamazepine and valproate should be avoided if all possible; they may cause neural tube defects. Congenital anomalies of gastroschisis and diaphragmatic hernia are not associated with the use of AEDs. DIF: Cognitive Level: Understand REF: p. 725 TOP: Nursing Process: Planning

3. In caring for a pregnant woman with sickle cell anemia, the nurse must be aware of the signs and symptoms of a sickle cell crisis. What do these include? (Select all that apply.) a. Fever b. Endometritis c. Abdominal pain d. Joint pain e. Urinary tract infection (UTI)

: A, C, D Women with sickle cell anemia have recurrent attacks (crises) of fever and pain, most often in the abdomen, joints, and extremities. These attacks are attributed to vascular occlusion when red blood cells (RBCs) assume the characteristic sickled shape. Crises are usually triggered by dehydration, hypoxia, or acidosis. Women with the sickle cell trait are usually at a greater risk for postpartum endometritis (uterine wall infection); however, this development is not likely to occur during the pregnancy and is not a sign for the disorder. Although women with sickle cell anemia are at an increased risk for UTIs, these infections are not an indication of a sickle cell crisis. DIF: Cognitive Level: Understand REF: p. 721 TOP: Nursing Process: Assessment

2. A lupus flare-up during pregnancy or early postpartum occurs in 15% to 60% of women with this disorder. Which conditions associated with systemic lupus erythematosus (SLE) are maternal risks? (Select all that apply.) a. Miscarriage b. Intrauterine growth restriction (IUGR) c. Nephritis d. Preeclampsia e. Cesarean birth

: A, C, D, E Maternal risks associated with SLE include miscarriage, nephritis, preeclampsia, and cesarean birth. IUGR is a fetal risk related to SLE. Other fetal risks include stillbirth and prematurity. DIF: Cognitive Level: Understand REF: p. 727 TOP: Nursing Process: Assessment

3. Which information should the nurse take into consideration when planning care for a postpartum client with cardiac disease? a. The plan of care for a postpartum client is the same as the plan for any pregnant woman. b. The plan of care includes rest, stool softeners, and monitoring of the effect of activity. c. The plan of care includes frequent ambulating, alternating with active range-of-motion exercises. d. The plan of care includes limiting visits with the infant to once per day.

: B Bed rest may be ordered, with or without bathroom privileges. Bowel movements without stress or strain for the woman are promoted with stool softeners, diet, and fluids. Care of the woman with cardiac disease in the postpartum period is tailored to the woman's functional capacity. The woman will be on bed rest to conserve energy and to reduce the strain on the heart. Although the woman may need help caring for the infant, breastfeeding and infant visits are not contraindicated. DIF: Cognitive Level: Understand REF: pp. 718-719 TOP: Nursing Process: Planning

9. Which information regarding the care of antepartum women with cardiac conditions is mostimportant for the nurse to understand? a. Stress on the heart is greatest in the first trimester and the last 2 weeks before labor. b. Women with class II cardiac disease should avoid heavy exertion and any activity that causes even minor symptoms. c. Women with class III cardiac disease should get 8 to 10 hours of sleep every day and limit housework, shopping, and exercise. d. Women with class I cardiac disease need bed rest through most of the pregnancy and face the possibility of hospitalization near term.

: B Class II cardiac disease is symptomatic with ordinary activity. Women in this category need to avoid heavy exertion and limit regular activities as symptoms dictate. Stress is greatest between weeks 28 and 32 of gestation, when hemodynamic changes reach their maximum. Class III cardiac disease is symptomatic with less-than-ordinary activity. These women need bed rest most of the day and face the possibility of hospitalization near term. Class I cardiac disease is asymptomatic at normal levels of activity. These women can perform limited normal activities with discretion, although they still need a good amount of sleep. DIF: Cognitive Level: Understand REF: p. 711 TOP: Nursing Process: Planning

12. The client makes an appointment for preconception counseling. The woman has a known heart condition and is unsure if she should become pregnant. Which is the only cardiac condition that would cause concern? a. Marfan syndrome b. Eisenmenger syndrome c. Heart transplant d. Ventricular septal defect (VSD)

: B Pregnancy is contraindicated in clients with Eisenmenger syndrome. Women who have had heart transplants are successfully having babies. However, conception should be postponed for at least 1 year after transplantation. Management of the client with Marfan syndrome during pregnancy includes bed rest, beta-blockers, and surgery before conception. VSD is usually corrected early in life and is therefore not a contraindication to pregnancy. DIF: Cognitive Level: Understand REF: p. 714 TOP: Nursing Process: Assessment

15. Bell palsy is an acute idiopathic facial paralysis, the cause for which remains unknown. Which statement regarding this condition is correct? a. Bell palsy is the sudden development of bilateral facial weakness. b. Women with Bell palsy have an increased risk for hypertension. c. Pregnant women are affected twice as often as nonpregnant women. d. Bell palsy occurs most frequently in the first trimester.

: B The clinical manifestations of Bell palsy include the development of unilateral facial weakness, pain surrounding the ears, difficulty closing the eye, and hyperacusis. The cause is unknown; however, Bell palsy may be related to a viral infection. Pregnant women are affected at a rate of three to five times that of nonpregnant women. The incidence rate peaks during the third trimester and puerperium. Women who develop Bell palsy in pregnancy have an increased risk for hypertension. DIF: Cognitive Level: Understand REF: p. 726 TOP: Nursing Process: Assessment

18. It is extremely rare for a woman to die in childbirth; however, it can happen. In the United States, the annual occurrence of maternal death is 12 per 100,000 cases of live birth. What are the leading causes of maternal death? a. Embolism and preeclampsia b. Trauma and motor vehicle accidents (MVAs) c. Hemorrhage and infection d. Underlying chronic conditions

: B Trauma is the leading cause of obstetric death in women of childbearing age. Most maternal injuries are the result of MVAs and falls. Although preeclampsia and embolism are significant contributors to perinatal morbidity, these are not the leading cause of maternal mortality. Maternal death caused by trauma may occur as the result of hemorrhagic shock or abruptio placentae. In these cases, the hemorrhage is the result of trauma, not childbirth. The wish to become a parent is not eliminated by a chronic health problem, and many women each year risk their lives to have a baby. Because of advanced pediatric care, many women are surviving childhood illnesses and reaching adulthood with chronic health problems such as cystic fibrosis, diabetes, and pulmonary disorders. DIF: Cognitive Level: Understand REF: p. 731 TOP: Nursing Process: Assessment

4. Autoimmune disorders often occur during pregnancy because a large percentage of women with an autoimmune disorder are of childbearing age. Which disorders fall into the category of collagen vascular disease? (Select all that apply.) a. Multiple sclerosis b. SLE c. Antiphospholipid syndrome d. Rheumatoid arthritis e. Myasthenia gravis

: B, C, D, E Multiple sclerosis is not an autoimmune disorder. This patchy demyelination of the spinal cord may be a viral disorder. Autoimmune disorders (collagen vascular disease) make up a large group of conditions that disrupt the function of the immune system of the body. These disorders include those listed, as well as systemic sclerosis. DIF: Cognitive Level: Comprehend REF: p. 726 TOP: Nursing Process: Assessment

6. Which important component of nutritional counseling should the nurse include in health teaching for a pregnant woman who is experiencing cholecystitis? a. Assess the woman's dietary history for adequate calories and proteins. b. Teach the woman that the bulk of calories should come from proteins. c. Instruct the woman to eat a low-fat diet and to avoid fried foods. d. Instruct the woman to eat a low-cholesterol, low-salt diet.

: C Eating a low-fat diet and avoiding fried foods is appropriate nutritional counseling for this client. Caloric and protein intake do not predispose a woman to the development of cholecystitis. The woman should be instructed to limit protein intake and choose foods that are high in carbohydrates. A low-cholesterol diet may be the result of limiting fats. However, a low-salt diet is not indicated. DIF: Cognitive Level: Apply REF: p. 728 TOP: Nursing Process: Implementation

10. A woman at 28 weeks of gestation experiences blunt abdominal trauma as the result of a fall. The nurse must closely observe the client for what? a. Alteration in maternal vital signs, especially blood pressure b. Complaints of abdominal pain c. Placental absorption d. Hemorrhage

: C Electronic fetal monitoring (EFM) tracings can help evaluate maternal status after trauma and can reflect fetal cardiac responses to hypoxia and hypoperfusion. Signs and symptoms of placental absorption include uterine irritability, contractions, vaginal bleeding, and changes in FHR characteristics. Hypoperfusion may be present in the pregnant woman before the onset of clinical signs of shock. EFM tracings show the first signs of maternal compromise, such as when the maternal heart rate, blood pressure, and color appear normal, yet the EFM printout shows signs of fetal hypoxia. Abdominal pain, in and of itself, is not the most important symptom. However, if it is accompanied by contractions, changes in the FHR, rupture of membranes, or vaginal bleeding, then the client should be evaluated for abruptio placentae. Clinical signs of hemorrhage do not appear until after a 30% loss of circulating volume occurs. Careful monitoring of fetal status significantly assists in maternal assessment, because the fetal monitor tracing works as an oximeter of internal well-being. DIF: Cognitive Level: Apply REF: p. 732 TOP: Nursing Process: Assessment

16. A pregnant woman at term is transported to the emergency department (ED) after a severe vehicular accident. The obstetric nurse responds and rushes to the ED with a fetal monitor. Cardiopulmonary arrest occurs as the obstetric nurse arrives. What is the highest priority for the trauma team? a. Obtaining IV access, and starting aggressive fluid resuscitation b. Quickly applying the fetal monitor to determine whether the fetus viability c. Starting cardiopulmonary resuscitation (CPR) d. Transferring the woman to the surgical unit for an emergency cesarean delivery in case the fetus is still alive

: C In a situation of severe maternal trauma, the systematic evaluation begins with a primary survey and the initial ABCs (airway, breathing, and circulation) of resuscitation. CPR is initiated first, followed by intravenous (IV) replacement fluid. After immediate resuscitation and successful stabilization measures, a more detailed secondary survey of the mother and fetus should be accomplished. Attempts at maternal resuscitation are made, followed by a secondary survey of the fetus. In the presence of multisystem trauma, a cesarean delivery may be indicated to increase the chance for maternal survival. DIF: Cognitive Level: Apply REF: p. 734 TOP: Nursing Process: Implementation

5. A woman with asthma is experiencing a postpartum hemorrhage. Which drug should be avoided when treating postpartum bleeding to avoid exacerbating asthma? a. Oxytocin (Pitocin) b. Nonsteroidal antiinflammatory drugs (NSAIDs) c. Hemabate d. Fentanyl

: C Prostaglandin derivatives should not be used to treat women with asthma, because they may exacerbate symptoms. Oxytocin is the drug of choice to treat this woman's bleeding; it will not exacerbate her asthma. NSAIDs are not used to treat bleeding. Fentanyl is used to treat pain, not bleeding. DIF: Cognitive Level: Analyze REF: p. 722 TOP: Nursing Process: Planning

4. A woman has experienced iron deficiency anemia during her pregnancy. She had been taking iron for 3 months before the birth. The client gave birth by cesarean 2 days earlier and has been having problems with constipation. After assisting her back to bed from the bathroom, the nurse notes that the woman's stools are dark (greenish-black). What should the nurse's initial action be? a. Perform a guaiac test, and record the results. b. Recognize the finding as abnormal, and report it to the primary health care provider. c. Recognize the finding as a normal result of iron therapy. d. Check the woman's next stool to validate the observation.

