QUIZ 5 MATERNITY
The nurse is monitoring a newborn who is large for gestational age for hypoglycemia. Which of these signs/symptoms should alert the nurse to the presence of hypoglycemia? Select all that apply. Tremors Alertness Strong cry Diaphoresis Hyperthermia
Tremors Diaphoresis RATIONALE: All stressed newborns are at risk for hypoglycemia. Signs/symptoms of hypoglycemia include poor feeding, hypothermia, and diaphoresis. Central nervous system signs/symptoms include tremors and jitteriness, weak cry, lethargy, seizures, and coma.
During the 30-week follow-up visit, the nurse assesses Janice and asks, "How are you feeling these days?" Which of these statements from Janice would indicate that further assessment is needed? Select all that apply. "I spend so much time going to the bathroom!" "I haven't been sleeping well for several days." "I've noticed that I get out of breath after I vacuum the floors." "Since yesterday I've noticed that the baby isn't moving as much." "I've noticed that my fingers and face have been swollen when I wake up in the morning."
"Since yesterday I've noticed that the baby isn't moving as much." "I've noticed that my fingers and face have been swollen when I wake up in the morning." RATIONALE: During the second and third trimesters of pregnancy, certain signs and symptoms may indicate complications. Any change in the pattern or frequency of fetal movements should be investigated immediately to detect or rule out fetal jeopardy. Swelling of the face or fingers may indicate a hypertensive condition or preeclampsia. Discomforts that are expected during this trimester of pregnancy include insomnia, frequent urination (caused by impingement of the enlarging uterus on the bladder, resulting in reduced bladder capacity), and shortness of breath (resulting from limitation of diaphragm movement by the enlarging uterus).
A nurse monitoring the fetal heart rate (FHR) pattern of a woman in the first stage of labor whose cervix is dilated 6 cm notes the presence of early decelerations. Based on this finding, what action should the nurse take? Contacting the nurse-midwife Continuing to monitor the FHR pattern Administering oxygen at 10 L by face mask Preparing the woman for immediate delivery
Continuing to monitor the FHR pattern RATIONALE: Early deceleration of FHR is a visually apparent gradual decrease and return to baseline FHR that occurs in response to fetal head compression during a contraction. It is a normal and benign finding, and therefore no intervention is necessary.
The nurse is monitoring a pregnant client in labor whose membranes have just ruptured. The nurse notes the presence of fetal bradycardia with variable decelerations during a uterine contraction and suspects prolapse of the umbilical cord. The nurse examines the client and sees that the cord is protruding from the vagina. Which immediate action should the nurse take? Gently push the cord into the vagina. Prepare the woman for vaginal delivery. Place the woman in a knee-chest position. Explain to the woman that a cesarean delivery is necessary.
Place the woman in a knee-chest position. RATIONALE: The immediate action the nurse must take is to place the women in a knee-chest position. When cord prolapse occurs, relieving pressure on the cord to improve blood flow through it until delivery is the priority. Cord pressure is immediately relieved by putting a sterile gloved hand into the vagina and holding the presenting part off the umbilical cord. The nurse would call for assistance and place the mother in a modified Sims, Trendelenburg, or knee-chest position to minimize pressure on the cord. If the cord is protruding from the vagina, no attempt should be made to replace it because doing so could traumatize and further reduce blood flow through the cord. Additionally, manipulating the cord can induce umbilical cord spasm, which could reduce blood flow between the fetus and placenta. The woman will be prepared for an immediate vaginal delivery if the cervix is fully dilated or for a cesarean birth if it is not.
The nurse is developing a plan of care for a newborn who will be treated with phototherapy. Which action should the nurse include in the plan? Leaving the child's diaper off during phototherapy Exposing the infant to phototherapy 24 hours a day Covering the infant with a sheet during phototherapy Placing patches over the infant's eyes before starting phototherapy
Placing patches over the infant's eyes before starting phototherapy RATIONALE: The infant's eyes are closed and patches placed over them to protect the eyes from the phototherapy light. The infant is checked every 2 hours to ensure that the patches are still in place. The patches are removed at least once per shift to inspect the eyes for infection or irritation and to permit eye contact. The infant is placed, unclothed except for a diaper, under the phototherapy light and turned every 2 hours to expose all body surfaces to the light. The infant may be removed from the phototherapy for feedings, diaper changes, and other general care but should undergo phototherapy every day (or for the number of hours prescribed by the primary health care provider.)
Janice attends her week 37 appointment with her primary health care provider and reports that she is not feeling well. Her primary health care provider admits her to the hospital for severe preeclampsia and induction of labor. The hospital nurse performs an admission assessment on Janice. Which findings linked to severe preeclampsia should the nurse expect to note? Proteinuria Complaints of fatigue Blood pressure 138/90 mm Hg Fetal heart rate 140 beats/min
Proteinuria RATIONALE: Severe preeclampsia is characterized by a blood pressure greater than 160/110 mm Hg, proteinuria of more than 5 g in 24 hours (3+ or more), and oliguria (less than 500 mL/24 hours). The client will also complain of headache, visual disturbances, and abdominal pain. The normal fetal heart rate ranges from a lower limit of 110 to 120 beats/min to an upper limit of 150 to 160 beats/min at term. Janice may be fatigued, but this is not significantly related to severe preeclampsia.
Which precautions should the nurse take to prevent newborn abduction? Select all that apply. Placing the newborn's crib close to the mother's door Instructing the mother to carry the newborn to the nursery after feeding Closing the hospital room door if the infant needs to be left unattended Questioning unknown person(s) who are carrying large bags or packages
Questioning unknown person(s) who are carrying large bags or packages Ensuring that all health care personnel wear proper name (identification) badges RATIONALE: Precautions to prevent infant abduction include placing a newborn's crib away from the door, transporting a newborn only in the crib and never carrying the newborn, expecting health care personnel to wear identification that is easily visible at all times, and asking a nurse to attend to the newborn if no one is available to watch the newborn (the newborn is never left unattended). The nurse should monitor the environment closely and question any suspicious or unknown person, especially one carrying a large bag or package that could contain an infant.
