Textbook questions OB Exam 3 chapters 18, 19, 20, 21, 22, 23, 25, 30, 31, 33, 34, 35, 36, and 37

A nurse is working with a postpartum client about resumption of menstrual activity following childbirth. Which of the following statements indicate that the client has a correct understanding?

"My first menstrual cycle will be heavier than normal and will return to my prepregnant volume within three or four cycles."

A nurse teaches a pregnant woman about the characteristics of true labor contractions. Which of the following statements indicates that the client correctly understands the nurse's instruction?

"True labor contractions will continue and get stronger even if I relax and take a shower."

A woman who is 39 weeks pregnant expresses fear about her impending labor and how she will manage. What is the best nursing response?

"It's normal to be anxious about labor. Let's discuss what makes you afraid."

A nurse is reviewing best practice for placing an infant to breast following birth. What timeframe should the nurse identify as representing a Baby-friendly hospital mandate?

1 hour Baby-friendly hospitals mandate that the infant be put to breast within the first hour after birth (BFHI, 2010). The ideal time to initiate breastfeeding is within the first 1 to 2 hours after delivery. In many countries this is the norm; however, the BFHI mandates 1 hour. Four hours is much too long to wait to initiate breastfeeding, whether the hospital is baby-friendly or not.

A nurse is caring for a postpartum client who is experiencing hypovolemic shock. Which ratio would the nurse use to restore effective circulating volume?

3:1 A 3:1 ratio, of 3 ml fluid infused for every 1 ml of estimated blood loss, is recommended to restore circulating volume.

A nurse is monitoring a healthy newborn's blood glucose level 90 minutes after birth. Which result should the nurse anticipate in terms of mg/dL?

55 to 60 In most healthy term newborns, blood glucose levels stabilize at 55 to 60 mg/dL between 30 and 90 minutes after birth. 80 to 100 mg/dL is the normal plasma glucose level in the adult. A blood glucose level less than 40 mg/dL in the newborn is considered abnormal and warrants intervention. An infant with this level can display classic symptoms of jitteriness, lethargy, apnea, feeding problems, or seizures. By the third day of life the blood glucose levels should be approximately 60 to 70 mg/dL.

The maternity nurse must be cognizant that cultural practices have significant influence on infant feeding methods. Which statement should the maternity identify as correct?

A common practice among Mexican women is known as las dos cosas. Las dos cosas refers to combining breastfeeding and commercial infant formula. It is based on the belief that combining the two feeding methods gives the mother and infant the benefits of breastfeeding along with the additional vitamins from formula. In the Muslim culture, breastfeeding for 24 months is customary; Muslim women may, however, choose to bottle-feed formula or expressed breast milk while in the hospital. Latino women born in the United States are less likely to breastfeed. East Indian and Arab women believe that hot foods, such as chicken and broccoli, are best for the new mother. The cultural descriptor hot has nothing to do with the temperature or spiciness of the food.

The nurse is assessing a newbown and discovers unequal movement or uneven gluteal skinfolds during the Ortolani maneuver. What should be the priority action taken by the nurse?

Alerts the physician that the infant has a dislocated hip. The Ortolani maneuver is a technique for checking hip integrity. Unequal movement suggests that the hip is dislocated. The physician should be notified. The statement in B is inappropriate and may result in unnecessary anxiety for the new parents. Molding refers to movement of the cranial bones and has nothing to do with the infant's hips.

A nurse is reviewing types of accretas that occur during pregnancy. Which of the following would the nurse identify as the most common kind of placental adherence?

Accreta Placenta accreta is the most common kind of placental adherence seen in pregnant women and is characterized by slight penetration of myometrium. In placenta previa, the placenta does not embed correctly and results in what is known as a low-lying placenta. It can be marginal, partial, or complete in how it covers the cervical os, and it increases the client's risk for painless vaginal bleeding during the pregnancy and/or delivery process. Placenta percreta leads to perforation of the uterus and is the most serious and invasive of all types of accrete. Placenta increta leads to deep penetration of the myometrium.