: C The nurse should recognize that dark stools are a common side effect in clients who are taking iron replacement therapy. A guaiac test would be indicated if gastrointestinal (GI) bleeding was suspected. GI irritation, including dark stools, is also a common side effect of iron therapy. Observation of stool formation is a normal nursing activity. DIF: Cognitive Level: Apply REF: p. 716 TOP: Nursing Process: Evaluation

7. Postoperative care of the pregnant woman who requires abdominal surgery for appendicitis includes which additional assessment? a. Intake and output (I&O) and intravenous (IV) site b. Signs and symptoms of infection c. Vital signs and incision d. Fetal heart rate (FHR) and uterine activity

: D Care of a pregnant woman undergoing surgery for appendicitis differs from that for a nonpregnant woman in one significant aspect: the presence of the fetus. Continuous fetal and uterine monitoring should take place. An assessment of I&O levels, along with an assessment of the IV site, are normal postoperative care procedures. Evaluating the client for signs and symptoms of infection is also part of routine postoperative care. Routine vital signs and evaluation of the incision site are expected components of postoperative care. DIF: Cognitive Level: Apply REF: p. 730 TOP: Nursing Process: Assessment

13. What form of heart disease in women of childbearing years generally has a benign effect on pregnancy? a. Cardiomyopathy b. Rheumatic heart disease c. Congenital heart disease d. Mitral valve prolapse

: D Mitral valve prolapse is a benign condition that is usually asymptomatic. Cardiomyopathy produces congestive heart failure during pregnancy. Rheumatic heart disease can lead to heart failure during pregnancy. Some congenital heart diseases produce pulmonary hypertension or endocarditis during pregnancy. DIF: Cognitive Level: Remember REF: p. 713 TOP: Nursing Process: Assessment

14. A pregnant woman at 33 weeks of gestation is brought to the birthing unit after a minor automobile accident. The client is experiencing no pain and no vaginal bleeding, her vital signs are stable, and the FHR is 132 beats per minute with variability. What is the nurse's highestpriority? a. Monitoring the woman for a ruptured spleen b. Obtaining a physician's order to discharge her home c. Monitoring her for 24 hours d. Using continuous EFM for a minimum of 4 hours

: D Monitoring the external FHR and contractions is recommended after blunt trauma in a viable gestation for a minimum of 4 hours, regardless of injury severity. Fetal monitoring should be initiated as soon as the woman is stable. In this scenario, no clinical findings indicate the possibility of a ruptured spleen. If the maternal and fetal findings are normal, then EFM should continue for a minimum of 4 hours after a minor trauma or a minor automobile accident. Once the monitoring has been completed and the health care provider is reassured of fetal well-being, the client may be discharged home. Monitoring for 24 hours is unnecessary unless the ERM strip is abnormal or nonreassuring. DIF: Cognitive Level: Apply REF: p. 732 TOP: Nursing Process: Planning

17. Another common pregnancy-specific condition is pruritic urticarial papules and plaques of pregnancy (PUPPP). A client asks the nurse why she has developed this condition and what can be done. What is the nurse's bestresponse? a. PUPPP is associated with decreased maternal weight gain. b. The rate of hypertension decreases with PUPPP. c. This common pregnancy-specific condition is associated with a poor fetal outcome. d. The goal of therapy is to relieve discomfort.

: D PUPPP is associated with increased maternal weight gain, increased rate of twin gestation, and hypertension. It is not, however, associated with poor maternal or fetal outcomes. The goal of therapy is simply to relieve discomfort. Antipruritic topical medications, topical steroids, and antihistamines usually provide relief. PUPPP usually resolves before childbirth or shortly thereafter. DIF: Cognitive Level: Apply REF: p. 724 TOP: Nursing Process: Planning

1. When caring for a pregnant woman with cardiac problems, the nurse must be alert for the signs and symptoms of cardiac decompensation. Which critical findings would the nurse find on assessment of the client experiencing this condition? a. Regular heart rate and hypertension b. Increased urinary output, tachycardia, and dry cough c. Shortness of breath, bradycardia, and hypertension d. Dyspnea, crackles, and an irregular, weak pulse

: D Signs of cardiac decompensation include dyspnea; crackles; an irregular, weak, and rapid pulse; rapid respirations; a moist and frequent cough; generalized edema; increasing fatigue; and cyanosis of the lips and nailbeds. A regular heart rate and hypertension are not generally associated with cardiac decompensation. Of the symptoms of increased urinary output, tachycardia, and dry cough, only tachycardia is indicative of cardiac decompensation. Of the symptoms of shortness of breath, bradycardia, and hypertension, only dyspnea is indicative of cardiac decompensation. DIF: Cognitive Level: Understand REF: p. 716 TOP: Nursing Process: Assessment

Which statement concerning the complication of maternal diabetes is the most accurate? a. Diabetic ketoacidosis (DKA) can lead to fetal death at any time during pregnancy. b. Hydramnios occurs approximately twice as often in diabetic pregnancies than in nondiabetic pregnancies. c. Infections occur about as often and are considered about as serious in both diabetic and nondiabetic pregnancies. d. Even mild-to-moderate hypoglycemic episodes can have significant effects on fetal well-being.

A Prompt treatment of DKA is necessary to save the fetus and the mother. Hydramnios occurs 10 times more often in diabetic pregnancies. Infections are more common and more serious in pregnant women with diabetes. Mild-to-moderate hypoglycemic episodes do not appear to have significant effects on fetal well-being.

Which major neonatal complication is carefully monitored after the birth of the infant of a diabetic mother? a. Hypoglycemia b. Hypercalcemia c. Hypobilirubinemia d. Hypoinsulinemia

A The neonate is at highest risk for hypoglycemia because fetal insulin production is accelerated during pregnancy to metabolize excessive glucose from the mother. At birth, the maternal glucose supply stops and the neonatal insulin exceeds the available glucose, thus leading to hypoglycemia. Hypocalcemia is associated with preterm birth, birth trauma, and asphyxia, all common problems of the infant of a diabetic mother. Excess erythrocytes are broken down after birth, and large amounts of bilirubin are released into the neonates circulation, with resulting hyperbilirubinemia. Because fetal insulin production is accelerated during pregnancy, hyperinsulinemia develops in the neonate.

The abuse of which of the following substances during pregnancy is the leading cause of mental retardation in the United States? A. Alcohol B. Tobacco C. Marijuana D. Heroin

A A. Correct: Alcohol abuse during pregnancy is recognized as one of the leading causes of mental retardation in the United States. B. Incorrect: Alcohol abuse during pregnancy is recognized as one of the leading causes of mental retardation in the United States. C. Incorrect: Alcohol abuse during pregnancy is recognized as one of the leading causes of mental retardation in the United States. D. Incorrect: Alcohol abuse during pregnancy is recognized as one of the leading causes of mental retardation in the United States. p. 1013

Which TORCH infection could be contracted by the infant because the mother owned a cat? A. Toxoplasmosis B. Varicella zoster (chicken pox) C. Parvovirus B19 D. Rubella

A A. Correct: Cats that eat birds infected with the Toxoplasma gondii protozoan excrete infective oocysts. Humans (including pregnant women) can become infected if they fail to wash their hands after cleaning the litter box. The infection is passed through the placenta. B. Incorrect: Cats that eat birds infected with the Toxoplasma gondii protozoan excrete infective oocysts. Humans (including pregnant women) can become infected if they fail to wash their hands after cleaning the litter box. The infection is passed through the placenta. C. Incorrect: Cats that eat birds infected with the Toxoplasma gondii protozoan excrete infective oocysts. Humans (including pregnant women) can become infected if they fail to wash their hands after cleaning the litter box. The infection is passed through the placenta. D. Incorrect: Cats that eat birds infected with the Toxoplasma gondii protozoan excrete infective oocysts. Humans (including pregnant women) can become infected if they fail to wash their hands after cleaning the litter box. The infection is passed through the placenta. p. 1004

With regard to injuries to the infant's plexus during labor and birth, nurses should be aware that: A. If the nerves are stretched with no avulsion, they should recover completely in 3 to 6 months. B. Erb palsy is damage to the lower plexus. C. Parents of children with brachial palsy are taught to pick up the child from under the axillae. D. Breastfeeding is not recommended for infants with facial nerve paralysis until the condition resolves.

A A. Correct: However, if the ganglia are disconnected completely from the spinal cord, the damage is permanent. B. Incorrect: Erb palsy is damage to the upper plexus and is less serious than brachial palsy. C. Incorrect: Parents of children with brachial palsy are taught to avoid picking up the child under the axillae or by pulling on the arms. D. Incorrect: Breastfeeding is not contraindicated, but both the mother and infant will need help from the nurse at the start. p. 994

A 3.8-kg infant was delivered vaginally at 39 weeks after a 30-minute second stage. There was a nuchal cord. After birth, the infant is noted to have petechiae over the face and upper back. Information given to the infant's parents should be based on the knowledge that petechiae: A. Are benign if they disappear within 48 hours of birth B. Result from increased blood volume C. Should always be further investigated D. Usually occur with forceps delivery

A A. Correct: Petechiae, or pinpoint hemorrhagic areas, acquired during birth may extend over the upper portion of the trunk and face. These lesions are benign if they disappear within 2 days of birth and no new lesions appear. B. Incorrect: Petechiae may result from decreased platelet formation. C. Incorrect: In this situation, the presence of petechiae is most likely a soft-tissue injury resulting from the nuchal cord at birth. Unless they do not dissipate in 2 days, there is no reason to alarm the family. D. Incorrect: Petechiae usually occur with a breech presentation vaginal birth. p. 993

A careful review of the literature on the various recreational and illicit drugs reveals that: A. More, longer term studies are needed to assess the lasting effects on infants when mothers have taken or are taking illegal drugs. B. Heroin and methadone cross the placenta; marijuana, cocaine, and PCP do not. C. Mothers should get off heroin (detox) any time they can during pregnancy. D. Methadone withdrawal for infants is less severe and shorter than heroin withdrawal.

A A. Correct: Studies on the effects of marijuana and cocaine use by mothers are somewhat contradictory. More, longer range studies are needed. B. Incorrect: Just about all of these drugs cross the placenta, including marijuana, cocaine, and PCP. C. Incorrect: Drug withdrawal is accompanied by fetal withdrawal, which can lead to fetal death. Therefore, detoxification from heroin is not recommended, particularly later, in pregnancy. D. Incorrect: Methadone withdrawal is more severe and more prolonged than heroin withdrawal. p. 1015

A pregnant woman presents in labor at term, having had no prenatal care. After birth, her infant is noted to be small for gestational age with small eyes and a thin upper lip. The infant also is microcephalic. Based on her infant's physical findings, this woman should be questioned about her use of which substance during pregnancy? A. Alcohol B. Cocaine C. Heroin D. Marijuana

A A. Correct: The description of the infant suggests fetal alcohol syndrome, which is consistent with maternal alcohol consumption during pregnancy. B. Incorrect: Fetal brain, kidney, and urogenital system malformations have been associated with maternal cocaine ingestions. C. Incorrect: Heroin use in pregnancy frequently results in IUGR. The infant may have a shrill cry and sleep cycle disturbances and may present with poor feeding, tachypnea, vomiting, diarrhea, hypothermia or hyperthermia, and sweating. D. Incorrect: Studies have found a higher incidence of meconium staining in infants born of mothers who used marijuana during pregnancy. p. 1013

During a prenatal examination, the woman reports having two cats at home. The nurse informs her that she should not be cleaning the litter box while she is pregnant. When the woman questions the nurse as to why, the nurse's best response would be: A. "Your cats could be carrying toxoplasmosis. This is a zoonotic parasite that can infect you and have severe effects on your unborn child." B. "You and your baby can be exposed to the HIV virus in your cats' feces." C. "It's just gross. You should make your husband clean the litter boxes." D. "Cat feces are known to carry E. coli, which can cause a severe infection in both you and your baby."

A A. Correct: Toxoplasmosis is a multisystem disease caused by the protozoal Toxoplasma gondii parasite, commonly found in cats, dogs, pigs, sheep, and cattle. About 30% of women who contract toxoplasmosis during gestation transmit the disease to their offspring. Clinical features ascribed to toxoplasmosis include hydrocephalus or microcephaly, chorioretinitis, seizures, or cerebral calcifications. B. Incorrect: HIV is not transmitted by cats. C. Incorrect: Although this may be a valid statement, it is not appropriate, does not answer the client's question, and is not the nurse's best response. D. Incorrect: E. coli is found in normal human fecal flora. It is not transmitted by cats. p. 1004

15. Which description most accurately describes the augmentation of labor? a. Is part of the active management of labor that is instituted when the labor process is unsatisfactory b. Relies on more invasive methods when oxytocin and amniotomy have failed c. Is a modern management term to cover up the negative connotations of forceps-assisted birth d. Uses vacuum cups

ANS: A Augmentation is part of the active management of labor that stimulates uterine contractions after labor has started but is not progressing satisfactorily. Augmentation uses amniotomy and oxytocin infusion, as well as some more gentle, noninvasive methods. Forceps-assisted births are less common than in the past and not considered a method of augmentation. A vacuum-assisted delivery occurs during childbirth if the mother is too exhausted to push. Vacuum extraction is not considered an augmentation methodology. DIF: Cognitive Level: Understand REF: pp. 785-786 TOP: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance

16. The exact cause of preterm labor is unknown but believed to be multifactorial. Infection is thought to be a major factor in many preterm labors. Which type of infection has not been linked to preterm birth? a. Viral b. Periodontal c. Cervical d. Urinary tract

ANS: A Infections that increase the risk of preterm labor and birth are bacterial and include cervical, urinary tract, periodontal, and other bacterial infections. Therefore, early, continual, and comprehensive participation by the client in her prenatal care is important. Recent evidence has shown a link between periodontal infections and preterm labor. Researchers recommend regular dental care before and during pregnancy, oral assessment as a routine part of prenatal care, and scrupulous oral hygiene to prevent periodontal infections. DIF: Cognitive Level: Remember REF: p. 760 TOP: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

An infant at 26 weeks of gestation arrives intubated from the delivery room. The nurse weighs the infant, places him under the radiant warmer, and attaches him to the ventilator at the prescribed settings. A pulse oximeter and cardiorespiratory monitor are placed. The pulse oximeter is recording oxygen saturations of 80%. The prescribed saturations are 92%. What is the nurse's most appropriate action at this time? a.Listening to breath sounds, and ensuring the patency of the endotracheal tube, increasing oxygen, and notifying a physician b.Continuing to observe and making no changes until the saturations are 75% c.Continuing with the admission process to ensure that a thorough assessment is completed d.Notifying the parents that their infant is not doing well

ANS: A Listening to breath sounds and ensuring the patency of the endotracheal tube, increasing oxygen, and notifying a physician are appropriate nursing interventions to assist in optimal oxygen saturation of the infant. Oxygen saturation should be maintained above 92%, and oxygenation status of the infant is crucial. The nurse should delay other tasks to stabilize the infant. Notifying the parents that the infant is not doing well is not an appropriate action. Further assessment and intervention are warranted before determining fetal status.