A nurse calculates an infant's Apgar score 1 minute after birth and obtains a score of 8. Based on this finding, which action should the nurse take? Notifying the infant's pediatrician Administering oxygen to the infant Recalculating the infant's Apgar score 5 minutes after birth Attempting to stimulate the infant by rubbing the infant's back
Recalculating the infant's Apgar score 5 minutes after birth RATIONALE: The nurse calculates the infant's Apgar score at 1 and 5 minutes after birth for rapid evaluation of early cardiopulmonary adaptation. If the score is between 8 and 10, no intervention is needed except for support of the infant's spontaneous efforts. If the score is between 4 and 7, the nurse gently stimulates the infant by rubbing his or her back and administers oxygen to the infant. A score between 0 and 3 indicates the need for resuscitation.
The primary health care provider prescribes a continuous infusion of magnesium sulfate to prevent seizures. Which equipment should the nurse ensure is available before starting the magnesium sulfate infusion? Select all that apply. Otoscope Tongue blades Reflex hammer Calcium gluconate Controlled infusion device Sphygmomanometer and stethoscope
Reflex hammer Calcium gluconate Controlled infusion device Sphygmomanometer and stethoscope RATIONALE: Magnesium sulfate is administered to the client with severe preeclampsia to prevent seizures. It acts as a central nervous system depressant by blocking neuromuscular transmission and decreasing the amount of acetylcholine being liberated. Because of the adverse effects of magnesium overdose, it is always administered with the use of a controlled infusion device. A reflex hammer is needed to monitor the client for the presence of deep tendon reflexes, because depressed reflexes are an early sign of magnesium intoxication. Blood pressure and pulse should be checked every 10 to 15 minutes, because hypotension may occur as a side effect. Calcium gluconate is the antidote to magnesium sulfate. Loss of deep tendon reflexes, respiratory depression, oliguria, and a decreased level of consciousness are signs/symptoms of magnesium toxicity. An otoscope and tongue blade are not necessary in this situation.
A nurse notes documentation in the medical record that a woman in labor is at +1 station. Based on this finding, what does the nurse determine is the presenting part of the fetus? 1 cm below the ischial spines 1 cm above the ischial spines At the level of the ischial spines Above the level of the ischial spines
1 cm below the ischial spines RATIONALE: Station is the relationship of the presenting part of the fetus to an imaginary line drawn between the maternal ischial spines. It is a measure of the degree of descent of the presenting part of the fetus through the birth canal. Station is expressed in centimeters above or below the spines. When the presenting part is 1 cm below the ischial spines, the station is noted as +1. When the presenting part is 1 cm above the ischial spines, the station is noted as -1. When the presenting part is at the level of the ischial spines, the station is noted as zero.
At 30 weeks' gestation, Janice is seen in the maternity clinic for a follow-up visit. The nurse checks the fundal height. Which measurement does the nurse expect to see? 20 cm 26 cm 30 cm 34 cm
30 cm RATIONALE: From 22 weeks to term, the fundal height, which is measured in centimeters, is roughly equal (plus or minus 2 cm) to the gestational age of the fetus in weeks. Therefore, because this client is at 30 weeks' gestation, her fundal height would be 30 (plus or minus 2 cm). If fundal height exceeds the number of weeks of gestation, additional assessment is necessary to investigate the cause of the unexpectedly large uterine size. If fundal height is less than expected on the basis of gestational age, the estimated date of delivery must be confirmed. If the dates are accurate, further assessment may be necessary to determine whether the fetus' growth is inadequate.
A woman who has just delivered a baby asks the nurse when she may resume sexual intercourse. Which response should the nurse give to the client? Intercourse may be resumed at any time after delivery. Intercourse may not be resumed until menstruation returns. Intercourse may not be resumed until after the 6-week checkup with the obstetrician. Intercourse may be resumed 2 to 4 weeks after delivery, once bleeding has stopped and the episiotomy has healed.
Intercourse may be resumed 2 to 4 weeks after delivery, once bleeding has stopped and the episiotomy has healed. RATIONALE: The woman who has just given birth should be told that she may safely resume sexual intercourse by the second to fourth week after delivery, when bleeding has stopped and the episiotomy has healed. The other options are incorrect.
A nurse provides instructions to a breastfeeding mother about measures that will provide relief from breast engorgement. Which statement by the mother indicates an understanding of the instructions? "I should switch to formula to feed my baby for 1 week." "I need to stop breastfeeding until the engorgement resolves." "I should apply warm packs to my breasts before each feeding." "I need to apply ice packs to my breasts 20 minutes before a feeding."
"I should apply warm packs to my breasts before each feeding."
The nurse in the maternity clinic is reading the records of several pregnant women who will be seen in the clinic today. Which clients are at highest risk for preeclampsia? Select all that apply. A 17-year-old primigravida A client with type 1 diabetes mellitus An obese client in her third pregnancy A 30-year-old client in her second pregnancy A 35-year-old client with a history of chronic renal disease
A 17-year-old primigravida A client with type 1 diabetes mellitus An obese client in her third pregnancy A 35-year-old client with a history of chronic renal disease RATIONALE: Risk factors associated with preeclampsia include primigravidity, maternal age younger than 19 years or older than 40, obesity, Rh incompatibility, personal history or family history of preeclampsia, history of chronic renal disease, history of chronic hypertension, hypertension, and diabetes mellitus.
