Quiz 3

If the patient's white blood cell (WBC) count is 25,000/mm3 on her second postpartum day, which action should the nurse take? Select one: a.Document the finding. b.Inform the health care provider. c.Begin antibiotic therapy immediately. d.Have the laboratory draw blood for reanalysis.

a.Document the finding. An increase in WBC count to 25,000/mm3 during the postpartum period is considered normal and not a sign of infection. The nurse should document the finding. There is no reason to alert the health care provider. Antibiotics are not needed because the elevated WBCs are caused by the stress of labor and not an infectious process. There is no need for reassessment as it is expected for the WBCs to be elevated.

A preterm infant is on a ventilator, with intravenous lines and other medical equipment. When the parents come to visit for the first time, what is the most important action by the nurse? Select one: a.Encourage the parents to touch their infant. b.Reassure the parents that the infant is progressing well. c.Discuss the care they will give their infant when the infant goes home. d.Suggest that the parents visit for only a short time to reduce their anxiety.

a.Encourage the parents to touch their infant. Touching the infant will increase the development of attachment. As the infant's condition improves the parents should be encouraged to provide Kangaroo care. It is important to keep the parents informed regarding the infant's progress; however, the nurse needs to be honest with the explanations. Discussing home care is an important part of parent teaching, although is not the most important priority during the first visit. Parents should be encouraged to visit for as long as they are comfortable.

Which patient would be most likely to have severe afterbirth pains and request a narcotic analgesic? Select one: a.Gravida 5, para 5 b.Primipara who delivered a 7-lb boy c.Patient who is bottle feeding her first child d.Patient who is breastfeeding her second child

a.Gravida 5, para 5 The discomfort of afterpains is more acute for multiparas because repeated stretching of muscle fibers leads to loss of uterine muscle tone. The uterus of a primipara tends to remain contracted. Afterpains are particularly severe during breastfeeding, not bottle feeding. The non-nursing mother may have engorgement problems that will cause her discomfort. The patient who is nursing her second child will have more afterpains than her first pregnancy; however, they will not be as severe as the grand multiparous patient.

The nurse must continually assess the infant who has meconium aspiration syndrome for the complication of Select one: a.persistent pulmonary hypertension. b.bronchopulmonary dysplasia. c.transitory tachypnea of the newborn. d.left-to-right shunting of blood through the foramen ovale.

a.persistent pulmonary hypertension. Persistent pulmonary hypertension has been associated with hypoxemia and acidosis as a result of the aspiration of meconium. Bronchopulmonary dysplasia is a complication of the use of positive-pressure oxygenation, which stretches the immature lung membranes. Transitory tachypnea of the newborn is the result of inadequate absorption of fetal lung fluid. Left-to-right shunting of blood through the foramen ovale is a congenital defect that can be caused by atrial septal defects, ventricular septal defects, patent ductus arteriosus, or atrioventricular canal defects.

Decreased surfactant production in the preterm lung is a problem because Select one: a.surfactant keeps the alveoli open during expiration. b.surfactant causes increased permeability of the alveoli. c.surfactant dilates the bronchioles, decreasing airway resistance. d.surfactant provides transportation for oxygen to enter the blood supply.

a.surfactant keeps the alveoli open during expiration. Surfactant prevents the alveoli from collapsing each time the infant exhales, thus reducing the work of breathing. It does not affect the bronchioles. By keeping the alveoli open, surfactant permits enhanced oxygen exchange. Infants treated with surfactant have higher survival rates.

Early postpartum hemorrhage is defined as a blood loss greater than Select one: a.500 mL within 24 hours after a vaginal birth. b.750 mL within 24 hours after a vaginal birth. c.1000 mL within 48 hours after a cesarean birth. d.1500 mL within 48 hours after a cesarean birth.

b.750 mL within 24 hours after a vaginal birth. The average amount of bleeding after a vaginal birth is 500 mL. Early postpartum hemorrhage occurs in the first 24 hours, not 48 hours. Blood loss after a cesarean birth averages 1000 mL. Late postpartum hemorrhage is 48 hours and later.

Which is the most useful factor in preventing premature birth? Select one: a.High socioeconomic status b.Adequate prenatal care c.Aid to Families with Dependent Children d.Women, Infants, and Children (WIC) nutritional program

b.Adequate prenatal care Prenatal care is vital for identifying possible problems. People with higher socioeconomic status are more likely to seek adequate prenatal care, which is the most helpful for prevention of premature births. Lower socioeconomic groups do not seek out health care, which puts them at risk for preterm labor. Aid to Families with Dependent Children and WIC assist in the nutritional status of the pregnant woman; however, the most helpful intervention for the prevention of premature births is adequate prenatal care.