15. With one exception, the safest pregnancy is one during which the woman is drug and alcohol free. What is the optimal treatment for women addicted to opioids? a. Methadone maintenance treatment (MMT) b. Detoxification c. Smoking cessation d. 4 Ps Plus

ANS: A MMT is currently considered the standard of care for pregnant women who are dependent on heroin or other narcotics. Buprenorphine is another medication approved for the treatment of opioid addiction that is increasingly being used during pregnancy. Opioid replacement therapy has been shown to decrease opioid and other drug use, reduce criminal activity, improve individual functioning, and decrease the rates of infections such as hepatitis B and C, human immunodeficiency virus (HIV), and other STIs. Detoxification is the treatment used for alcohol addiction. Pregnant women requiring withdrawal from alcohol should be admitted for inpatient management. Women are more likely to stop smoking during pregnancy than at any other time in their lives. A smoking cessation program can assist in achieving this goal. The 4 Ps Plus is a screening tool specifically designed to identify pregnant women who need in-depth assessment related to substance abuse. DIF: Cognitive Level: Apply REF: p. 755 TOP: Nursing Process: Planning MSC: Client Needs: Psychosocial Integrity

A pregnant woman was admitted for induction of labor at 43 weeks of gestation with sure dates. A nonstress test (NST) in the obstetrician's office revealed a nonreactive tracing. On artificial rupture of membranes, thick meconium-stained fluid was noted. What should the nurse caring for the infant after birth anticipate? a.Meconium aspiration, hypoglycemia, and dry, cracked skin b.Excessive vernix caseosa covering the skin, lethargy, and RDS c.Golden yellow to green-stained skin and nails, absence of scalp hair, and an increased amount of subcutaneous fat d.Hyperglycemia, hyperthermia, and an alert, wide-eyed appearance

ANS: A Meconium aspiration, hypoglycemia, and dry, cracked skin are consistent with a postmature infant. Excessive vernix caseosa, lethargy, and RDS are consistent with a very premature infant. The skin may be meconium stained, but the infant will most likely have long hair and decreased amounts of subcutaneous fat. Postmaturity with a nonreactive NST is indicative of hypoxia. Signs and symptoms associated with fetal hypoxia are hypoglycemia, temperature instability, and lethargy.

During the assessment of a preterm infant, the nurse notices continued respiratory distress even though oxygen and ventilation have been provided. In this situation, which condition should the nurse suspect? a.Hypovolemia and/or shock b.Excessively cool environment c.Central nervous system (CNS) injury d.Pending renal failure

ANS: A Other symptoms might include hypotension, prolonged capillary refill, and tachycardia, followed by bradycardia. Intervention is necessary. Preterm infants are susceptible to temperature instability. The goal of thermoregulation is to provide a neutral thermal environment. Hypoglycemia is likely to occur if the infant is attempting to conserve heat. CNS injury is manifested by hyperirritability, seizures, and abnormal movements of the extremities. Urine output and testing of specific gravity are appropriate interventions for the infant with suspected renal failure. This neonate is unlikely to be delivered with respiratory distress.

6. According to research, which risk factor for PPD is likely to have the greatest effect on the client postpartum? a. Prenatal depression b. Single-mother status c. Low socioeconomic status d. Unplanned or unwanted pregnancy

ANS: A Prenatal depression has been found to be a major risk factor for PPD. Single-mother status and low socioeconomic status are both small-relationship predictors for PPD. Although an unwanted pregnancy may contribute to the risk for PPD, it does not pose as great an effect as prenatal depression. DIF: Cognitive Level: Understand REF: p. 744 TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

4. Despite warnings, prenatal exposure to alcohol continues to far exceed exposure to illicit drugs. Which condition is rarely associated with fetal alcohol syndrome (FAS)? a. Respiratory conditions b. Intellectual impairment c. Neural development disorder d. Alcohol-related birth defects (ARBDs)

ANS: A Respiratory difficulties are not attributed to exposure to alcohol in utero. Other abnormalities related to FAS include mental retardation, neurodevelopment disorders, and ARBDs. DIF: Cognitive Level: Understand REF: p. 752 TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

A premature infant with respiratory distress syndrome (RDS) receives artificial surfactant. How does the nurse explain surfactant therapy to the parents? a."Surfactant improves the ability of your baby's lungs to exchange oxygen and carbon dioxide." b."The drug keeps your baby from requiring too much sedation." c."Surfactant is used to reduce episodes of periodic apnea." d."Your baby needs this medication to fight a possible respiratory tract infection."

ANS: A Surfactant can be administered as an adjunct to oxygen and ventilation therapy. With the administration of an artificial surfactant, respiratory compliance is improved until the infant can generate enough surfactant on his or her own. Surfactant has no bearing on the sedation needs of the infant. Surfactant is used to improve respiratory compliance, including the exchange of oxygen and carbon dioxide. The goal of surfactant therapy in an infant with RDS is to stimulate the production of surfactant in the type 2 cells of the alveoli. The clinical presentation of RDS and neonatal pneumonia may be similar. The infant may be started on broad-spectrum antibiotics to treat infection.

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

ANS: A The woman is assisted into a modified Sims position, Trendelenburg position, or the knee-chest position in which gravity keeps the pressure of the presenting part off the cord. Although covering the cord in sterile gauze soaked saline, preparing the woman for a cesarean, and starting oxygen by face mark are appropriate nursing interventions in the event of a prolapsed cord, the intervention of top priority would be positioning the mother to relieve cord compression. DIF: Cognitive Level: Apply REF: p. 797 TOP: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

What is the most important nursing action in preventing neonatal infection? a.Good handwashing b.Isolation of infected infants c.Separate gown technique d.Standard Precautions

ANS: A Virtually all controlled clinical trials have demonstrated that effective handwashing is responsible for the prevention of nosocomial infection in nursery units. Measures to be taken include Standard Precautions, careful and thorough cleaning, frequent replacement of used equipment, and disposal of excrement and linens in an appropriate manner. Overcrowding must be avoided in nurseries. However, the most important nursing action for preventing neonatal infection is effective handwashing.

3. Women who are obese are at risk for several complications during pregnancy and birth. Which of these would the nurse anticipate with an obese client? (Select all that apply.) a. Thromboembolism b. Cesarean birth c. Wound infection d. Breech presentation e. Hypertension

ANS: A, B, C, E A breech presentation is not a complication of pregnancy or birth for the client who is obese. Venous thromboembolism is a known risk for obese women. Therefore, the use of thromboembolism-deterrent (TED) hose and sequential compression devices may help decrease the chance for clot formation. Women should also be encouraged to ambulate as soon as possible. In addition to having an increased risk for complications with a cesarean birth, in general, obese women are also more likely to require an emergency cesarean birth. Many obese women have a pannus (i.e., large roll of abdominal fat) that overlies a lower transverse incision made just above the pubic area. The pannus causes the area to remain moist, which encourages the development of infection. Obese women are more likely to begin pregnancy with comorbidities such as hypertension and type 2 diabetes. DIF: Cognitive Level: Analyze REF: p. 778 TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

Infants born between 34 0/7 and 36 6/7 weeks of gestation are called late-preterm infants because they have many needs similar to those of preterm infants. Because they are more stable than early-preterm infants, they may receive care that is similar to that of a full-term baby. These infants are at increased risk for which conditions? (Select all that apply.) a.Problems with thermoregulation b.Cardiac distress c.Hyperbilirubinemia d.Sepsis e.Hyperglycemia

ANS: A, C, D Thermoregulation problems, hyperbilirubinemia, and sepsis are all conditions related to immaturity and warrant close observation. After discharge, the infant is at risk for rehospitalization related to these problems. Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN) launched the Near-Term Infant Initiative to study the problem and ways to ensure that these infants receive adequate care. The nurse should ensure that this infant is adequately feeding before discharge and that parents are taught the signs and symptoms of these complications. Late-preterm infants are also at increased risk for respiratory distress and hypoglycemia.

A premature infant never seems to sleep longer than an hour at a time. Each time a light is turned on, an incubator closes, or people talk near her crib, she wakes up and inconsolably cries until held. What is the correct nursing diagnosis beginning with "ineffective coping, related to"? a.Severe immaturity b.Environmental stress c.Physiologic distress d.Behavioral responses

ANS: B "Ineffective coping, related to environmental stress" is the most appropriate nursing diagnosis for this infant. Light and sound are known adverse stimuli that add to an already stressed premature infant. The nurse must closely monitor the environment for sources of overstimulation. Although the infant may be severely immature in this case, she is responding to environmental stress. Physiologic distress is the response to environmental stress. The result is stress cues such as increased metabolic rate, increased oxygen and caloric use, and depression of the immune system. The infant's behavioral response to the environmental stress is crying. The appropriate nursing diagnosis reflects the cause of this response.

24. What is a maternal indication for the use of vacuum-assisted birth? a. Wide pelvic outlet b. Maternal exhaustion c. History of rapid deliveries d. Failure to progress past station 0

ANS: B A mother who is exhausted may be unable to assist with the expulsion of the fetus. The client with a wide pelvic outlet will likely not require vacuum extraction. With a rapid delivery, vacuum extraction is not necessary. A station of 0 is too high for a vacuum-assisted birth. DIF: Cognitive Level: Understand REF: p. 786 TOP: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

1. A client with a history of bipolar disorder is called by the postpartum support nurse for follow-up. Which symptoms would reassure the nurse that the client is not experiencing a manic episode? a. Psychomotor agitation and lack of sleep b. Increased appetite and lack of interest in activities c. Hyperactivity and distractibility d. Pressured speech and grandiosity

ANS: B An increased appetite and a lack of interest would reassure the nurse that the client is not experiencing an episode of mania. Clinical manifestations of a manic episode include at least three of the following: grandiosity, decreased need for sleep, pressured speech, flight of ideas, distractibility, psychomotor agitation, and excessive involvement in pleasurable activities. The pregnant woman exhibiting symptoms of a manic episode will likely have a decreased interest in eating and an increased level of interest in pleasurable activities without regard for negative consequences. Psychomotor agitation and a lack of sleep, hyperactivity and distractibility, and pressured speech and grandiosity are all clinical manifestations of a manic episode. DIF: Cognitive Level: Apply REF: p. 746 TOP: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

14. A number of methods can be used for inducing labor. Which cervical ripening method falls under the category of mechanical or physical? a. Prostaglandins are used to soften and thin the cervix. b. Labor can sometimes be induced with balloon catheters or laminaria tents. c. Oxytocin is less expensive and more effective than prostaglandins but creates greater health risks. d. Amniotomy can be used to make the cervix more favorable for labor.

ANS: B Balloon catheters or laminaria tents are mechanical means of ripening the cervix. Ripening the cervix, making it softer and thinner, increases the success rate of induced labor. Prostaglandin E1 is less expensive and more effective than oxytocin but carries a greater risk. Amniotomy is the artificial rupture of membranes, which is used to induce labor only when the cervix is already ripe. DIF: Cognitive Level: Apply REF: p. 781 TOP: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance

10. The nurse who elects to work in the specialty of obstetric care must have the ability to distinguish between preterm birth, preterm labor, and low birth weight. Which statement regarding this terminology is correct? a. Terms preterm birth and low birth weight can be used interchangeably. b. Preterm labor is defined as cervical changes and uterine contractions occurring between 20 and 37 weeks of gestation. c. Low birth weight is a newborn who weighs below 3.7 pounds. d. Preterm birth rate in the United States continues to increase.