A client who gave birth 5 weeks ago reports to the primary health care provider's office because she is experiencing pelvic heaviness, backache, fatigue, and excessive lochial discharge. On assessment, the client's uterus feels larger and softer than expected at this point in the puerperium, and subinvolution of the uterus is suspected. Which treatment should the nurse expect the primary health care provider prescribe to treat this condition? Hysterectomy Hourly fundal massage Immediate hospitalization and strict bedrest Administration of methylergonovine
Administration of methylergonovine RATIONALE: Subinvolution is slower-than-expected return of the uterus to its non-pregnancy size after childbirth. Usually an oral dose of methylergonovine every 3 to 4 hours for 24 to 48 hours is prescribed to provide sustained contraction of the uterus. Hysterectomy, hourly fundal massage, and hospitalization with strict bedrest are all unnecessary. If the cause of the subinvolution is retained placental fragments, dilation and curettage may be performed. Fundal massage is used to treat uterine atony, but hourly massage would not be prescribed.
That evening, during an assessment, the nurse finds that Annie's uterine fundus is above the umbilicus and to the left of the midline of the abdomen. What action by the nurse is a priority? Performing fundal massage Performing a sterile urinary catheterization Assessing the lochia on Annie's perineal pad Assisting Annie to the bathroom to help her void
Assisting Annie to the bathroom to help her void RATIONALE: A full bladder causes the uterus to be displaced above the level of the umbilicus and off to one side of the midline of the abdomen. It may also lead to uterine atony, because it prevents the uterus from contracting normally. The priority nursing intervention is to assist the woman in emptying her bladder as soon as possible, either by taking her to the bathroom or offering a bedpan if she is not ambulatory. Fundal massage should be performed, if the fundus is boggy, once the bladder has been emptied. Catheterization is done only if the woman is unable to void after measures have been taken to encourage urination. Assessing the lochia does not address the problem.
Laboratory tests are performed on a woman in the first trimester of pregnancy, and the results indicate that she is negative for Rh factor. Which explanation of this finding should the nurse provide to the woman? The result of the Rh factor screen is normal. Because the Rh factor is not present, no additional testing is necessary. Because the Rh factor is not present, the newborn infant will need to receive immunization immediately after birth. Because the Rh factor is not present, the client will need to receive Rh immune globulin at about 28 weeks' gestation.
Because the Rh factor is not present, the client will need to receive Rh immune globulin at about 28 weeks' gestation. RATIONALE: If the client is Rh negative and the result of an antibody screen is negative, she will need repeat antibody screens and should receive Rh immune globulin around 28 weeks' gestation to prevent the formation of anti-Rh antibodies. An Rh-negative woman should also receive Rh immune globulin within 72 hours of delivery if her newborn is Rh-positive. On the basis of the data provided in the question, the other options are incorrect.
A nurse assists an obstetrician in performing an amniotomy on a woman admitted to the labor unit. Which action should the nurse take immediately after the procedure? Helping the woman walk Checking the fetal heart rate Assisting the woman in bathing Checking the woman's temperature
Checking the fetal heart rate RATIONALE: Amniotomy is the artificial rupture of membranes that is performed by the primary health care provider to stimulate labor. The primary risk associated with amniotomy is that the umbilical cord will slip down in the gush of fluid and become compressed between the fetal presenting part and the woman's pelvis, obstructing blood flow to and from the placenta and reducing gas exchange. Therefore the nurse's action immediately after the procedure would be to check the fetal heart rate. Although the nurse would monitor the woman's temperature and help the woman bathe, these are not immediately necessary actions. The woman would not be allowed to walk unless this has specifically been prescribed.
Which priority action would the nurse take after attaching an external electronic fetal monitor to a pregnant client? Checking the fetal heart rate Discussing the labor process with the client Assessing the frequency of the contractions Documenting the time that the monitor was attached
Checking the fetal heart rate RATIONALE: Assessing the fetal heart rate is the priority action after an electronic fetal monitor is attached to a pregnant client. Although assessment of the frequency of contractions is important, it is not the priority. Likewise, documenting and discussing the labor process with the client are components of the plan of care but are not the priority.
A nurse is preparing to apply erythromycin ophthalmic ointment to a newborn's eyes. Which action should the nurse plan to take? Cleansing the infant's eyes before applying the ointment Applying the ointment to the upper conjunctival sac of each eye Rinsing the excess ointment from the eye using normal saline solution Applying the ointment from the outer canthus to the inner canthus of the eye
Cleansing the infant's eyes before applying the ointment RATIONALE: The infant's eyes are cleansed before the administration of eye ointment. The ointment is placed in the lower conjunctival sac of each eye and deposited from the inner canthus to the outer canthus. The ointment is not rinsed from the eye, although it may be wiped from the outer eye area after 1 minute.
A nurse performing an initial assessment of a newborn who is awake and alert counts the infant's apical heart rate and obtains a rate of 130 beats/min. Based on this finding, which action should the nurse take? Documenting the finding Contacting the pediatrician Reassessing the heart rate in 5 minutes Stimulating the infant and reassessing the heart rate
Documenting the finding RATIONALE: The normal heart rate of a newborn is 100 to 160 beats/min. Therefore the nurse would document the finding. The other options are incorrect and unnecessary.
The nurse assessing a client who has just given birth is preparing to check the client's uterine fundus. The nurse notes that the fundus, which was difficult to locate, is soft. Which immediate action should the nurse take? Massaging the uterus Asking the client to urinate Helping the client out of bed to walk Pushing on the uterus to express any accumulated clots
Massaging the uterus RATIONALE: If the uterus is not firmly contracted, the nurse's immediate intervention is massaging the fundus to help it become firm and to express clots that may have accumulated within. If the uterus does not remain contracted as a result of uterine massage, the problem may be a distended bladder, and the nurse should help the woman urinate. Pushing on an uncontracted uterus could result in uterine inversion and cause massive hemorrhage and rapid shock. The nurse would not ask a client at risk for bleeding to walk.