Which pelvic shape is most conducive to vaginal labor and birth? Select one: a.Android b.Gynecoid c.Platypelloid d.Anthropoid

b.Gynecoid The gynecoid pelvis is round and cylinder-shaped, with a wide pubic arch and is considered the most suitable for a vaginal birth. An android pelvis has been described as heart shaped, with more prominent ischial spines and a narrow pubic arch. A vaginal birth will be more difficult, with the need for harder pushing and often some form of instrumentation. The anthropoid pelvis is a long narrow oval, with a narrow pubic arch. It is more favorable than the android or platypelloid pelvic shape. The platypelloid pelvis is flat, wide, short, and oval and has a very poor prognosis for vaginal birth. Most women have characteristics from two or more types of pelvic shapes.

Which action by the nurse prevents infection in the labor and birth area? Select one: a.Using clean techniques for all procedures b.Keeping underpads and linens as dry as possible c.Cleaning secretions from the vaginal area by using a back to front motion d.Performing vaginal examinations every hour while the patient is in active labor

b.Keeping underpads and linens as dry as possible Bacterial growth prefers a moist, warm environment. Use an aseptic technique if membranes are not ruptured; use a sterile technique if membranes are ruptured. Vaginal drainage should be removed with a front to back motion to decrease fecal contamination. Vaginal examinations should be limited to decrease transmission of vaginal organisms into the uterine cavity.

Which technique is least effective for the patient with persistent occiput posterior position? Select one: a.Squatting b.Lying supine and relaxing c.Sitting or kneeling, leaning forward with support d.Rocking the pelvis back and forth while on hands and knees

b.Lying supine and relaxing Lying supine increases the discomfort of back labor. Squatting aids rotation and fetal descent. A sitting or kneeling position may help the fetal head to rotate to occiput anterior. Rocking the pelvis encourages rotation from occiput posterior to occiput anterior.

A patient with polyhydramnios is admitted to a labor-birth-recovery-postpartum (LDRP) suite. Her membranes rupture and the fluid is clear and odorless; however, the fetal heart monitor indicates bradycardia and variable decelerations. Which action should be taken next? Select one: a.Perform Leopold maneuvers. b.Perform a vaginal examination. c.Apply warm saline soaks to the vagina. d.Place the patient in a high Fowler position.

b.Perform a vaginal examination. A prolapsed cord may not be visible but may be palpated on vaginal examination. The priority is to relieve pressure on the umbilical cord. Leopold maneuvers are not an appropriate action at this time. Moist towels retard cooling and drying of the prolapsed cord, but it is hoped the fetus will be delivered before this occurs. The high Fowler position will increase cord compression and decrease fetal oxygenation.

Four hours after the birth of a healthy neonate of an insulin-dependent (type 1) diabetic mother, the baby appears jittery and irritable and has a high-pitched cry. Which nursing action has top priority? Select one: a.Notify the clinician stat. b.Test for the blood glucose level. c.Start an intravenous line with D10W. d.Document the event in the nurses' notes.

b.Test for the blood glucose level. These symptoms are indications of hypoglycemia in the newborn. Permanent damage can occur if glucose is not constantly available to the brain. It is not common practice to administer intravenous glucose to a newborn unless their condition does not allow for enteral feedings. Feeding the infant is preferable as formula or breast milk will maintain glucose stability. Determine the blood glucose level according to agency policy, treat symptoms with standing orders protocol, and notify the physician with the results. Documentation can wait until the infant has been tested and treated if a problem is present.

Which fundal assessment finding at 12 hours after birth requires further assessment? Select one: a.The fundus is palpable at the level of the umbilicus. b.The fundus is palpable two fingerbreadths above the umbilicus. c.The fundus is palpable one fingerbreadth below the umbilicus. d.The fundus is palpable two fingerbreadths below the umbilicus.

b.The fundus is palpable two fingerbreadths above the umbilicus. The fundus rises to the umbilicus after birth and remains there for about 24 hours. A fundus that is above the umbilicus may indicate uterine atony or urinary retention. The fundus palpable at the umbilicus is an appropriate assessment finding for 12 hours postpartum. The fundus palpable one fingerbreadth below the umbilicus is an appropriate assessment finding for 12 hours postpartum. The fundus palpable two fingerbreadths below the umbilicus is an unusual finding for 12 hours postpartum; however, it is still appropriate.