ANS: B Before 20 weeks of gestation, the fetus is not viable (miscarriage); after 37 weeks, the fetus can be considered term. Although these terms are used interchangeably, they have different meanings: preterm birth describes the length of gestation (before 37 weeks), regardless of the newborn's weight; low birth weight describes only the infant's weight at the time of birth (2500 g or less), whenever it occurs. Low birth weight is anything below 2500 g or approximately pounds. In 2011, the preterm birth rate in the United States was 11.7 %; it has dropped every year since 2008. DIF: Cognitive Level: Understand REF: p. 759 TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

In appraising the growth and development potential of a preterm infant, the nurse should be cognizant of the information that is best described in which statement? a.Tell the parents that their child will not catch up until approximately age 10 years (for girls) to age 12 years (for boys). b.Correct for milestones, such as motor competencies and vocalizations, until the child is approximately 2 years of age. c.Know that the greatest catch-up period is between 9 and 15 months postconceptual age. d.Know that the length and breadth of the trunk is the first part of the infant to experience catch-up growth.

ANS: B Corrections are made with a formula that adds gestational age and postnatal age. Whether a girl or boy, the infant experiences catch-up body growth during the first 2 to 3 years of life. Maximum catch-up growth occurs between 36 and 40 weeks of postconceptual age. The head is the first to experience catch-up growth.

Parents have asked the nurse about organ donation after that infant's death. Which information regarding organ donation is important for the nurse to understand? a.Federal law requires the medical staff to ask the parents about organ donation and then to contact their state's organ procurement organization (OPO) to handle the procedure if the parents agree. b.Organ donation can aid grieving by giving the family an opportunity to see something positive about the experience. c.Most common donation is the infant's kidneys. d.Corneas can be donated if the infant was either stillborn or alive as long as the pregnancy went full term.

ANS: B Evidence indicates that organ donation can promote healing among the surviving family members. The federal Gift of Life Act made state OPOs responsible for deciding whether to request a donation and for making that request. The most common donation is the cornea. For cornea donation, the infant must have been born alive at 36 weeks of gestation or later.

With regard to infants who are SGA (small for gestational age) and intrauterine growth restriction (IUGR), the nurse should be aware of which information? a.In the first trimester, diseases or abnormalities result in asymmetric IUGR. b.Infants with asymmetric IUGR have the potential for normal growth and development. c.In asymmetric IUGR, weight is slightly larger than SGA, whereas length and head circumference are somewhat less than SGA. d.Symmetric IUGR occurs in the later stages of pregnancy.

ANS: B IUGR is either symmetric or asymmetric. The symmetric form occurs in the first trimester; infants who are SGA have reduced brain capacity. The asymmetric form occurs in the later stages of pregnancy. Weight is less than the 10th percentile; head circumference is greater than the 10th percentile. Infants with asymmetric IUGR have the potential for normal growth and development.

3. During an inpatient psychiatric hospitalization, what is the most important nursing intervention? a. Contacting the client's significant other b. Supervising and guiding visits with her infant c. Allowing no contact with anyone who annoys her d. Having the infant with the mother at all times

ANS: B In the hospital setting, the reintroduction of the infant to the mother can and should occur at the mother's own pace. A schedule is set that increases the number of hours the mother cares for her infant over several days, culminating in the infant staying overnight in the mother's room. These supervised and guided visits allow the mother to experience meeting the infant's needs and giving up sleep for the infant. Reintroducing the mother to her infant while in a supervised setting is essential. Another important task for a mother under psychiatric care is to reestablish positive interactions with others. DIF: Cognitive Level: Understand REF: pp. 749-750 TOP: Nursing Process: Planning MSC: Client Needs: Psychosocial Integrity

Which finding would indicate to the nurse that the grieving parents have progressed to the reorganization phase of grieving? a.The parents say that they "feel no pain." b.The parents are discussing sex and a future pregnancy, even if they have not yet sorted out their feelings. c.The parents have abandoned those moments of "bittersweet grief." d.The parents' questions have progressed from "Why?" to "Why us?"

ANS: B Many couples have conflicting feelings about sexuality and future pregnancies. A little pain is always present, certainly beyond the first year when recovery begins to peak. Bittersweet grief describes the brief grief response that occurs with reminders of a loss, such as anniversary dates. Most couples never abandon these reminders. Recovery is ongoing. Typically, a couple's search for meaning progresses from "Why?" in the acute phase to "Why me?" in the intense phase to "What does this loss mean to my life?" in the reorganizational phase.

14. The use of methamphetamine (meth) has been described as a significant drug problem in the United States. The nurse who provides care to this client population should be cognizant of what regarding methamphetamine use? a. Methamphetamines are similar to opiates. b. Methamphetamines are stimulants with vasoconstrictive characteristics. c. Methamphetamines should not be discontinued during pregnancy. d. Methamphetamines are associated with a low rate of relapse.

ANS: B Methamphetamines are stimulants with vasoconstrictive characteristics similar to cocaine and are similarly used. As is the case with cocaine users, methamphetamine users are urged to immediately stop all use during pregnancy. Unfortunately, because methamphetamine users are extremely psychologically addicted, the rate of relapse is extremely high. DIF: Cognitive Level: Understand REF: p. 753 TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

Necrotizing enterocolitis (NEC) is an inflammatory disease of the gastrointestinal mucosa. The signs of NEC are nonspecific. What are generalized signs and symptoms of this condition? a.Hypertonia, tachycardia, and metabolic alkalosis b.Abdominal distention, temperature instability, and grossly bloody stools c.Hypertension, absence of apnea, and ruddy skin color d.Scaphoid abdomen, no residual with feedings, and increased urinary output

ANS: B Some generalized signs of NEC include decreased activity, hypotonia, pallor, recurrent apnea and bradycardia, decreased oxygen saturation values, respiratory distress, metabolic acidosis, oliguria, hypotension, decreased perfusion, temperature instability, cyanosis, abdominal distention, residual gastric aspirates, vomiting, grossly bloody stools, abdominal tenderness, and erythema of the abdominal wall. The infant may display hypotonia, bradycardia, and metabolic acidosis.

2. Which nursing intervention is paramount when providing care to a client with preterm labor who has received terbutaline? a. Assess deep tendon reflexes (DTRs). b. Assess for dyspnea and crackles. c. Assess for bradycardia. d. Assess for hypoglycemia.

ANS: B Terbutaline is a beta2-adrenergic agonist that affects the mother's cardiopulmonary and metabolic systems. Signs of cardiopulmonary decompensation include adventitious breath sounds and dyspnea. An assessment for dyspnea and crackles is important for the nurse to perform if the woman is taking magnesium sulfate. Assessing DTRs does not address the possible respiratory side effects of using terbutaline. Since terbutaline is a beta2-adrenergic agonist, it can lead to hyperglycemia, not hypoglycemia. Beta2-adrenergic agonist drugs cause tachycardia, not bradycardia. DIF: Cognitive Level: Analyze REF: pp. 767-768 TOP: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

A client is diagnosed with having a stillborn infant. At first, she appears stunned by the news, cries a little, and then asks the nurse to call her mother. What is the proper term for the phase of bereavement that this client is experiencing? a.Anticipatory grief b.Acute distress c.Intense grief d.Reorganization

ANS: B The immediate reaction to news of a perinatal loss or infant death encompasses a period of acute distress. Disbelief and denial can occur. However, parents also feel very sad and depressed. Intense outbursts of emotion and crying are normal. However, a lack of affect, euphoria, and calmness may occur and may reflect numbness, denial, or personal ways of coping with stress. Anticipatory grief applies to the grief related to a potential loss of an infant. The parent grieves in preparation of the infant's possible death, although he or she clings to the hope that the child will survive. Intense grief occurs in the first few months after the death of the infant. This phase encompasses many different emotions, including loneliness, emptiness, yearning, guilt, anger, and fear. Reorganization occurs after a long and intense search for meaning. Parents are better able to function at work and home, experience a return of self-esteem and confidence, can cope with new challenges, and have placed the loss in perspective.

A newborn was admitted to the neonatal intensive care unit (NICU) after being delivered at 29 weeks of gestation to a 28-year-old multiparous, married, Caucasian woman whose pregnancy was uncomplicated until the premature rupture of membranes and preterm birth. The newborn's parents arrive for their first visit after the birth. The parents walk toward the bedside but remain approximately 5 feet away from the bed. What is the nurse's most appropriate action? a.Wait quietly at the newborn's bedside until the parents come closer. b.Go to the parents, introduce him or herself, and gently encourage them to meet their infant. Explain the equipment first, and then focus on the newborn. c.Leave the parents at the bedside while they are visiting so that they have some privacy. d.Tell the parents only about the newborn's physical condition and caution them to avoid touching their baby.

ANS: B The nurse is instrumental in the initial interactions with the infant. The nurse can help the parents see the infant rather than focus on the equipment. The importance and purpose of the apparatus that surrounds their infant also should be explained to them. Parents often need encouragement and recognition from the nurse to acknowledge the reality of the infant's condition. Parents need to see and touch their infant as soon as possible to acknowledge the reality of the birth and the infant's appearance and condition. Encouragement from the nurse is instrumental in this process. Telling the parents to avoid touching their baby is inappropriate and unhelpful.

A newborn in the neonatal intensive care unit (NICU) is dying as a result of a massive infection. The parents speak to the neonatologist, who informs them of their son's prognosis. When the father sees his son, he says, "He looks just fine to me. I can't understand what all this is about." What is the most appropriate response or reaction by the nurse at this time? a."Didn't the physician tell you about your son's problems?" b."This must be a difficult time for you. Tell me how you're doing." c.Quietly stand beside the infant's father. d."You'll have to face up to the fact that he is going to die sooner or later."

ANS: B The phase of intense grief can be very difficult, especially for fathers. Parents should be encouraged to share their feelings during the initial steps in the grieving process. This father is in a phase of acute distress and is reaching out to the nurse as a source of direction in his grieving process. Shifting the focus is not in the best interest of the parent. Nursing actions may help the parents actualize the loss of their infant through a sharing and verbalization of their feelings of grief. Telling the father that his son is going to die sooner or later is dispassionate and an inappropriate statement on the part of the nurse.

During a follow-up home visit, the nurse plans to evaluate whether parents have progressed to the second stage of grieving (phase of intense grief). Which behavior would the nurse not anticipate finding? a.Guilt, particularly in the mother b.Numbness or lack of response c.Bitterness or irritability d.Fear and anxiety, especially about getting pregnant again

ANS: B The second phase of grieving encompasses a wide range of intense emotions, including guilt, anger, bitterness, fear, and anxiety. What the nurse would hope not to see is numbness or unresponsiveness, which indicates that the parents are still in denial or shock.

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

ANS: B This client's preterm labor is being controlled with tocolytics. Once she is stable, home care may be a viable option for this type of client. Care of a client with preterm labor is multidisciplinary and multifactorial; the goal is to prevent delivery. In many cases, this goal may be achieved at home. Managed care may dictate an earlier hospital discharge or a shift from hospital to home care. Insurance coverage may be one factor in client care, but ultimately, client safety remains the most important factor. DIF: Cognitive Level: Apply REF: p. 765 TOP: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance

MULTIPLE RESPONSE 1. The nurse recognizes that uterine hyperstimulation with oxytocin requires emergency interventions. What clinical cues alert the nurse that the woman is experiencing uterine hyperstimulation? (Select all that apply.) a. Uterine contractions lasting <90 seconds and occurring >2 minutes in frequency b. Uterine contractions lasting >90 seconds and occurring <2 minutes in frequency c. Uterine tone <20 mm Hg d. Uterine tone >20 mm Hg e. Increased uterine activity accompanied by a nonreassuring FHR and pattern

ANS: B, D, E Uterine contractions that occur less frequently than 2 minutes apart and last longer than 90 seconds, a uterine tone over 20 mm Hg, and a nonreassuring FHR and pattern are indications of uterine hyperstimulation with oxytocin administration. Uterine contractions that occur more frequently than 2 minutes apart and last less than 90 seconds are the expected goal of oxytocin induction. A uterine tone less than 20 mm Hg is normal. DIF: Cognitive Level: Analyze REF: p. 785 TOP: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

11. A woman at 24 weeks of gestation states that she has a glass of wine with dinner every evening. Why would the nurse counsel the client to eliminate all alcohol? a. Daily consumption of alcohol indicates a risk for alcoholism. b. She will be at risk for abusing other substances as well. c. The fetus is placed at risk for altered brain growth. d. The fetus is at risk for multiple organ anomalies.

ANS: C No period exists when consuming alcohol during pregnancy is safe. The documented effects of alcohol consumption during pregnancy include mental retardation, learning disabilities, high activity level, and short attention span. The brain grows most rapidly in the third trimester and is vulnerable to alcohol exposure during this time. Abuse of other substances has not been linked to alcohol use. DIF: Cognitive Level: Apply REF: p. 752 TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity

21. What is the primary purpose for the use of tocolytic therapy to suppress uterine activity? a. Drugs can be efficaciously administered up to the designated beginning of term at 37 weeks gestation. b. Tocolytic therapy has no important maternal (as opposed to fetal) contraindications. c. The most important function of tocolytic therapy is to provide the opportunity to administer antenatal glucocorticoids. d. If the client develops pulmonary edema while receiving tocolytic therapy, then intravenous (IV) fluids should be given.