A nurse assessing a newborn's reflexes tests the Babinski (plantar) reflex. The nurse notes that when the reflex is elicited, the infant's toes hyperextend and the big toe dorsiflexes. How should the nurse document this finding? Positive Negative Unresponsive Depressed
Positive
The nurse notes documentation in the record of a client in labor that the client is completely effaced. Based on this information, what conclusion should the nurse make? The cervical os is completely dilated. The client will require induction with the use of oxytocin. Enlargement of the cervical canal that occurs during the first stage of labor is complete. The shortening and thinning of the cervix that occurs during the first stage of labor is complete.
The shortening and thinning of the cervix that occurs during the first stage of labor is complete. RATIONALE: Effacement is the shortening and thinning of the cervix that occurs during the first stage of labor. Dilation is the enlargement of the cervical os and cervical canal during the first stage. When the cervical os is completely dilated, the client is prepared for the birth of the baby. Induction is the deliberate initiation of uterine contractions that stimulates labor. In this situation, induction is not necessary.
A pregnant woman at 20 weeks' gestation calls the nurse at the maternity clinic and reports that she has noticed a white fluid draining from her nipples. What should the nurse tell the client? She must come to the clinic to be checked. This is an expected occurrence during pregnancy. This is frequently the first sign of a breast infection. She should notify the nurse-midwife of this finding.
This is an expected occurrence during pregnancy.
A pregnant client who is taking a prescribed iron supplement calls the nurse in the obstetrician's office and reports that she has been constipated. What is the best response the nurse should give to the client? To increase her daily intake of high-fiber foods That this is a normal occurrence during pregnancy To take the iron supplement every other day instead of every day To start taking an oral laxative daily until the constipation resolves
To increase her daily intake of high-fiber foods RATIONALE: The best response is for the client to increase her daily intake of high-fiber foods. Constipation is common during pregnancy. It may be caused by decreased intestinal motility or pressure from the uterus or may be a result of iron supplementation. The client should not discontinue or change the frequency of administration of an iron supplement that has been prescribed. If constipation persists, the client would be instructed to consult with the primary health care provider or nurse-midwife regarding a prescription for a laxative; taking a laxative on a daily basis could be harmful. Although constipation is a normal occurrence during pregnancy, the nurse should teach the client measures, such as including additional fiber in the diet, to alleviate and prevent its occurrence.
A nurse has just assisted in the delivery of a newborn infant and is preparing to help deliver the placenta. For which sign/symptom of placental separation does the nurse monitor the woman? A soft, boggy fundus Shortening of the umbilical cord Vaginal fullness on examination Assumption of a discoid shape by the uterus
Vaginal fullness on examination RATIONALE: Signs/symptoms of placental separation include a firmly contracting fundus; a change in the uterus from a discoid to a globular shape, which occurs as the placenta moves into the lower uterine segment; a sudden gush of dark blood from the introitus; apparent lengthening of the umbilical cord as the placenta descends to the introitus; the presence of vaginal fullness (placenta) on vaginal or rectal examination; and the presence of fetal membranes at the introitus.
A non-stress test is performed on a pregnant woman, and the woman is told by the obstetrician that the results are nonreactive. Based on this test result, what determination does the nurse make? Fetal well-being has been established. A contraction stress test will be scheduled. Placental function and oxygenation are adequate. The results are inadequate and the non-stress test must be repeated.
A contraction stress test will be scheduled.
A client with partial placental previa is admitted to the maternity unit. Which findings should the nurse expect to note while performing an admission assessment? Select all that apply. Uterine rigidity Acute abdominal pain Dark-red vaginal bleeding A soft, relaxed, non-tender uterus Fundal height greater than expected for gestational age
A soft, relaxed, non-tender uterus Fundal height greater than expected for gestational age RATIONALE: A woman with placenta previa typically presents sometime after 24 weeks' gestation with painless bright-red vaginal bleeding and a soft, relaxed, non-tender uterus. The fundal height may be greater than expected for gestational age. Acute abdominal pain, uterine rigidity, and dark-red vaginal bleeding are clinical manifestations of placental abruption.
A client with type 1 diabetes mellitus who is pregnant for the first time asks the nurse whether she will need to take more insulin than usual because of the pregnancy. Which response should the nurse give the client? Insulin will be needed only during labor and delivery. Insulin needs increase during the second and third trimesters. Insulin is not usually needed during pregnancy because the body secretes additional insulin. Insulin needs increase during the first trimester and then decrease during the second and third trimesters.
Insulin needs increase during the second and third trimesters. RATIONALE: The client with type 1 diabetes mellitus will need insulin throughout the pregnancy. Insulin needs increase markedly during the second and third trimesters, when placental hormones, which initiate maternal resistance to the effects of insulin, reach their peak. Insulin needs generally decline during the first trimester because the secretion of placental hormones antagonistic to insulin remains low.