The nurse understands that late postpartum hemorrhage may be prevented by Select one: a.manually removing the placenta. b.inspecting the placenta after birth. c.administering broad-spectrum antibiotics. d.pulling on the umbilical cord to hasten the birth of the placenta.

b.inspecting the placenta after birth. If a portion of the placenta is missing, the clinician can explore the uterus, locate the missing fragments, and remove the potential cause of late postpartum hemorrhage. Manual removal of the placenta increases the risk of postpartum hemorrhage. Broad-spectrum antibiotics will be given if postpartum infection is suspected. The placenta is usually delivered 5 to 30 minutes after birth of the baby without pulling on the cord. That can cause uterine inversion.

The nurse is responsible for monitoring the feedings of the infant with hyperbilirubinemia every 2 to 3 hours around the clock. If breastfeeding must be supplemented, formula should be used instead of water. The purpose of this plan is to Select one: a.prevent hyperglycemia. b.provide fluids and protein. c.decrease gastrointestinal motility. d.prevent rapid emptying of the bilirubin from the bowel.

b.provide fluids and protein. Proteins help maintain the albumin level in the blood, and the extra fluids help eliminate the excess bilirubin from the infant's system. Feedings every 2 hours will help prevent hypoglycemia. Increased gastrointestinal motility can facilitate the prompt emptying of the bilirubin from the bowel. Breast milk or formula is more effective in promoting stooling and removal of bilirubin.

Which newborn should the nurse recognize as being at the greatest risk for developing respiratory distress syndrome? Select one: a.A 35-week-gestation male baby born vaginally to a mother addicted to heroin. b.A 35-week-gestation female baby born vaginally 72 hours after the rupture of membranes. c.A 36-week-gestation male baby born by cesarean birth to a mother with insulin-dependent diabetes. d.A 35-week-gestation female baby born vaginally to a mother who has pregnancy-induced hypertension.

c.A 36-week-gestation male baby born by cesarean birth to a mother with insulin-dependent diabetes. Infants of mothers with diabetes have delayed production of surfactant, thus placing the infant at risk for respiratory distress syndrome. A 35-week-gestation male baby born vaginally to a mother addicted to heroin is at risk for withdrawal. A 35-week-gestation female baby born vaginally 72 hours after the rupture of membranes is at risk for infection because of the prolonged rupture of membranes. A 35-week-gestation female baby born vaginally to a mother who has pregnancy-induced hypertension is at risk for hypoxia.

A pregnant patient with premature rupture of membranes is at higher risk for postpartum infection. Which assessment data indicates a potential infection? Select one: a.Fetal heart rate, 150 beats/minute b.Maternal temperature, 37.2°C (99°F) c.Cloudy amniotic fluid, with strong odor d.Lowered maternal pulse and decreased respiratory rates

c.Cloudy amniotic fluid, with strong odor Amniotic fluid should be clear and have a mild odor, if any. Fetal tachycardia of greater than 160 beats/minute is often the first sign of intrauterine infection. A temperature of 38°C (100.4°F) or higher is a classic symptom of infection. Vital signs should be assessed hourly to identify tachycardia or tachypnea, which often accompany temperature elevation.

Which preterm infant should receive gavage feedings instead of bottle feedings? Select one: a.Sucks on a pacifier during gavage feedings b.Sometimes gags when a feeding tube is inserted c.Has a sustained respiratory rate of 70 breaths per minute d.Has an axillary temperature of 36.9°C (98.4°F), an apical pulse of 149 beats/minute, and respirations of 54 breaths per minute

c.Has a sustained respiratory rate of 70 breaths per minute Infants less than 34 weeks of gestation or those who weigh less than 1500 g generally have difficulty with bottle-feeding. Gavage feedings should be initiated if the respiratory rate is above 60 breaths per minute. Providing a pacifier during gavage feedings gives positive oral stimulation and helps the infant associate the comfortable feeling of fullness with sucking. The presence of the gag reflex is important before initiating bottle-feeding. Axillary temperature of 36.9°C (98.4°F), an apical pulse of 149 beats/minute, and respirations of 54 breaths per minute are within expected limits and an indication that the infant is not having respiratory problems at that time.