ANS: C Buying time for antenatal glucocorticoids to accelerate fetal lung development may be the best reason to use tocolytic therapy. Once the pregnancy has reached 34 weeks, however, the risks of tocolytic therapy outweigh the benefits. Important maternal contraindications to tocolytic therapy exist. Tocolytic-induced edema can be caused by IV fluids. DIF: Cognitive Level: Comprehend REF: p. 766 TOP: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity

12. A pregnant woman who abuses cocaine admits to exchanging sex to finance her drug habit. This behavior places the client at the greatest risk for what? a. Depression of the CNS b. Hypotension and vasodilation c. Sexually transmitted infections (STIs) d. Postmature birth

ANS: C Exchanging sex acts for drugs places the woman at increased risk for STIs because of multiple partners and the lack of protection. Cocaine is a CNS stimulant that causes hypertension and vasoconstriction. Premature delivery of the infant is one of the more common problems associated with cocaine use during pregnancy. DIF: Cognitive Level: Understand REF: p. 754 TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

An infant is to receive gastrostomy feedings. Which intervention should the nurse institute to prevent bloating, gastrointestinal reflux into the esophagus, vomiting, and respiratory compromise? a.Rapid bolusing of the entire amount in 15 minutes b.Warm cloths to the abdomen for the first 10 minutes c.Slow, small, warm bolus feedings over 30 minutes d.Cold, medium bolus feedings over 20 minutes

ANS: C Feedings by gravity are slowly accomplished over 20- to 30-minute periods to prevent adverse reactions. Rapid bolusing would most likely lead to the adverse reactions listed. Temperature stability in the newborn is critical. Applying warm cloths to the abdomen would not be appropriate because the environment is not thermoregulated. In addition, abdominal warming is not indicated with feedings of any kind. Small feedings at room temperature are recommended to prevent adverse reactions.

With regard to an eventual discharge of the high-risk newborn or the transfer of the newborn to a different facility, which information is essential to provide to the parents? a.Infants stay in the NICU until they are ready to go home. b.Once discharged to go home, the high-risk infant should be treated like any healthy term newborn. c.Parents of high-risk infants need special support and detailed contact information. d.If a high-risk infant and mother need to be transferred to a specialized regional center, then waiting until after the birth and until the infant is stabilized is best.

ANS: C High-risk infants can cause profound parental stress and emotional turmoil. Parents need support, special teaching, and quick access to various resources available to help them care for their baby. Parents and their high-risk infant should get to spend a night or two in a predischarge room, where care for the infant is provided away from the NICU. Simply because high-risk infants are eventually discharged does not mean they are normal, healthy babies. Follow-up by specialized practitioners is essential. Ideally, the mother and baby are transported with the fetus in utero; this reduces neonatal morbidity and mortality.

A nurse practicing in the perinatal setting should promote kangaroo care regardless of an infant's gestational age. Which statement regarding this intervention is most appropriate? a.Kangaroo care was adopted from classical British nursing traditions. b.This intervention helps infants with motor and CNS impairments. c.Kangaroo care helps infants interact directly with their parents and enhances their temperature regulation. d.This intervention gets infants ready for breastfeeding.

ANS: C Kangaroo care is skin-to-skin holding in which the infant, dressed only in a diaper, is placed directly on the parent's bare chest and then covered. The procedure helps infants interact with their parents and regulates their temperature, among other developmental benefits. Kangaroo care was established in Bogota, Colombia, assists the infant in maintaining an organized state, and decreases pain perception during heelsticks. Even premature infants who are unable to suckle benefit from kangaroo care. This practice fosters increased vigor and an enhanced breastfeeding experience as the infant matures.

Which options for saying "good-bye" would the nurse want to discuss with a woman who is diagnosed with having a stillborn girl? a.The nurse should not discuss any options at this time; plenty of time will be available after the baby is born. b."Would you like a picture taken of your baby after birth?" c."When your baby is born, would you like to see and hold her?" d."What funeral home do you want notified after the baby is born?"

ANS: C Mothers and fathers may find it helpful to see their infant after delivery. The parents' wishes should be respected. Interventions and support from the nursing and medical staff after a prenatal loss are extremely important in the healing of the parents. The initial intervention should be directly related to the parents' wishes concerning seeing or holding their dead infant. Although information about funeral home notification may be relevant, this information is not the most appropriate option at this time. Burial arrangements can be discussed after the infant is born.

7. Which is the most accurate description of PPD without psychotic features? a. Postpartum baby blues requiring the woman to visit with a counselor or psychologist b. Condition that is more common among older Caucasian women because they have higher expectations c. Distinguishable by pervasive sadness along with mood swings d. Condition that disappears without outside help

ANS: C PPD is characterized by an intense pervasive sadness along with labile mood swings and is more persistent than postpartum baby blues. PPD, even without psychotic features, is more serious and persistent than postpartum baby blues. PPD is more common among younger mothers and African-American mothers. Most women need professional help to get through PPD, including pharmacologic intervention. DIF: Cognitive Level: Understand REF: p. 745 TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

8. While providing care to the maternity client, the nurse should be aware that one of these anxiety disorders is likely to be triggered by the process of labor and birth. Which disorder fits this criterion? a. Phobias b. Panic disorder c. Posttraumatic stress disorder (PTSD) d. Obsessive-compulsive disorder (OCD)

ANS: C PTSD can occur as the result of a past trauma such as rape. Symptoms of PTSD include re-experiencing the event, numbing, irritability, angry outbursts, and exaggerated startle reflex. With the increased bodily touch and vaginal examinations that occur during labor, the client may have memories of the original trauma. The process of giving birth may result in her feeling out of control. The nurse should verbalize an understanding and reassure the client as necessary. Phobias are irrational fears that may lead a person to avoid certain events or situations. Panic disorders may occur in as many as 3% to 5% of women in the postpartum period and are described as episodes of intense apprehension, fear, and terror. Symptoms of a panic disorder may include palpitations, chest pain, choking, or smothering. OCD symptoms include recurrent, persistent, and intrusive thoughts. The mother may repeatedly check and recheck her infant once he or she is born, although she realizes that this behavior is irrational. OCD is optimally treated with medications. DIF: Cognitive Level: Understand REF: p. 742 TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

Which statement most accurately describes complicated grief? a.Occurs when, in multiple births, one child dies and the other or others live b.Is a state during which the parents are ambivalent, as with an abortion c.Is an extremely intense grief reaction that persists for a long time d.Is felt by the family of adolescent mothers who lose their babies

ANS: C Parents showing signs of complicated grief should be referred for counseling. Multiple births, in which not all of the babies survive, create a complicated parenting situation but not complicated bereavement. Abortion can generate complicated emotional responses, but these responses do not constitute complicated bereavement. Families of lost adolescent pregnancies may have to deal with complicated issues, but these issues are not complicated bereavement.

7. Prostaglandin gel has been ordered for a pregnant woman at 43 weeks of gestation. What is the primary purpose of prostaglandin administration? a. To enhance uteroplacental perfusion in an aging placenta b. To increase amniotic fluid volume c. To ripen the cervix in preparation for labor induction d. To stimulate the amniotic membranes to rupture

ANS: C Preparations of prostaglandin E1 and E2 are effective when used before labor induction to ripen (i.e., soften and thin) the cervix. Uteroplacental perfusion is not altered by the use of prostaglandins. The insertion of prostaglandin gel has no effect on the level of amniotic fluid. In some cases, women will spontaneously begin laboring after the administration of prostaglandins, thereby eliminating the need for oxytocin. It is not common for a woman's membranes to rupture as a result of prostaglandin use. DIF: Cognitive Level: Apply REF: p. 779 TOP: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity

When assisting the mother, father, and other family members to actualize the loss of an infant, which action is most helpful? a.Using the words lost or gone rather than dead or died b.Making sure the family understands that naming the baby is important c.Ensuring the baby is clothed or wrapped if the parents choose to visit with the baby d.Setting a firm time for ending the visit with the baby so that the parents know when to let go

ANS: C Presenting the baby as nicely as possible stimulates the parents' senses and provides pleasant memories of their baby. Baby lotion or powder can be applied, and the baby should be wrapped in a soft blanket, clothed, and have a cap placed on his or her head. Nurses must use the words dead and died to assist the bereaved in accepting the reality. Although naming the baby can be helpful, creating the sense that the parents have to name the baby is not important. In fact, some cultural taboos and religious rules prohibit the naming of an infant who has died. Parents need different times with their baby to say "good-bye." Nurses need to be careful not to rush the process.

For clinical purposes, the most accurate definition of preterm and post-term infants is defined as what? a.Preterm: Before 34 weeks of gestation if the infant is appropriate for gestational age (AGA); before 37 weeks if the infant is small for gestational age (SGA) b.Postterm: After 40 weeks of gestation if the infant is large for gestational age (LGA); beyond 42 weeks if the infant is AGA c.Preterm: Before 37 weeks of gestation and postterm beyond 42 weeks of gestation; no matter the size for gestational age at birth d.Preterm: Before 38 to 40 weeks of gestation if the infant is SGA; postterm, beyond 40 to 42 weeks gestation if the infant is LGA

ANS: C Preterm and postterm are strictly measures of time—before 37 weeks and beyond 42 weeks, respectively—regardless of the size for gestational age.

1. In planning for home care of a woman with preterm labor, which concern should the nurse need to address? a. Nursing assessments are different from those performed in the hospital setting. b. Restricted activity and medications are necessary to prevent a recurrence of preterm labor. c. Prolonged bed rest may cause negative physiologic effects. d. Home health care providers are necessary.

ANS: C Prolonged bed rest may cause adverse effects such as weight loss, loss of appetite, muscle wasting, weakness, bone demineralization, decreased cardiac output, risk for thrombophlebitis, alteration in bowel functions, sleep disturbance, and prolonged postpartum recovery. Nursing assessments differ somewhat from those performed in the acute care setting, but this concern does not need to be addressed. Restricted activity and medications may prevent preterm labor but not in all women. In addition, the plan of care is individualized to meet the needs of each client. Many women receive home health nurse visits, but care is individualized for each woman. DIF: Cognitive Level: Analyze REF: p. 777 TOP: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance

9. Which substance used during pregnancy causes vasoconstriction and decreased placental perfusion, resulting in maternal and neonatal complications? a. Alcohol b. Caffeine c. Tobacco d. Chocolate

ANS: C Smoking in pregnancy is known to cause a decrease in placental perfusion and is the cause of low-birth-weight infants. Prenatal alcohol exposure is the single greatest preventable cause of mental retardation. Alcohol use during pregnancy can cause high blood pressure, miscarriage, premature birth, stillbirth, and anemia. Caffeine may interfere with certain medications and worsen arrhythmias. Chocolate, particularly dark chocolate, contains caffeine that may interfere with certain medications. DIF: Cognitive Level: Remember REF: p. 752 TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

An infant is being discharged from the NICU after 70 days of hospitalization. The infant was born at 30 weeks of gestation with several conditions associated with prematurity, including RDS, mild bronchopulmonary dysplasia (BPD), and retinopathy of prematurity (ROP), requiring surgical treatment. During discharge teaching, the infant's mother asks the nurse if her baby will meet developmental milestones on time, as did her son who was born at term. What is the nurse's most appropriate response? a."Your baby will develop exactly like your first child." b."Your baby does not appear to have any problems at this time." c."Your baby will need to be corrected for prematurity." d."Your baby will need to be followed very closely."

ANS: C The age of a preterm newborn is corrected by adding the gestational age and the postnatal age. The infant's responses are accordingly evaluated against the norm expected for the corrected age of the infant. The baby is currently 40 weeks of postconceptional age and can be expected to be doing what a 40-week-old infant would be doing. Although predicting with complete accuracy the growth and development potential of each preterm infant is impossible, certain measurable factors predict normal growth and development. The preterm infant experiences catch-up body growth during the first 2 to 3 years of life. Development needs to be evaluated over time. The growth and developmental milestones are corrected for gestational age until the child is approximately years old.

5. A primigravida at 40 weeks of gestation is having uterine contractions every to 2 minutes and states that they are very painful. Her cervix is dilated 2 cm and has not changed in 3 hours. The woman is crying and wants an epidural. What is the likely status of this woman's labor? a. She is exhibiting hypotonic uterine dysfunction. b. She is experiencing a normal latent stage. c. She is exhibiting hypertonic uterine dysfunction. d. She is experiencing precipitous labor.