The mother of a newborn is upset because her newborn has a birthmark on the left side of the forehead. The mother, on being told that it is a nevus vasculosus (strawberry mark), asks the nurse whether the mark is permanent. What should the nurse tell the mother? It is a permanent mark It will need to be removed with surgery It will disappear on its own by the early school years It is nothing to be concerned about because it is so small
It will disappear on its own by the early school years
Janice asks the nurse about her expected date of delivery. The date of her last period was August 25th, 2016. Using Nagele's rule, what does the nurse calculate the estimated date of delivery (EDD)? May 25, 2017 May 31, 2017 June 1, 2017 July 1, 2017
June 1, 2017
During labor, Janice's baby exhibits fetal distress. Which interventions should the nurse implement? Select all that apply. Placing Janice in the supine position Preparing for an emergency cesarean section Continuing to monitor maternal and fetal status Increasing the rate of the oxytocin infusion Administering oxygen at 2 L/min by way of nasal cannula
Preparing for an emergency cesarean section Continuing to monitor maternal and fetal status RATIONALE: Preparing for an emergency cesarean section and continued monitoring of the maternal and fetal status are the correct interventions. Janice would be placed in a left lateral position, not supine; the supine position could result in vena cava syndrome and inhibit placental blood flow. If an oxytocin solution is infusing, it will be stopped to prevent further fetal distress. Oxygen would be administered at 8 to 10 L/min by way of face mask.
A pregnant client with tuberculosis will be taking isoniazid and rifampin. The client has also been instructed to take pyridoxine and asks the nurse about the purpose of the vitamin. The nurse should make which statement to the client about the purpose of pyridoxine? Prevents fetal neurotoxicity Promotes effectiveness of the other medications Prevents the side effects associated with rifampin Increases compliance with medication administration
Prevents fetal neurotoxicity RATIONALE: One adverse effect of isoniazid is neurotoxicity. Pyridoxine should be given with isoniazid to prevent fetal neurotoxicity and because pregnancy increases the requirement for this vitamin. Promoting the effectiveness of other medications, preventing side effects associated with rifampin, and increasing compliance with medication administration are not uses of this vitamin.
A nurse monitoring lochial flow in a woman who delivered 2 hours earlier notes that the client's perineal pad shows drainage measuring less than 1 inch in a 1-hour period. How should the nurse report the lochial flow? Scant Light Heavy Excessive
Scant RATIONALE: Lochia is the discharge from the uterus in the postpartum period, consists of blood from the vessels of the placental site and debris from the decidua (thick layer of modified mucous membrane that lines the uterus during pregnancy and is shed with afterbirth). The following guide may be used to determine the amount of flow: scant, less than 2.5 cm (1 inch) on menstrual pad in 1 hour; light, less than 10 cm (4 inches) on pad in 1 hour; moderate, less than 15 cm (6 inches) on pad in 1 hour; heavy, saturation of pad in 1 hour; and excessive, saturation of pad in 15 minutes.
A rubella antibody screen performed on a pregnant client reveals a titer of 1:8. Which interpretation of this result should the nurse give to the client? She is immune to rubella (German measles). She will need to receive the rubella vaccine immediately. She must have been exposed to someone who had rubella. She is not immune to rubella and will require postpartum follow-up.
She is not immune to rubella and will require postpartum follow-up. RATIONALE: A prenatal rubella antibody screen of the pregnant client is conducted to determine whether she is immune to rubella. A titer of 1:8 or less indicates that the client is not immune. Immunization with the rubella vaccine is performed in the postpartum period. This prevents rubella infection and possible severe congenital defects in the fetus during a subsequent pregnancy. Exposure to rubella usually provides immunity to the disease and would produce a titer greater than 1:8. However, if exposure to rubella occurs during pregnancy the primary healthcare provider must be informed immediately. The vaccine is not administered during pregnancy because of the risk of fetal anomalies. TEST-TAKING STRATEGY: Focus on the subject, pregnant client with a rubella antibody screen titer of 1:8. Eliminate the options that are comparable or alike in that they indicate that the client is immune to rubella. To select from the remaining options, recall that rubella can cause serious fetal anomalies, which will direct you to the correct option.
A nurse reviewing the record of a client seen in the clinic notes that the nurse-midwife documented the presence of the Goodell sign during examination of the client. What conclusion does the nurse make on the basis of this finding? The client is definitely pregnant. The nurse-midwife noted softening of the cervix. The client exhibits a presumptive sign of pregnancy. The nurse-midwife noted a violet coloration of the cervix.
The nurse-midwife noted softening of the cervix. RATIONALE: In the early weeks of pregnancy, the cervix softens as a result of pelvic congestion (Goodell sign). Cervical softening is noted on physical examination. The presence of the Goodell sign is a probable indication of pregnancy. Another probable indication of pregnancy is the Chadwick sign, in which the cervix changes from pink to a violet color. Presumptive indications of pregnancy are also termed subjective changes because they are experienced and reported by the woman. Positive indications of pregnancy include auscultation of fetal heart sounds, fetal movement felt by the examiner, and visualization of the fetus on ultrasonography.
The nurse preparing to auscultate the fetal heart rate of a client in the second trimester of pregnancy assists the client into a supine position on the examining table. As the nurse listens to the fetal heart rate, the client suddenly complains of lightheadedness, dizziness, and nausea. Which immediate action should the nurse take? Call the primary health care provider. Turn the client on her side. Check the client's blood pressure. Obtain an emesis basin from the supply closet.
Turn the client on her side. RATIONALE: Supine hypotensive syndrome (also known as vena cava syndrome) occurs when the venous return to the heart is impaired by the weight of the uterus. If the woman lies on her back, the enlarged uterus may occlude the vena cava and descending aorta, leading to reduced cardiac return, cardiac output, and blood pressure. When this occurs, the woman may experience dizziness or lightheadedness, nausea, or diaphoresis. The nurse's immediate action is to turn the client on her side to restore circulation. Although the nurse might check the client's blood pressure, this would not be the immediate action. There is no reason to call the primary health care provider. Although an emesis basin would be helpful if the client vomits, the nurse would not leave the client.
Maureen and Robert decide to have James Nicholas circumcised before he is discharged from the hospital. The nurse conducts teaching for home care of the circumcised newborn. Which statement by Maureen indicates a need for further instruction? "I'll clean the penis with a baby wipe during each diaper change." "I'll check the circumcision site for bleeding during each diaper change." "I'll apply petroleum jelly to the penis during each diaper change until it heals." "If his penis turns red, swells, or has a discharge, I'll call the pediatrician right away."