A nurse is working with a client in labor. Which of the following should the nurse not include in the plan of care?

Administer antibiotics

The nurse is observing a postpartum client who has been bleeding excessively during the first hour, saturating multiple pads. Which interventions would the nurse anticipate that the physician would order? (Select all that apply.)

Administer oxygen via nonrebreather mask @ 10 L/minute Insert a secondary intravenous line access Administration of oxygen @ 10L/minute via nonrebreather mask would be an anticipated order, as would insertion of a secondary line access for administration of fluids, blood, and/or medications. Although documentation of findings in a health care record is required, this is part of the nursing role and does not require an order by the physician. With regard to the presence of hypovolemic shock, intravenous fluids would be increased and maintained. The flow rate would not typically be decreased unless there was another comorbidity leading to potential fluid overload. Type & Screen would not be an anticipated order because no blood would be held for use; rather a Type & Cross order would be anticipated.

A nurse is reviewing types of thrombosis. Which thromboembolic condition would the nurse identify as not being associated with postpartum period?

Amniotic fluid embolism (AFE) An AFE occurs during the intrapartum period, when amniotic fluid containing particles of debris enters the maternal circulation. Although AFE is rare, the mortality rate is as high as 80%. A superficial venous thrombosis includes involvement of the superficial saphenous venous system. With deep vein thrombosis, the involvement varies but can extend from the foot to the iliofemoral region. A pulmonary embolism is a complication of deep vein thrombosis, occurring when part of a blood clot dislodges and is carried to the pulmonary artery, where it occludes the vessel and obstructs blood flow to the lungs.

A nurse is reviewing the clinical diagnosis of thalassemia. Which statement should the nurse identify as being accurate?

An insufficient amount of hemoglobin is produced to fill the red blood cells (RBCs). Thalassemia is a hereditary disorder that involves the abnormal synthesis of the alpha or beta chains of hemoglobin. An insufficient amount of hemoglobin is produced to fill the RBCs. The statement in B is the underlying description for sickle cell anemia. Folate deficiency is the most common cause of megaloblastic anemias during pregnancy. Deficiency of vitamin B12 must also be considered if the pregnant woman presents with anemia.

A nurse is reviewing the characteristics of uterine contractions. Which option should the nurse indicate as not being a characteristic?

Appearance (shape and height)

The nurse observes accelerations on the fetal monitor in a laboring client. How should the nurse interpret this finding?

As reassuring.

A nurse is reviewing the 5 As screening intervention tool. What does the nurse identify as describing the components of the tool?

Ask, assess, advise, assist, and arrange follow-up The 5 As stand for ask, assess, advise, assist, and arrange follow-up.

The nurse is caring for a pregnant woman with a history of asthma. Which finding would the nurse anticipate as causing the greatest impact on fetal well-being?

Associated with intrauterine growth restriction and preterm birth. Asthma appears to be associated with intrauterine growth restriction and preterm birth. Asthma is a chronic condition which can have considerable impact on pregnancy for those woman who are either poorly controlled or who may have exacerbations during pregnancy. As such there is a need for maternal medication during pregnancy as well as monitoring the client's oxygenation status. An increased need for US examination would not be considered to be a problem. The method of planned delivery is based on clincial presentation.

A nurse is reviewing treatment of alcohol withdrawal during pregnancy. Which medication should the nurse identify as being a treatment?

Benzodiazepines. Symptoms that occur during alcohol withdrawal can be managed with short-acting barbiturates or benzodiazepines. Disulfiram is contraindicated in pregnancy because it is teratogenic. Corticosteroids and aminophylline are not used to treat alcohol withdrawal.

A nurse is reviewing factors related to the prevalence of perinatal mental health problems. Which of the following statements would the nurse identify as being accurate? (Select all that apply.)