ANS: C The contraction pattern observed in this woman signifies hypertonic uterine activity. Typically, uterine activity in this phase occurs at 4- to 5-minute intervals lasting 30 to 45 seconds. Women who experience hypertonic uterine dysfunction, or primary dysfunctional labor, are often anxious first-time mothers who are having painful and frequent contractions that are ineffective at causing cervical dilation or effacement to progress. With hypotonic uterine dysfunction, the woman initially makes normal progress into the active stage of labor; then the contractions become weak and inefficient or stop altogether. Precipitous labor is one that lasts less than 3 hours from the onset of contractions until time of birth. DIF: Cognitive Level: Apply REF: p. 773 TOP: Nursing Process: Diagnosis MSC: Client Needs: Health Promotion and Maintenance

By understanding the four mechanisms of heat transfer (convection, conduction, radiation, and evaporation), the nurse can create an environment for the infant that prevents temperature instability. Which significant symptoms will the infant display when experiencing cold stress? a.Decreased respiratory rate b.Bradycardia, followed by an increased heart rate c.Mottled skin with acrocyanosis d.Increased physical activity

ANS: C The infant has minimal-to-no fat stores. During times of cold stress, the skin becomes mottled and acrocyanosis develops, progressing to cyanosis. Even if the infant is being cared for on a radiant warmer or in an isolette, the nurse's role is to observe the infant frequently to prevent heat loss and to respond quickly if signs and symptoms of cold stress occur. The respiratory rate increases, followed by periods of apnea. The infant initially tries to conserve heat and burns more calories, after which the metabolic system goes into overdrive. In the preterm infant who is experiencing heat loss, the heart rate initially increases, followed by periods of bradycardia. In the term infant, increased physical activity is the natural response to heat loss. However, in a term infant who is experiencing respiratory distress or in a preterm infant, physical activity is decreased.

During the initial acute distress phase of grieving, parents still must make unexpected and unwanted decisions about funeral arrangements and even naming the baby. What is the nurse's role at this time? a.To take over as much as possible to relieve the pressure b.To encourage the grandparents to take over c.To ensure that the parents, themselves, approve the final decisions d.To leave them alone to work things out

ANS: C The nurse is always the client's advocate. Nurses can offer support and guidance and yet leave room for the same from grandparents. In the end, however, nurses should let the parents make the final decisions. For the nurse to be able to present options regarding burial and autopsy, among other issues, in a sensitive and respectful manner is essential. The nurse should assist the parents in any way possible; however, taking over all arrangements is not the nurse's role. Grandparents are often called on to help make the difficult decisions regarding funeral arrangements or the disposition of the body because they have more life experiences with taking care of these painful, yet required arrangements. Some well-meaning relatives may try to take over all decision-making responsibilities. The nurse must remember that the parents, themselves, should approve all of the final decisions. During this time of acute distress, the nurse should be present to provide quiet support, answer questions, obtain information, and act as a client advocate.

2. When a woman is diagnosed with postpartum depression (PPD) with psychotic features, what is the nurse's primary concern in planning the client's care? a. Displaying outbursts of anger b. Neglecting her hygiene c. Harming her infant d. Losing interest in her husband

ANS: C Thoughts of harm to herself or to the infant are among the most serious symptoms of PPD and require immediate assessment and intervention. Although outbursts of anger and neglecting personal hygiene are symptoms attributable to PPD, the major concern remains the potential of harm to herself or her infant. Although this client is likely to lose interest in her spouse, it is not the nurse's primary concern. DIF: Cognitive Level: Understand REF: p. 748 TOP: Nursing Process: Planning MSC: Client Needs: Psychosocial Integrity

A family is visiting two surviving triplets. The third triplet died 2 days ago. What action indicates that the family has begun to grieve for the dead infant? a.Refers to the two live infants as twins b.Asks about the dead triplet's current status c.Brings in play clothes for all three infants d.Refers to the dead infant in the past tense

ANS: D Accepting that the infant is dead (in the past tense of the word) demonstrates an acceptance of the reality and that the family has begun to grieve. Parents of multiples are challenged with the task of parenting and grieving at the same time. Referring to the two live infants as twins does not acknowledge an acceptance of the existence of their third child. Bringing in play clothes for all three infants indicates that the parents are still in denial regarding the death of the third triplet. The death of the third infant has imposed a confusing and ambivalent induction into parenthood for this couple. If the two live infants are referred to as twins and/or if play clothes for all three infants are still considered, then the family is clearly still in denial regarding the death of one of the triplets.

Which statement is the most appropriate for the nurse to make when caring for bereaved parents? a."This happened for the best." b."You have an angel in heaven." c."I know how you feel." d."What can I do for you?"

ANS: D Acknowledging the loss and being open to listening is the best action that the nurse can do. No bereaved parent would find the statement "This has happened for the best" to be comforting in any way, and it may sound judgmental. Nurses must resist the impulse to speak about the afterlife to people in pain. They should also resist the temptation to give advice or to use clichés. Unless the nurse has lost a child, he or she does not understand how the parents feel.

Which condition might premature infants who exhibit 5 to 10 seconds of respiratory pauses, followed by 10 to 15 seconds of compensatory rapid respiration, be experiencing? a.Suffering from sleep or wakeful apnea b. Experiencing severe swings in blood pressure c.Trying to maintain a neutral thermal environment d.Breathing in a respiratory pattern common to premature infants

ANS: D Breathing in a respiratory pattern is called periodic breathing and is common to premature infants. This pattern may still require nursing intervention of oxygen and/or ventilation. Apnea is the cessation of respirations for 20 seconds or longer and should not be confused with periodic breathing.

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

ANS: D Cervical changes such as shortened endocervical length, effacement, and dilation are predictors of imminent preterm labor. Changes in the cervix accompanied by regular contractions indicate labor at any gestation. Estriol is a form of estrogen produced by the fetus that is present in plasma at 9 weeks of gestation. Levels of salivary estriol have been shown to increase before preterm birth. Irregular, mild contractions that do not cause cervical change are not considered a threat. The presence of fetal fibronectin in vaginal secretions between 24 and 36 weeks of gestation could predict preterm labor, but it has only a 20% to 40% positive predictive value. Of more importance are other physiologic clues of preterm labor such as cervical changes. DIF: Cognitive Level: Apply REF: p. 759 TOP: Nursing Process: Assessment | Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance

5. As a powerful central nervous system (CNS) stimulant, which of these substances can lead to miscarriage, preterm labor, placental separation (abruption), and stillbirth? a. Heroin b. Alcohol c. Phencyclidine (1-phenylcyclohexylpiperidine; PCP) d. Cocaine

ANS: D Cocaine is a powerful CNS stimulant. Effects on pregnancy associated with cocaine use include abruptio placentae, preterm labor, precipitous birth, and stillbirth. Heroin is an opiate; its use in pregnancy is associated with preeclampsia, intrauterine growth restriction, miscarriage, premature rupture of membranes, infections, breech presentation, and preterm labor. The most serious effect of alcohol use in pregnancy is FAS. The major concern regarding PCP use in pregnant women is its association with polydrug abuse and its neurobehavioral effects on the neonate. DIF: Cognitive Level: Understand REF: pp. 752-753 TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

Which clinical findings would alert the nurse that the neonate is expressing pain? a.Low-pitched crying; tachycardia; eyelids open wide b.Cry face; flaccid limbs; closed mouth c.High-pitched, shrill cry; withdrawal; change in heart rate d.Cry face; eyes squeezed; increase in blood pressure

ANS: D Crying and an increased heart rate are manifestations indicative of pain in the neonate. Typically, infants tightly close their eyes when in pain, not open them wide. In addition, infants may display a rigid posture with the mouth open and may also withdraw limbs and become tachycardic with pain. A high-pitched, shrill cry is associated with genetic or neurologic anomalies.

When providing an infant with a gavage feeding, which infant assessment should be documented each time? a.Abdominal circumference after the feeding b.Heart rate and respirations before feeding c.Suck and swallow coordination d.Response to the feeding

ANS: D Documentation of a gavage feeding should include the size of the feeding tube, the amount and quality of the residual from the previous feeding, the type and quantity of the fluid instilled, and the infant's response to the procedure. Abdominal circumference is not measured after a gavage feeding. Although vital signs may be obtained before feeding, the infant's response to the feeding is more important. Similarly, some older infants may be learning to suck; the most important factor to document would still be the infant's response to the feeding, including the attempts to suck.

11. The nurse is performing an assessment on a client who thinks she may be experiencing preterm labor. Which information is the most important for the nurse to understand and share with the client? a. Because all women must be considered at risk for preterm labor and prediction is so variable, teaching pregnant women the symptoms of preterm labor probably causes more harm through false alarms. b. Braxton Hicks contractions often signal the onset of preterm labor. c. Because preterm labor is likely to be the start of an extended labor, a woman with symptoms can wait several hours before contacting the primary caregiver. d. Diagnosis of preterm labor is based on gestational age, uterine activity, and progressive cervical change.

ANS: D Gestational age of 20 to 37 weeks, uterine contractions, and a cervix that is 80% effaced or dilated 2 cm indicates preterm labor. It is essential that nurses teach women how to detect the early symptoms of preterm labor. Braxton Hicks contractions resemble preterm labor contractions, but they are not true labor. Waiting too long to see a health care provider could result in essential medications failing to be administered. Preterm labor is not necessarily long-term labor. DIF: Cognitive Level: Understand REF: p. 759 TOP: Nursing Process: Planning MSC: Client Needs: Safe and Effective Care Environment

13. Which statement related to the induction of labor is most accurate? a. Can be achieved by external and internal version techniques b. Is also known as a trial of labor (TOL) c. Is almost always performed for medical reasons d. Is rated for viability by a Bishop score

ANS: D Induction of labor is likely to be more successful with a Bishop score of 9 or higher for first-time mothers or 5 or higher for veterans. Version is the turning of the fetus to a better position by a physician for an easier or safer birth. A TOL is the observance of a woman and her fetus for several hours of active labor to assess the safety of vaginal birth. Two thirds of cases of induced labor are elective and not done for medical reasons. DIF: Cognitive Level: Understand REF: p. 780 TOP: Nursing Process: Diagnosis MSC: Client Needs: Safe and Effective Care Environment

22. When would an internal version be indicated to manipulate the fetus into a vertex position? a. Fetus from a breech to a cephalic presentation before labor begins b. Fetus from a transverse lie to a longitudinal lie before a cesarean birth c. Second twin from an oblique lie to a transverse lie before labor begins d. Second twin from a transverse lie to a breech presentation during a vaginal birth

ANS: D Internal version is used only during a vaginal birth to manipulate the second twin into a presentation that allows it to be vaginally born. For internal version to occur, the cervix needs to be completely dilated. DIF: Cognitive Level: Remember REF: p. 779 TOP: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

On day 3 of life, a newborn continues to require 100% oxygen by nasal cannula. The parents ask if they may hold their infant during his next gavage feeding. Considering that this newborn is physiologically stable, what response should the nurse provide? a."Parents are not allowed to hold their infants who are dependent on oxygen." b."You may only hold your baby's hand during the feeding." c."Feedings cause more physiologic stress; therefore, the baby must be closely monitored. I don't think you should hold the baby." d."You may hold your baby during the feeding."

ANS: D Physical contact with the infant is important to establish early bonding. The nurse as the support person and teacher is responsible for shaping the environment and making the caregiving responsive to the needs of both the parents and the infant. Allowing the parents to hold their baby is the most appropriate response by the nurse. Parental interaction by holding should be encouraged during gavage feedings; nasal cannula oxygen therapy allows for easy feedings and psychosocial interactions. The parent can swaddle the infant or provide kangaroo care while gavage feeding their infant. Both swaddling and kangaroo care during feedings provide positive interactions for the infant and help the infant associate feedings with positive interactions.

19. Which assessment is least likely to be associated with a breech presentation? a. Meconium-stained amniotic fluid b. Fetal heart tones heard at or above the maternal umbilicus c. Preterm labor and birth d. Postterm gestation

ANS: D Postterm gestation is not likely to occur with a breech presentation. The presence of meconium in a breech presentation may be a result of pressure on the fetal wall as it traverses the birth canal. Fetal heart tones heard at the level of the umbilical level of the mother are a typical finding in a breech presentation because the fetal back would be located in the upper abdominal area. Breech presentations often occur in preterm births. DIF: Cognitive Level: Analyze REF: pp. 775-776 TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

10. As part of the discharge teaching, the nurse can prepare the mother for her upcoming adjustment to her new role by instructing her regarding self-care activities to help prevent PPD. Which statement regarding this condition ismost helpful for the client? a. Stay home, and avoid outside activities to ensure adequate rest. b. Be certain that you are the only caregiver for your baby to facilitate infant attachment. c. Keep your feelings of sadness and adjustment to your new role to yourself. d. Realize that PPD is a common occurrence that affects many women.