"I'll clean the penis with a baby wipe during each diaper change." RATIONALE: Many newborn infants are discharged soon after circumcision, and thorough client teaching is important. Parents should be taught to check carefully for bleeding, to cleanse the site with warm water until the circumcision is healed (5 to 6 days), and to apply petroleum jelly during each diaper change until the site is healed. Redness, swelling, or discharge indicates infection, and the primary health care provider should be notified immediately if any of these findings are noted. Commercial baby wipes should not be used because they contain alcohol, which may delay healing and cause discomfort for the newborn.
A mother changing her newborn daughter's diaper notes the presence of a small amount of blood on the infant's labia. The mother is concerned and tells the nurse that the infant is bleeding from the vaginal area. After assessing the infant, what response does the nurse provide to the mother? The pediatrician will need to check the infant. A small amount of vaginal bleeding is normal. The bleeding is nothing to be concerned about. The bleeding is probably a result of trauma from the birth process.
A small amount of vaginal bleeding is normal.
Along explaining the need for weekly appointments, what other instructions related to preeclampsia should the nurse plan to give Janice so she can take care of herself and the fetus at home? Select all that apply. Reduce activity. Check weight weekly. Perform a daily fetal movement count. Check the urine for protein, using a dipstick. Perform a blood pressure check every other day.
Reduce activity. Perform a daily fetal movement count. Check the urine for protein, using a dipstick. RATIONALE: Janice will have to reduce her level of activity to allow blood that would be circulated to skeletal muscles to be conserved for circulation to her vital organs and the placenta. When Janice is in bed, she should lie on her side to improve blood flow to the placenta. Maternal assessment of fetal activity ("kick counts") helps determine the viability of the fetus. Janice should report any decrease in movements or report it if none occurs during a 4-hour period. She should also check her urine (a first-void clean-catch specimen) for protein, using a dipstick. The weight is recorded daily (not weekly), on the same scale and in the same type of clothing and at the same time of day, to help detect any sudden weight gain, an indication of worsening preeclampsia. Because increased blood pressure may be an initial indication of a problem, blood pressure monitoring is performed two to four times per day, using the same arm and with the client in the same position
A nurse teaches a pregnant woman how to perform Kegel exercises to help maintain bladder control. Which instruction should the nurse provide? Select all that apply. Perform the exercise while urinating. Perform the exercise once only after urinating. Repeat the contraction-relaxation cycle 30 times a day. Contract the muscles around the vagina and hold for 10 seconds, then relax the muscles for 10 seconds. Continuously contract and relax the muscles around the vagina at least 30 times and perform the exercise three times a day.
Repeat the contraction-relaxation cycle 30 times a day. Contract the muscles around the vagina and hold for 10 seconds, then relax the muscles for 10 seconds. RATIONALE: Kegel exercises improve tone of the muscles of the pelvic floor and help maintain bladder control. They are not performed during urination, because urine retention increases the risk of urinary tract infection. The woman is taught to contract the muscles around the vagina and hold for 10 seconds, then relax the muscles for 10 seconds. The contraction-relaxation cycle is repeated 30 times a day.
A nurse teaches the husband of a woman who is in the active phase of stage 1 labor how to perform effleurage on his wife. Which observation by the nurse indicates that the spouse is performing the procedure correctly? The man lightly pushes on his wife's sacral area with his fist. The man exerts steady pressure on his wife's abdomen during a contraction. The man lightly strokes his wife's abdomen in rhythm with her breathing during a contraction. The man exerts light pressure with the heel of the hand over the area of the uterine fundus.
The man lightly strokes his wife's abdomen in rhythm with her breathing during a contraction. RATIONALE: Effleurage (light massage) and counter pressure are two methods that provide pain relief to a woman in the first stage of labor. Effleurage is light stroking, usually of the abdomen, in rhythm with breathing during a contraction. It is used to distract the woman from contraction pain. Counter pressure is steady pressure, applied to the sacral area with the fist or heel of the hand, that may help the woman cope with the sensations of internal pressure and pain in the lower back. Therefore the other options are incorrect.
One hour after delivery, the nurse checks Annie for postpartum bleeding. Which procedure is best for this purpose? Assessing Annie's blood pressure Visually assessing bleeding by checking Annie's perineal pad Asking Annie how much bleeding she has had since the last check Visually assessing bleeding by checking the linens under Annie's buttocks and the perineal pad
Visually assessing bleeding by checking the linens under Annie's buttocks and the perineal pad
The lactation consultant nurse visits Annie to discuss breastfeeding and to observe as Annie breastfeeds her baby. The nurse discusses mastitis, its signs and symptoms, how to prevent it, and what to do if it occurs. Which statements by Annie reflect understanding of the information that is being presented? Select all that apply. "It won't hurt to miss a few feedings if I'm too tired." "I'll wash my nipples carefully before and after feedings." "I should expect to have sore, cracked nipples when starting to breastfeed." "If I get mastitis, I'll have to stop breastfeeding from that side until it is healed." "If my nipples are sore, I should apply warm water compresses before breastfeeding." "If I get mastitis, I can continue to breastfeed and will make sure to empty the breast every 2 to 4 hours."
"I'll wash my nipples carefully before and after feedings." "If my nipples are sore, I should apply warm water compresses before breastfeeding." "If I get mastitis, I can continue to breastfeed and will make sure to empty the breast every 2 to 4 hours." RATIONALE: Mastitis, a breast infection, may affect one or both breasts. It may be prevented with the use of proper technique and positioning for breastfeeding, preventing the development of cracked nipples, and emptying the breasts at regular intervals by means of breastfeeding, manual expression, or breast pumping. Cleanliness is also important. If mastitis occurs, breastfeeding is still recommended, because it is important to empty the breasts. Missed feedings can contribute to mastitis. The nipples may be sore (but not cracked) at the beginning of breastfeeding, and warm water compresses may be comforting before breastfeeding.