Between 30 and 50 billion dollars accounts for productivity and direct medical costs related to depression in women. Up to a ¼ of pregnant women will experience some aspect of depression during their pregnancies. Income status plays a significant role in the presentation of perinatal mental health problems. Recognition of perinatal mental health problems have been recognized and discussed throughout history. Childbearing women, ages 18 to 45, are at the highest risk to develop a psychiatric disoder. Low income plays a significant factor in the presentation of perinatal mental health problems. There is a high percentage of maternal suicides during the postpartum period linked with depression. The economic costs related to depression treatment in women are extremely high, ranging between 30 and 50 billion dollars.

A nursing student is reviewing concepts related to infant feeding. Which statement should the nurse identify as being correct concerning tandem feeding?

Breastfeeding an infant and an older sibling during the same period. In tandem feeding, a mother nurses both an infant and an older child during the same period.

A nurse is reviewing the concept of breastfeeding. Which statement should the nurse identify as being accurate as it relates to the effect of breastfeeding on the family or society at large?

Breastfeeding costs employers in terms of time lost from work. Less time is lost from work by breastfeeding mothers, in part because infants are healthier than bottle-fed infants. Breastfeeding is convenient because it does not require cleaning or transporting bottles and other equipment, and it saves families money because the cost of formula far exceeds the cost of extra food for the lactating mother. Also, breastfeeding uses a renewable resource; it does not need fossil fuels, advertising, shipping, or disposal.

A group of nurses are discussing care options for lesbian partners in childbearing experiences. Which opportunity should the nurses identified as not being able to be provided to male partners?

Breastfeeding the infant An option not available to male partners is to actually breastfeed the infant. The nonchildbearing female partner can stimulate milk production through induced lactation using medications and regular pumping. A supplemental feeding device containing expressed breast milk or formula can be used to provide additional milk to the breastfeeding infant. Labor support is a very appropriate role for the "other mother" or "co-parent." Pregnancy for lesbian couples is an intentional event, and generally both mothers will want to be very involved. As with heterosexual couples, if institutional policy allows, the nonbiologic mother should be allowed to cut the umbilical cord after delivery. Like any heterosexual parents, lesbian couples face challenges in adjusting to life with a new baby. Encouraging rooming-in assists with this transition.

A nurse is discussing with an obese client potential long-term consequences of infant feeding practices. Which method should the nurse identify to the client as having a decreased risk for the development of childhood obesity for the infant?

Breastfeeding. Breastfeeding is the best prevention strategy for decreasing childhood and adolescent obesity. Breastfeeding also helps the woman return to her prepregnant weight sooner.All breastfed infants should be fed on demand. Use of lower-calorie formula is an inappropriate strategy that does not meet the infant's nutritional needs. Breastfeeding is the most appropriate choice for infant feeding. Smaller feedings are not necessary. Infants should continue to be fed every 2 to 3 hours in the newborn period.

During a physical assessment of an at-risk client, the nurse notes generalized edema, crackles at the bases of the lungs, and some pulse irregularity. What clinical finding should the nurse anticipate based on these findings?

Cardiac decompensation. Symptoms of cardiac decompensation may appear abruptly or gradually. Euglycemia is a condition of normal glucose levels. Rheumatic fever can cause heart problems, but it does not manifest with these symptoms. Pneumonia is an inflammation of the lungs and would not likely generate these symptoms.

A nurse is taking care of a client in labor who is exhibiting signs and symptoms of maternal hypotension syndrome. Which action should the nurse implement?

Change in position.

A nurse is preparing to perform a vaginal exam on a client in labor. Which principle should guide the nurse's action?

Cleanse the vulva and perineum before and after the examination as needed.

A nurse is caring for a postpartum client experiencing hemorrhagic shock. Which indicator would lead the nurse to suspect that the client is getting worse?

Client complaint of headache and increased reaction time to questioning Client complaint of a headache accompanied by an increased reaction (response) time indicates that cerebral hypoxia is getting worse. Return of blood pressure to normal range would indicate resolving symptoms. Brisk capillary refill is a normal finding. The client may see "stars" early on in decreased blood flow states.

A nurse is caring for a postpartum client who has a significant bleed. In which clincial situations would the nurse identify the use of Methergine or prostaglandin be contraindicated even if the client was experiencing a postpartum significant bleed? (Select all that apply.)