ANS: D Should the new mother experience symptoms of the baby blues, it is important that she be aware that these symptoms are nothing to be ashamed of. As many as 10% to 15% of new mothers experience similar symptoms. Although obtaining enough rest is important for the mother, she should not distance herself from her family and friends. Her spouse or partner can communicate the best visiting times to enable the new mother to obtain adequate rest. It is also important that she not isolate herself at home by herself during this time of role adjustment. Even if breastfeeding, other family members can participate in the infant's care. If depression occurs, then the symptoms will often interfere with mothering functions; therefore, family support is essential. The new mother should share her feelings with someone else and avoid overcommitting herself or feel as though she has to besuperwoman. A telephone call to the hospital "warm line" may provide reassurance with lactation issues and other infant care questions. Should symptoms continue, a referral to a professional therapist may be necessary. DIF: Cognitive Level: Apply REF: p. 748 TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity

Parents are often asked if they would like to have an autopsy performed on their infant. Nurses who are assisting parents with this decision should be aware of which information? a.Autopsies are usually covered by insurance. b.Autopsies must be performed within a few hours after the infant's death. c.In the current litigious society, more autopsies are performed than in the past. d.Some religions prohibit autopsy.

ANS: D Some religions prohibit autopsies or limit the choice to the times when it may help prevent further loss. The cost of the autopsy must be considered; it is not covered by insurance and can be very expensive. There is no rush to perform an autopsy unless evidence of a contagious disease or maternal infection is present at the time of death. The rate of autopsies is declining, in part because of a fear by medical facilities that errors by the staff might be revealed, resulting in litigation.

A nurse caring for a family during a loss might notice that a family member is experiencing survivor guilt. Which family member is most likely to exhibit this guilt? a.Siblings b.Mother c.Father d.Grandparents

ANS: D Survivor guilt is sometimes felt by grandparents because they feel that the death is out of order; they are still alive, while their grandchild has died. They may express anger that they are alive and their grandchild is not. The siblings of the expired infant may also experience a profound loss. A young child will respond to the reactions of the parents and may act out. Older children have a more complete understanding of the loss. School-age children are likely to be frightened, whereas teenagers are at a loss on how to react. The mother of the infant is experiencing intense grief at this time. She may be dealing with questions such as, "Why me?" or "Why my baby?" and is unlikely to be experiencing survival guilt. Realizing that fathers can be experiencing deep pain beneath their calm and quiet appearance and may need help acknowledging these feelings is important. This need, however, is not the same as survivor guilt.

9. The obstetric provider has informed the nurse that she will be performing an amniotomy on the client to induce labor. What is the nurse's highest priority intervention after the amniotomy is performed? a. Applying clean linens under the woman b. Taking the client's vital signs c. Performing a vaginal examination d. Assessing the fetal heart rate (FHR)

ANS: D The FHR is assessed before and immediately after the amniotomy to detect any changes that might indicate cord compression or prolapse. Providing comfort measures, such as clean linens, for the client is important but not the priority immediately after an amniotomy. The woman's temperature should be checked every 2 hours after the rupture of membranes but not the priority immediately after an amniotomy. The woman would have had a vaginal examination during the procedure. Unless cord prolapse is suspected, another vaginal examination is not warranted. Additionally, FHR assessment provides clinical cues to a prolapsed cord. DIF: Cognitive Level: Analyze REF: p. 783 TOP: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

13. What is the most dangerous effect on the fetus of a mother who smokes cigarettes while pregnant? a. Genetic changes and anomalies b. Extensive CNS damage c. Fetal addiction to the substance inhaled d. Intrauterine growth restriction

ANS: D The major consequences of smoking tobacco during pregnancy are low-birth-weight infants, prematurity, and increased perinatal loss. Cigarettes will not normally cause genetic changes or extensive CNS damage. Addiction to tobacco is not a usual concern related to the neonate. DIF: Cognitive Level: Understand REF: p. 752 TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

Because of the premature infant's decreased immune functioning, what nursing diagnosis should the nurse include in a plan of care for a premature infant? a.Delayed growth and development b.Ineffective thermoregulation c.Ineffective infant feeding pattern d.Risk for infection

ANS: D The nurse needs to understand that decreased immune functioning increases the risk for infection. Growth and development, thermoregulation, and feeding may be affected, although only indirectly.

After giving birth to a stillborn infant, the woman turns to the nurse and says, "I just finished painting the baby's room. Do you think that caused my baby to die?" What is the nurse's most appropriate response? a."That's an old wives' tale; lots of women are around paint during pregnancy, and this doesn't happen to them." b."That's not likely. Paint is associated with elevated pediatric lead levels." c.Silence. d."I can understand your need to find an answer to what caused this. What else are you thinking about?"

ANS: D The statement "I can understand your need to find an answer to what caused this. What else are you thinking about?" is very appropriate for the nurse. It demonstrates caring and compassion and allows the mother to vent her thoughts and feelings, which is therapeutic in the process of grieving. The nurse should resist the temptation to give advice or to use clichés in offering support to the bereaved. In addition, trying to give bereaved parents answers when no clear answers exist or trying to squelch their guilt feeling does not help the process of grieving. Silence would probably increase the mother's feelings of guilt. One of the most important goals of the nurse is to validate the experience and feelings of the parents by encouraging them to tell their stories and then listening with care. The nurse should encourage the mother to express her thoughts.

A client with maternal phenylketonuria (PKU) has come to the obstetrical clinic to begin prenatal care. Why would this preexisting condition result in the need for closer monitoring during pregnancy? a. PKU is a recognized cause of preterm labor. b. The fetus may develop neurologic problems. c. A pregnant woman is more likely to die without strict dietary control. d. Women with PKU are usually mentally handicapped and should not reproduce.

B Children born to women with untreated PKU are more likely to be born with mental retardation, microcephaly, congenital heart disease, and low birth weight. Maternal PKU has no effect on labor. Women without dietary control of PKU are more likely to miscarry or bear a child with congenital anomalies. Screening for undiagnosed maternal PKU at the first prenatal visit may be warranted, especially in individuals with a family history of the disorder, with low intelligence of an uncertain cause, or who have given birth to microcephalic infants.

The nurse who is caring for a woman hospitalized for hyperemesis gravidarum would expect the initial treatment to involve what? a. Corticosteroids to reduce inflammation b. Intravenous (IV) therapy to correct fluid and electrolyte imbalances c. Antiemetic medication, such as pyridoxine, to control nausea and vomiting d. Enteral nutrition to correct nutritional deficits

B Initially, the woman who is unable to down clear liquids by mouth requires IV therapy to correct fluid and electrolyte imbalances. Corticosteroids have been successfully used to treat refractory hyperemesis gravidarum, but they are not the expected initial treatment for this disorder. Pyridoxine is vitamin B6, not an antiemetic medication. Promethazine, a common antiemetic, may be prescribed. In severe cases of hyperemesis gravidarum, enteral nutrition via a feeding tube may be necessary to correct maternal nutritional deprivation but is not the initial treatment for this client.

Preconception counseling is critical in the safe management of diabetic pregnancies. Which complication is commonly associated with poor glycemic control before and during early pregnancy? a. Frequent episodes of maternal hypoglycemia b. Congenital anomalies in the fetus c. Hydramnios d. Hyperemesis gravidarum

B Preconception counseling is particularly important since strict metabolic control before conception and in the early weeks of gestation is instrumental in decreasing the risk of congenital anomalies. Frequent episodes of maternal hypoglycemia may occur during the first trimester (not before conception) as a result of hormonal changes and the effects on insulin production and use. Hydramnios occurs approximately 10 times more often in diabetic pregnancies than in nondiabetic pregnancies. Typically, it is observed in the third trimester of pregnancy. Hyperemesis gravidarum may exacerbate hypoglycemic events because the decreased food intake by the mother and glucose transfer to the fetus contribute to hypoglycemia.

A 26-year-old primigravida has come to the clinic for her regular prenatal visit at 12 weeks. She appears thin and somewhat nervous. She reports that she eats a well-balanced diet, although her weight is 5 pounds less than it was at her last visit. The results of laboratory studies confirm that she has a hyperthyroid condition. Based on the available data, the nurse formulates a plan of care. Which nursing diagnosis is most appropriate for the client at this time? a. Deficient fluid volume b. Imbalanced nutrition: less than body requirements c. Imbalanced nutrition: more than body requirements d. Disturbed sleep pattern

B This clients clinical cues include weight loss, which supports a nursing diagnosis of Imbalanced nutrition: less than body requirements. No clinical signs or symptoms support a nursing diagnosis of deficient fluid volume. This client reports weight loss, not weight gain. Although the client reports nervousness, the most appropriate nursing diagnosis, based on the clients other clinical symptoms, is Imbalanced nutrition: less than body requirements.

In terms of the incidence and classification of diabetes, which information should the nurse keep in mind when evaluating clients during their ongoing prenatal appointments? a. Type 1 diabetes is most common. b. Type 2 diabetes often goes undiagnosed. c. GDM means that the woman will receive insulin treatment until 6 weeks after birth. d. Type 1 diabetes may become type 2 during pregnancy.

B Type 2 diabetes often goes undiagnosed because hyperglycemia gradually develops and is often not severe. Type 2, sometimes called adult-onset diabetes, is the most common type of diabetes. GDM refers to any degree of glucose intolerance first recognized during pregnancy; insulin may or may not be needed. People do not go back and forth between type 1 and type 2 diabetes.

With regard to skeletal injuries sustained by a neonate during labor or birth, nurses should be aware that: A. A newborn's skull is still forming and fractures fairly easily. B. Unless a blood vessel is involved, linear skull fractures heal without special treatment. C. Clavicle fractures often need to be set with an inserted pin for stability. D. Other than the skull, the most common skeletal injuries are to leg bones.

B A. Incorrect: Because the newborn skull is flexible, considerable force is required to fracture it. B. Correct: About 70% of neonatal skull fractures are linear. C. Incorrect: Clavicle fractures need no special treatment. D. Incorrect: The clavicle is the bone most often fractured during birth. p. 993

With regard to the classification of neonatal bacterial infection, nurses should be aware that: A. Congenital infection progresses slower than nosocomial infection. B. Nosocomial infection can be prevented by effective handwashing; early onset cannot. C. Infections occur with about the same frequency in boy and girl infants, although female mortality is higher. D. The clinical sign of a rapid, high fever makes infection easier to diagnose.

B A. Incorrect: Congenital (early onset) infections progress more rapidly than nosocomial (late onset) infections. B. Correct: Handwashing is an effective preventative measure for late onset (nosocomial) infections, because these infections come from the environment around the infant. Early onset, or congenital, infections are caused by the normal flora at the maternal vaginal tract. Congenital (early onset) infections progress more rapidly than nosocomial (late onset) infections. C. Incorrect: Infection occurs about twice as often in boys and results in higher mortality. Congenital (early onset) infections progress more rapidly than nosocomial (late onset) infections. D. Incorrect: Clinical signs of neonatal infection are nonspecific and similar to noninfectious problems, making diagnosis difficult. Congenital (early onset) infections progress more rapidly than nosocomial (late onset) infections. p. 1002

When planning care for an infant with a fractured clavicle, the nurse should recognize that in addition to gentle handling: A. Prone positioning will facilitate bone alignment. B. No special treatment is necessary. C. Parents should be taught range of motion exercises. D. The shoulder should be immobilized with a splint.

B A. Incorrect: Fractures in newborns generally heal rapidly. Except for gentle handling, no accepted treatment for a fractured clavicle exists. B. Correct: Fractures in newborns generally heal rapidly. Except for gentle handling, no accepted treatment for a fractured clavicle exists. C. Incorrect: Movement should be limited, and the infant should be gently handled. It is not necessary to perform range of motion exercises on the infant. D. Incorrect: A fractured clavicle does not require immobilization with a splint. p. 994

With regard to the understanding and treatment of infants born to mothers who are substance abusers, nurses should be aware that: A. Infants born to addicted mothers are also addicted. B. Mothers who abuse one substance likely will use or abuse another, compounding the infant's difficulties. C. The NICU Network Neurobehavioral Scale (NNNS) is designed to assess the damage the mother has done to herself. D. No laboratory procedures are available that can identify the intrauterine drug exposure of the infant.

B A. Incorrect: Infants of substance-abusing mothers may have some of the physiologic signs but are not addicted in the behavioral sense. "Drug-exposed newborn" is a more accurate description than "addict." B. Correct: Multiple substance use (even just alcohol and tobacco) makes it difficult to assess the problems of the exposed infant, particularly with regard to withdrawal manifestations. C. Incorrect: The NNNS is designed to assess the neurologic, behavioral, and stress/abstinence function of the neonate. D. Incorrect: Newborn urine, hair, or meconium sampling may be used to identify an infant's intrauterine drug exposure. p. 1017

A number of metabolic changes occur throughout pregnancy. Which physiologic adaptation of pregnancy will influence the nurses plan of care? a. Insulin crosses the placenta to the fetus only in the first trimester, after which the fetus secretes its own. b. Women with insulin-dependent diabetes are prone to hyperglycemia during the first trimester because they are consuming more sugar. c. During the second and third trimesters, pregnancy exerts a diabetogenic effect that ensures an abundant supply of glucose for the fetus. d. Maternal insulin requirements steadily decline during pregnancy.