The nurse is monitoring a client in labor who has a history of heart disease. Which finding should prompt the nurse to contact the nurse-midwife? Anxiety Complaints of back discomfort A fetal heart rate of 130 beats/min A maternal pulse rate of 120 beats/min
A maternal pulse rate of 120 beats/min RATIONALE: The nurse closely monitors the client with cardiac disease for signs/symptoms of cardiac decompensation (i.e., cough, dyspnea, fatigue, peripheral edema, palpitations and tachycardia, angina-type pain, signs/symptoms of pulmonary edema). The labor process is cause for apprehension in all women, but the woman with impaired cardiac function has additional reason to be anxious because labor and giving birth place an additional burden on her already compromised cardiovascular system. Back discomfort often occurs during labor because the fetal head puts pressure on the woman's sacral promontory (occiput posterior position). Positions that encourage the fetus to move away from the sacral promontory, such as the hands-and-knees position, can help ease back pain and enhance the internal-rotation mechanism of labor. The fetal heart rate at term ranges from a lower limit of 110 to 120 to an upper limit of 150 to 160 beats/min. A maternal pulse rate of 100/beats/min or faster or a respiratory rate of 25 breaths/min or faster is cause for concern.
A nurse taking the vital signs of a client who delivered a healthy newborn infant 4 hours ago notes that the client's oral temperature is 101.2° F (38.4° C). Which action would be appropriate? Documenting the findings Notifying the primary health care provider Retaking the temperature rectally Telling the client that the temperature at this level is expected at this time
Notifying the primary health care provider RATIONALE: Temperatures up to 100.4° F (38.0° C) in the 24 hours after birth are often related to the dehydrating effects of labor. The appropriate action is to increase hydration by encouraging oral fluids, which should bring the temperature to a normal reading. However, a temperature higher than 100.4° F indicates an infection, and the primary health care provider should be notified. Although the nurse also would document the findings, the appropriate action would be to contact the primary health care provider. There is no useful reason for taking the temperature rectally. Telling the client that her increased temperature is expected at this time is incorrect.
A pregnant client has been scheduled for amniocentesis, and the nurse is providing information to her about the procedure. What should the nurse tell the woman? The procedure will take about 2 hours. The obstetrician will locate the fetus with the use of the Leopold's maneuvers. The client may feel pressure as the needle is inserted and mild cramping as the needle enters the uterine muscle. Several serious risks are associated with the procedure, and several informed consent forms will have to be signed.
The client may feel pressure as the needle is inserted and mild cramping as the needle enters the uterine muscle. RATIONALE: Amniocentesis is a relatively simple and safe procedure that permits the diagnosis of many fetal anomalies and confirms fetal maturity. It is a relatively painless procedure that takes only a short amount of time. Ultrasonography is used to locate the fetus and placenta and identify the largest pockets of amniotic fluid that can safely be sampled. A small amount of local anesthetic may be injected into the skin. The woman may feel pressure as the needle is inserted and mild cramping as the needle enters the myometrium. Leopold's maneuvers are a common and systematic way to determine the position of a fetus inside the woman's uterus. Informed consent will need to be provided by the client before the procedure. Although risks are associated with the procedure, the need for several informed consents to be signed is not warranted.
A woman in the first trimester of pregnancy calls the nurse at her obstetrician's office and reports that brown patches have developed on her face. What should the nurse tell the client? She should cover the discoloration with makeup. She should come to the clinic immediately to be checked. This is a normal skin change, the result of the hormonal fluctuations that occur during pregnancy. She should monitor the discoloration and make an appointment with the obstetrician if the patches worsen.
This is a normal skin change, the result of the hormonal fluctuations that occur during pregnancy. RATIONALE: Increased skin pigmentation, a normal occurrence during pregnancy, may begin as early as the second month of pregnancy, when estrogen and progesterone cause the level of melanocyte-stimulating hormone to increase. Women with dark hair or skin exhibit more hyperpigmentation than do women with very light skin. Areas of pigmentation include brownish patches, called chloasma, that usually involve the forehead, cheeks, and bridge of the nose. This sign/symptom is commonly called the "mask of pregnancy." Covering the discoloration with makeup may diminish the appearance of the brown patches, but it is not the most appropriate option. It is not necessary for the client to come to the clinic immediately, nor is it necessary for the client to make an appointment if the patches worsen.
A nurse who has just assisted in the delivery of a newborn infant is providing initial care to the infant. Which action should the nurse take to prevent heat loss by way of conduction in the infant? Keeping the infant away from drafty areas Keeping the infant away from cold windows Warming the hands before touching the infant Drying the infant as soon as possible after birth
Warming the hands before touching the infant RATIONALE: Conduction of heat away from the body occurs when a newborn comes in direct contact with an object that is cooler than his or her skin. Placing an infant on a cold surface or touching the newborn with cold hands or a cold stethoscope causes this type of heat loss. Convective heat loss occurs when heat is transferred to air surrounding the infant. Keeping the infant out of drafts and maintaining warm environmental temperatures help prevent this type of heat loss. Radiation is the transfer of heat to cooler objects that are not in direct contact with the infant. An infant placed near a cold window loses heat by way of radiation. Heat loss by way of evaporation occurs when a wet surface is exposed to air. Drying the infant as soon as possible after birth and after bathing prevents this type of heat loss.
