Quiz: Maternity and Women's Health Nursing: Pregnancy, Labor, Childbirth, Postpartum - Uncomplicated, Pregnancy, Labor, Childbirth, Postpartum - At Risk, Nursing Care of the Newborn

A client with worsening preeclampsia is admitted to the high-risk unit, and the nurse manager places her in a private room. A nonstimulating environment is important for a client with increased cerebral irritability because it:

Decreases the probability of generalized seizures. (Even minimal sensory stimuli can trigger exaggerated cerebral responses such as seizures; therefore a nonstimulating environment is therapeutic.)

A nurse who is caring for a client in labor uses nitrazine paper to test the pH of the client's leaking vaginal fluid. What color will the nitrazine paper turn if the leakage is amniotic fluid?

Blue. (Amniotic fluid is alkaline (pH of 7-7.50) and turns nitrazine paper blue.)

In a noisy room a sleeping newborn initially startles and exhibits rapid movements but soon goes back to sleep. What is the most appropriate nursing action in response to this behavior?

Documenting an intact reflex. (The initial response is a reflection of the startle reflex ; when the stimulus is repetitive, the response to the stimulus decreases; this decrease in response is called habituation and is expected.)

A nurse determines that a 1-day-old newborn has a heart rate of 138 beats/min. What is the best nursing action at this time?

Documenting the heart rate. (The infant's heart rate is within the expected range of 130 to 140 beats/min for the newborn.)

What clinical manifestation requires immediate intervention in a woman with a probable ruptured tubal pregnancy?

Sudden onset of knifelike pain in one of the lower quadrants. (One symptom of sudden rupture of a fallopian tube is pain on the affected side, usually sudden, excruciating, and radiating over the lower abdomen and to the shoulder; sometimes the pain is associated with nausea, vomiting, and diarrhea. )

A postpartum client who was receiving an intravenous infusion of oxytocin (Pitocin) to stimulate labor asks the nurse why it is not being discontinued now that the baby is born. The nurse responds:

"The oxytocin causes contraction of the uterine musculature." (Oxytocin (Pitocin) intensifies contractions of the uterus and promotes return of the uterus to its prepregnant state.)

A pregnant client uses a computer almost continuously during her working hours. This has implications for her plan of care during pregnancy. What should the nurse recommend?

"Try to walk around every few hours during the workday." (Maintaining the sitting position for prolonged periods may constrict the vessels of the legs, particularly in the popliteal spaces, as well as diminish venous return.)

A 7-lb, 4-oz (3290-g) boy is admitted to the nursery and placed in a warm crib. The neonate begins to choke on mucus. How should the nurse suction him with a bulb syringe?

By suctioning the mouth before the nostrils. (The mouth is suctioned before the nostrils because if the nostrils are suctioned first a reflex gasp may be stimulated, resulting in aspiration of mucus from the mouth.)

A client who has missed two menstrual periods arrives at the prenatal clinic with vaginal bleeding and one-sided lower quadrant pain. What condition does the nurse suspect?

Ectopic pregnancy (A tubal ectopic pregnancy causes first-trimester bleeding; unless an embryo and placenta happen to be located in the abdominal cavity, they cannot grow outside the uterus for longer than 10 to 12 weeks without causing the classic signs of pressure and bleeding)

A nurse in the newborn nursery receives a call from the emergency department saying that a woman with active herpes virus lesions gave birth in a taxicab while coming to the hospital. What does the nurse consider about the transmission of the herpes virus?

It can be acquired during a vaginal birth. (Herpes virus infection can be fatal to a newborn, and the infant should be admitted to the neonatal intensive care unit.)

A client is admitted in active labor. The nurse, performing Leopold maneuvers, determines that the fetus is in the left occiput anterior (LOA) position. Where should the nurse place the transducer of the electronic fetal monitor?

Left lower quadrant (The LOA position indicates that the fetus is on the left side of the mother and in a head presentation with the occiput anterior; therefore fetal heart sounds are best found in the left lower quadrant of the woman's abdomen.)

During the first hour after a cesarean birth, a nurse notes that the client's lochia has saturated one perineal pad. In light of the knowledge of expected lochial flow, what should the nurse conclude that this indicates?

Lochial flow within expected limits. (It is expected that as many as two perineal pads will be saturated in the first hour.)