C Pregnant women develop increased insulin resistance during the second and third trimesters. Insulin never crosses the placenta; the fetus starts making its own around the 10th week. As a result of normal metabolic changes during pregnancy, insulin-dependent women are prone to hypoglycemia (low levels). Maternal insulin requirements may double or quadruple by the end of pregnancy.

A primigravida has just delivered a healthy infant girl. The nurse is about to administer erythromycin ointment in the infant's eyes when the mother asks, "What is that medicine for?" The nurse responds: A. "It is an eye ointment to help your baby see you better." B. "It is to protect your baby from contracting herpes from your vaginal tract." C. "Erythromycin is given prophylactically to prevent a gonorrheal infection." D. "This medicine will protect your baby's eyes from drying out over the next few days."

C A. Incorrect: Erythromycin has no bearing on enhancing vision. B. Incorrect: Erythromycin is used to prevent an infection caused by gonorrhea, not herpes. C. Correct: With the prophylactic use of erythromycin, the incidence of gonococcal conjunctivitis has declined to less than 0.5%. Eye prophylaxis is administered at or shortly after birth to prevent ophthalmia neonatorum. D. Incorrect: Erythromycin is given to prevent infection, not for lubrication. p. 1004

With regard to central nervous system injuries to the infant during labor and birth, nurses should be aware that: A. Intracranial hemorrhage (ICH) as a result of birth trauma is more likely to occur in the preterm, low-birth-weight infant. B. Subarachnoid hemorrhage (the most common form of ICH) occurs in term infants as a result of hypoxia. C. In many infants, signs of hemorrhage in a full-term infant are absent and diagnosed only through laboratory tests. D. Spinal cord injuries almost always result from forceps-assisted deliveries.

C A. Incorrect: ICH as a result of birth trauma is more likely to occur in the full-term, large infant. B. Incorrect: Subarachnoid hemorrhage in term infants is a result of trauma; in preterm infants, it is a result of hypoxia. C. Correct: Abnormalities in lumbar punctures or red blood cell counts, for instance, or in visuals on CT scan might reveal a hemorrhage. D. Incorrect: Spinal cord injuries are almost always from breech births; they are rare today because cesarean birth often is used for breech presentation. p. 995

Infants of mothers with diabetes are at higher risk for developing: A. Anemia B. Hyponatremia C. Respiratory distress syndrome D. Sepsis

C A. Incorrect: Infants of diabetic mothers (IDMs) are not at risk for anemia. They are at risk for polycythemia. B. Incorrect: IDMs are not at risk for hyponatremia. They are at risk for hypocalcemia and hypomagnesemia. C. Correct: IDMs are at risk for macrosomia, birth trauma, perinatal asphyxia, respiratory distress syndrome, hypoglycemia, hypocalcemia, hypomagnesemia, cardiomyopathy, hyperbilirubinemia, and polycythemia. D. Incorrect: IDMs are not at risk for sepsis. p. 996

Providing care for the neonate born to a mother who abuses substances can present a challenge for the health care team. Nursing care for this infant requires a multisystem approach. The first step in the provision of this care is: A. Pharmacologic treatment B. Reduction of environmental stimuli C. Neonatal abstinence syndrome scoring D. Adequate nutrition and maintenance of fluid and electrolyte balance

C A. Incorrect: Pharmacologic treatment is based on the severity of withdrawal symptoms. Symptoms are determined by using a standard assessment tool. Medications of choice are morphine, phenobarbital, diazepam, or diluted tincture of opium. B. Incorrect: Swaddling, holding, and reducing environmental stimuli are essential in providing care to the infant who is experiencing withdrawal. These nursing interventions are appropriate for the infant who displays central nervous system disturbances. C. Correct: Neonatal abstinence syndrome (NAS) is the term used to describe the cohort of symptoms associated with drug withdrawal in the neonate. The Neonatal Abstinence Scoring System evaluates CNS, metabolic, vasomotor, respiratory, and gastrointestinal disturbances. This evaluation tool enables the care team to develop an appropriate plan of care. The infant is scored throughout the length of stay and the treatment plan is adjusted accordingly. D. Incorrect: Poor feeding is one of the GI symptoms common to this client population. Fluid and electrolyte balance must be maintained and adequate nutrition provided. These infants often have a poor suck reflex and may need to be fed via gavage. pp. 1017-1019

A plan of care for an infant experiencing symptoms of drug withdrawal should include: A. Administering chloral hydrate for sedation B. Feeding every 4 to 6 hours to allow extra rest C. Swaddling the infant snugly and holding the baby tightly D. Playing soft music during feeding

C A. Incorrect: Phenobarbital or diazepam may be administered to decrease CNS irritability. B. Incorrect: The infant should be fed in small, frequent amounts and burped well to diminish aspiration and maintain hydration. C. Correct: The infant should be wrapped snugly to reduce self-stimulation behaviors and protect the skin from abrasions. D. Incorrect: The infant should not be stimulated (such as with music), because this will increase activity and potentially increase CNS irritability. p. 1017

In caring for the mother who has abused (or is abusing) alcohol and for her infant, nurses should be aware that: A. The pattern of growth restriction of the fetus begun in prenatal life is halted after birth, and normal growth takes over. B. Two-thirds of newborns with fetal alcohol syndrome (FAS) are boys. C. Alcohol-related neurodevelopmental disorders (ARND) not sufficient to meet FAS criteria (learning disabilities, speech and language problems) are often not detected until the child goes to school. D. Both the distinctive facial features of the FAS infant and the diminished mental capacities tend toward normal over time.

C A. Incorrect: The pattern of growth restriction persists after birth. B. Incorrect: Two-thirds of newborns with FAS are girls. C. Correct: Some learning problems do not become evident until the child is at school. D. Incorrect: Although the distinctive facial features of the FAS infant tend to become less evident, the mental capacities never become normal. p. 1013

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

D A. Incorrect: Macrosomic infants are at high risk for hypoglycemia after birth and need to be observed closely. This can be achieved in the mother's room with nursing interventions, depending on the condition of the fetus. It may be more appropriate for observation to occur in the nursery. B. Incorrect: Macrosomic infants are at high risk for hypoglycemia after birth and need to be observed closely. Observation may occur in the nursery or in the mother's room, depending on the condition of the fetus. C. Incorrect: Regardless of gestational age, this infant is macrosomic. Macrosomia is defined as fetal weight over 4000 g. Hypoglycemia affects many macrosomic infants. Blood glucose levels should be observed closely. D. Correct: This infant is macrosomic (over 4000 g) and is at high risk for hypoglycemia. Blood glucose levels should be monitored frequently, and the infant should be observed closely for signs of hypoglycemia. p. 997

A pregnant woman at 37 weeks of gestation has had ruptured membranes for 26 hours. A cesarean section is performed for failure to progress. The fetal heart rate before birth is 180 beats/min with limited variability. At birth, the newborn has Apgar scores of 6 and 7 at 1 and 5 minutes and is noted to be pale and tachypneic. Based on the maternal history, the cause of this newborn's distress is most likely to be: A. Hypoglycemia B. Phrenic nerve injury C. Respiratory distress syndrome D. Sepsis

D A. Incorrect: The prolonged rupture of membranes is the most indicative clinical cue to this infant's condition. An FHR of 180 beats/min is also indicative. This infant is at high risk for sepsis. B. Incorrect: The prolonged rupture of membranes is the most indicative clinical cue to this infant's condition. An FHR of 180 beats/min is also indicative. This infant is at high risk for sepsis. C. Incorrect: The prolonged rupture of membranes is the most indicative clinical cue to this infant's condition. An FHR of 180 beats/min is also indicative. This infant is at high risk for sepsis. D. Correct: The prolonged rupture of membranes and the tachypnea (before and after birth) both suggest sepsis. p. 1001

HIV may be perinatally transmitted: A. Only in the third trimester from the maternal circulation B. By a needlestick injury at birth from unsterile instruments C. Only through the ingestion of amniotic fluid D. Through the ingestion of breast milk from an infected mother

D A. Incorrect: Transmission of HIV from the mother to the infant may occur transplacentally at various gestational ages. Transmission close to or at the time of birth is thought to account for 50% to 80% of cases. B. Incorrect: Transmission of HIV may occur through the placenta from the mother to the fetus or through breast milk postnatally. C. Incorrect: Transmission of HIV may occur through the placenta from the mother to the fetus or through breast milk postnatally. D. Correct: Postnatal transmission of HIV through breastfeeding may occur. p. 1006

The nurse should be aware that a pessary would be most effective in the treatment of what disorder? a. Cystocele b. Uterine prolapse c. Rectocele d. Stress urinary incontinence

b. Uterine prolapse A fitted pessary may be inserted into the vagina to support the uterus and hold it in the correct position. A pessary is not used for a cystocele, a rectocele, or stress urinary incontinence.

Complicated bereavement: a. Occurs when, in multiple births, one child dies, and the other or others live. b. Is a state in which the parents are ambivalent, as with an abortion. c. Is an extremely intense grief reaction that persists for a long time. d. Is felt by the family of adolescent mothers who lose their babies.

c. Is an extremely intense grief reaction that persists for a long time.

During the initial acute distress phase of grieving, parents still must make unexpected and unwanted decisions about funeral arrangements and even naming the baby. The nurse's role should be to: a. Take over as much as possible to relieve the pressure. b. Encourage grandparents to take over. c. Make sure the parents themselves approve the final decisions. d. Let them alone to work things out.

c. Make sure the parents themselves approve the final decisions. The nurse is always the client's advocate. Nurses can offer support and guidance and leave room for the same from grandparents. However, in the end nurses should strive to let the parents make the final decisions.

What infection is contracted mostly by first-time mothers who are breastfeeding? a. Endometritis b. Wound infections c. Mastitis d. Urinary tract infections

c. Mastitis Mastitis is infection in a breast, usually confined to a milk duct. Most women who suffer this are first-timers who are breastfeeding.

The first and most important nursing intervention when a nurse observes profuse postpartum bleeding is to: a. Call the woman's primary health care provider. b. Administer the standing order for an oxytocic. c. Palpate the uterus and massage it if it is boggy. d. Assess maternal blood pressure and pulse for signs of hypovolemic shock.

c. Palpate the uterus and massage it if it is boggy. The initial management of excessive postpartum bleeding is firm massage of the uterine fundus. Though calling the health care provider, administering an oxytocic, and assessing maternal BP are appropriate interventions, the primary intervention should be to assess the uterus. Uterine atony is the leading cause of postpartum hemorrhage (PPH).

A woman who has recently given birth complains of pain and tenderness in her leg. On physical examination the nurse notices warmth and redness over an enlarged, hardened area. The nurse should suspect __________ and should confirm the diagnosis by ___________. a. Disseminated intravascular coagulation; asking for laboratory tests b. von Willebrand disease; noting whether bleeding times have been extended c. Thrombophlebitis; using real-time and color Doppler ultrasound d. Coagulopathies; drawing blood for laboratory analysis

c. Thrombophlebitis; using real-time and color Doppler ultrasound Pain and tenderness in the extremities, which show warmth, redness, and hardness, likely indicate thrombophlebitis. A Doppler ultrasound is a common noninvasive way to confirm diagnosis.

To provide adequate postpartum care, the nurse should be aware that postpartum depression (PPD) with psychotic features: a. Is more likely to occur in women with more than two children. b. Is rarely delusional and then is usually about someone trying to harm her (the mother). c. Although serious, is not likely to need psychiatric hospitalization. d. May include bipolar disorder (formerly called "manic depression").

d. May include bipolar disorder (formerly called "manic depression"). Manic mood swings are possible. PPD is more likely to occur in first-time mothers. Delusions may be present in 50% of women with PPD, usually about something being wrong with the infant. PPD with psychosis is a psychiatric emergency that requires hospitalization.

Nurses need to know the basic definitions and incidence data about postpartum hemorrhage (PPH). For instance: a. PPH is easy to recognize early; after all, the woman is bleeding. b. Traditionally it takes more than 1000 mL of blood after vaginal birth and 2500 mL after cesarean birth to define the condition as PPH. c. If anything, nurses and doctors tend to overestimate the amount of blood loss. d. Traditionally PPH has been classified as early or late with respect to birth.

d. Traditionally PPH has been classified as early or late with respect to birth. Early PPH is also known as primary, or acute, PPH; late PPH is known as secondary PPH. Unfortunately PPH can occur with little warning and often is recognized only after the mother has profound symptoms. Traditionally a 500-ml blood loss after a vaginal birth and a 1000-ml blood loss after a cesarean birth constitute PPH. Medical personnel tend to underestimate blood loss by as much as 50% in their subjective observations.