A multiparous patient is admitted to the postpartum unit after a rapid labor and birth of a 4000-g infant. Her fundus is boggy, lochia is heavy, and vital signs are unchanged. The nurse has the patient void and massages her fundus; however, the fundus remains difficult to find and the rubra lochia remains heavy. Which action should the nurse take next? Select one: a.Recheck vital signs. b.Insert a Foley catheter. c.Notify the health care provider. d.Continue to massage the fundus.

c.Notify the health care provider. Treatment of excessive bleeding requires the collaboration of the health care provider and the nurses. Do not leave the patient alone. The nurse should call the clinician while a second nurse rechecks the vital signs. The patient has voided successfully, therefore a Foley catheter is not needed at this time. The uterine muscle can be overstimulated by massage, leading to uterine atony and rebound hemorrhage.

Transitory tachypnea of the newborn (TTN) is thought to occur as a result of Select one: a.a lack of surfactant. b.hypoinflation of the lungs. c.inadequate absorption of fetal lung fluid. d.a delayed vaginal birth associated with meconium-stained fluid.

c.inadequate absorption of fetal lung fluid. Inadequate absorption of fetal lung fluid is thought to be the clinical reason for TTN. Lack of surfactant in the premature infant is likely to result in respiratory distress syndrome. A delayed vaginal birth will help prevent TTN. This condition usually resolves within 24 to 48 hours. TTN is the most common respiratory cause of admissions to the NICU.

Which statement by a postpartum patient indicates that further teaching regarding thrombus formation is unnecessary? Select one: a."I'll keep my legs elevated with pillows." b."I'll sit in my rocking chair most of the time." c."I'll stay in bed for the first 3 days after my baby is born." d."I'll put my support stockings on every morning before rising."

d."I'll put my support stockings on every morning before rising." Venous congestion begins as soon as the patient stands up. The stockings should be applied before she rises from the bed in the morning. The patient should avoid knee pillows because they increase pressure on the popliteal space. Sitting in a chair with legs in a dependent position causes pooling of blood in the lower extremities. As soon as possible, the patient should ambulate frequently.

Which maternal event is abnormal in the early postpartal period? Select one: a.Diuresis and diaphoresis b.Flatulence and constipation c.Extreme hunger and thirst d.Lochial color changes from rubra to alba

d.Lochial color changes from rubra to alba For the first 3 days after childbirth, lochia is termed rubra. Lochia serosa follows, and then at about 11 days, the discharge becomes clear, colorless, or white. The body rids itself of increased plasma volume. Urine output of 3000 mL/day is common for the first few days after birth and is facilitated by hormonal changes in the mother. Bowel tone remains sluggish for days. Many women anticipate pain during defecation and are unwilling to exert pressure on the perineum. The new mother is hungry because of energy used in labor and thirsty because of fluid restrictions during labor.

Postpartal overdistention of the bladder and urinary retention can lead to which complication? Select one: a.Fever and increased blood pressure b.Postpartum hemorrhage and eclampsia c.Urinary tract infection and uterine rupture d.Postpartum hemorrhage and urinary tract infection

d.Postpartum hemorrhage and urinary tract infection Incomplete emptying and overdistention of the bladder can lead to urinary tract infection. Overdistention of the bladder displaces the uterus and prevents contraction of the uterine muscle. There is no correlation between bladder distention and blood pressure or fever. There is no correlation between bladder distention and eclampsia. The risk of uterine rupture decreases after the birth.

In comparison with the term infant, the preterm infant has Select one: a.more subcutaneous fat. b.well-developed flexor muscles. c.few blood vessels visible through the skin. d.greater surface area in proportion to weight.

d.greater surface area in proportion to weight. Preterm infants have greater surface area in proportion to their weight. More subcutaneous fat, well-developed flexor muscles, and few blood vessels visible through the skin are features that are more characteristic of a term infant.

A steady trickle of bright red blood from the vagina in the presence of a firm fundus suggests Select one: a.uterine atony. b.perineal hematoma. c.infection of the uterus. d.lacerations of the genital tract.

d.lacerations of the genital tract. Undetected lacerations will bleed slowly and continuously. Bleeding from lacerations will not be affected by uterine contraction. The fundus would be boggy with a clinical finding of uterine atony. A hematoma would occur internally with swelling and discoloration. With an infection of the uterus, there would be an odor to the lochia and systemic symptoms such as fever and malaise.