The next day, the newborn's blood type comes back as A-positive. Annie is type B-negative. The obstetrician prescribes an intramuscular dose of Rho(D) immunoglobulin (RhoGAM) for Annie. The nurse explains the purpose of the RhoGAM, and prepares the injection. Which statement by Annie reflects a need for further education? "My baby will need a dose of this medication, too." "My husband doesn't need to have a dose of this medication." "This shot will prevent a reaction in my body from the blood of my baby." "This shot will make it safer for my future babies if they have a positive blood type."
"My baby will need a dose of this medication, too." RATIONALE: Rho(D) immunoglobulin (RhoGAM) is given within 72 hours of delivery to prevent antibody sensitization in a Rh-negative woman who has given birth to a Rh-positive infant, in whom fetomaternal transfusion may have occurred. The immune globulin promotes the destruction of any fetal Rh-positive cells that may have entered the mother's bloodstream before her body has had a chance to form antibodies against them. As a result, future pregnancies with Rh-positive infants will not be at risk for hemolysis. Only the mother receives the injection.
A nurse in a prenatal clinic, performing an initial assessment of a pregnant client, is using Nagele's Rule to determine the client's estimated date of delivery (EDD). The client tells the nurse that her last menstrual period (LMP) began on February 10, 2016. What EDD does the nurse calculate with this information? October 17, 2016 November 17, 2016 September 17, 2016 December 17, 2017
November 17, 2016 RATIONALE: For Nagele's Rule to be accurate, the woman must have a regular 28-day menstrual cycle. The nurse would subtract 3 months and then add 7 days to the first day of the LMP, then add 1 year to that date. Subtracting 3 months from February 10, 2016 is November 10, 2015. Adding 7 days to November 10, 2015 is November 17, 2015. Adding 1 year to November 17, 2015 yields the correct answer, November 17, 2016.
A nurse preparing a woman in the third trimester of pregnancy for a physical examination assists the woman into the supine position on the examining table. While waiting for the obstetrician to arrive, the woman suddenly complains of feeling lightheaded and dizzy. Which immediate action should the nurse take? Checking the woman's blood pressure Calling the obstetrician to the examining room Placing a cool cloth on the woman's forehead Assisting the client into a lateral recumbent position
Assisting the client into a lateral recumbent position RATIONALE: When a pregnant woman is in the supine position, particularly during the second and third trimesters, the weight of the gravid uterus partially occludes the vena cava and descending aorta. The occlusion impedes return of blood from the lower extremities and consequently reduces cardiac return, cardiac output, and blood pressure. This is known as supine hypotensive syndrome. Signs/symptoms include faintness, lightheadedness, dizziness, and agitation. A lateral recumbent position alleviates the pressure on the blood vessels and quickly corrects supine hypotension. Although the nurse may take the woman's blood pressure, this is not the action to take immediately. It is not necessary to call the obstetrician to the examining room. Placing a cool cloth on the woman's forehead will not alleviate the problem.
A nurse prepares to teach a pregnant woman to perform tailor-sitting exercises. Which instruction should the nurse provide to the client? Lie flat on the back and place both feet against a wall. Position self on the hands and knees and arch the back five times in a 30-second period. Sit with the legs straight, press the knees toward the floor, and hold the position for 10 seconds. Bend the knees, place the soles together, use the thigh muscles to press the knees to the floor, and hold the position for 5 to 15 minutes.
Bend the knees, place the soles together, use the thigh muscles to press the knees to the floor, and hold the position for 5 to 15 minutes. RATIONALE: Tailor-sitting exercises are useful in alleviating heartburn and shortness of breath or dyspnea. The woman sits on the floor, bends her knees, places the soles together, uses her thigh muscles to press the knees to the floor, and holds the position for 5 to 15 minutes. The other options are incorrect descriptions of this exercise.
A pregnant woman infected with hepatitis B virus (HBV) asks the nurse whether she will be able to breastfeed her newborn infant. Which response should the nurse give the client? Breastfeeding is contraindicated in HBV infection. The decision is made by the primary health care provider after delivery. Breastfeeding is safe as long as the newborn has been vaccinated. It will depend on the degree of fetal exposure to maternal body fluids at the time of delivery.
Breastfeeding is safe as long as the newborn has been vaccinated. RATIONALE: Breastfeeding is considered safe as long as the newborn has been vaccinated with hepatitis B immune globulin and the HBV vaccine. The decision to breastfeed is made by the mother; once the newborn has been vaccinated, breastfeeding may be started. The possibility of breastfeeding in the presence of HBV infection is not dependent on the degree of fetal exposure to maternal body fluids at the time of delivery.
Penny's labor is progressing slowly because her contractions are inadequate, so the obstetrician prescribes intravenous oxytocin to augment labor. While the oxytocin is being administered, the nurse monitoring Penny closely, notes that her contractions are occurring every 3 minutes and are lasting 60 seconds. Which action should the nurse take? Contact the obstetrician Stop the oxytocin infusion Transport Penny to the delivery room Maintain the current dosage of oxytocin
Maintain the current dosage of oxytocin RATIONALE: Oxytocin, a hormone naturally produced by the posterior pituitary gland, stimulates uterine contractions and may be used to induce labor or to augment a labor that is progressing slowly because of inadequate uterine contractions. The nurse monitors the client closely and maintains the dosage if the intensity of contractions results in intrauterine pressure of 40 to 90 mm Hg (as shown by an internal monitor), if the duration of contractions is 40 to 90 seconds, if the contractions come at 2- to 3-minute intervals, or if cervical dilation of 1 cm/hr occurs in the active stage. Oxytocin is stopped if uterine hyperstimulation or a non-reassuring pattern of fetal heart rate occurs. There is no need to contact the obstetrician at this time or to transport Penny to the delivery room, because she is still progressing through the first stage of labor.