Client's blood pressure postpartum is 180/90.. Client has a history of asthma. Client has a mitral valve prolapse. Twin pregnancies successfully delivered and grand multiparity are not contraindications to the use of these medications. If a client is hypertensive or has cardiovascular disease, these medications would not be used. If a client has a history of asthma, prostaglandin medication would not be used.

A group of nurses are discussing delivery care for pregnant women who have mental health issues. What would the nurses identify as being the most common delivery place for these clients?

Community hospital settings Unless there is some specific psychiatric mental health issue that requires that a client remain in a locked unit, most pregnant women who have mental health issues deliver in community settings. Although midwives are trained to provide obstetric care, they typically do not take care of complex clients, and a woman who had a diagnosed mental health issue would be classified as a complex client.

The nurse is assessing the respiratory system of a newborn. Which statement should the nurse be aware of with regard to the respiratory development of the newborn?

Crying increases the distribution of air in the lungs. Respirations in the newborn can be stimulated by mechanical factors such as changes in intrathoracic pressure resulting from the compression of the chest during vaginal birth. With birth, the pressure on the chest is released, helping draw air into the lungs. The positive pressure created by crying helps keep the alveoli open and increases distribution of air throughout the lungs. Newborns continue to expel fluid for the first hour of life. They are natural nose breathers and may not have the mouth-breathing response to nasal blockage for 3 weeks. Seesaw respirations instead of normal abdominal respirations are not normal and should be reported.

Two hours after giving birth, a primiparous woman becomes anxious and complains of intense perineal pain with a strong urge to have a bowel movement. Her fundus is firm, at the umbilicus, and midline. Her lochia is moderate rubra with no clots. What clinical finding should the nurse expect?

Hematoma formation Increasing perineal pressure along with a firm fundus and moderate lochial flow are characteristic of hematoma formation. Bladder distention results in an elevation of the fundus above the umbilicus and deviation to the right or left of midline. Uterine atony results in a boggy fundus. Constipation is unlikely at this time.

A nurse is reviewing the stages of labor. Which statement should the nurse identify as correct?

Descent phase: significant increase in contractions, Ferguson reflux activated, average duration varies

A nurse is taking care of a postpartum client diagnosed with von Willebrand diseaee who is experiencing a postpartum hemorrhage. Which medication should the nurse anticipate as being used first?

Desmopressin Desmopressin is the primary treatment of choice. This hormone, which can be administered orally, nasally, and intravenously, promotes the release of factor VIII and vWf from storage. Treatment with cryoprecipitate or with plasma products such as factor VIII and vWf is acceptable, but because of the associated risk of possible viruses from donor blood products, other modalities are considered safer. Although the administration of the synthetic prostaglandin in Hemabate is known to promote contraction of the uterus during postpartum hemorrhage, it is not effective for the client who presents with a bleeding disorder.

A group of nurses are reviewing Category Characteristics of Fetal Monitoring. Which finding should the nurses identify as being representative of Category I ?

Early decelerations, either present or absent. Early decelerations, the absence of late decelerations, and the presence of accelerations indicate a normal category I tracing. Bradycardia not accompanied by variability is a category II tracing, as is fetal tachycardia. A sinusoidal pattern is considered an ominous sign and is definitely an abnormal category III tracing.

The birth weight of a breastfed newborn was 8 lb, 4 oz. On the third day the newborn's weight is 7 lb, 12 oz. Which action should the nurse take based on this finding?

Encourage the mother to continue breastfeeding because it is effective in meeting the newborn's nutrient and fluid needs. Weight loss of 8 oz falls within the 5% to 10% expected weight loss from birth weight during the first few days of life, which for this newborn would be 6.6 to 13.2 oz. The infant is not undernourished, and the physician does not need to be notified. Breastfeeding is effective, and bottle feeding does not need to be initiated at this time.

When managing the care of a woman in the second stage of labor, the nurse uses various measures to enhance the progress of fetal descent. Which measure should the nurse include?

Encouraging the woman to try various upright positions, including squatting and standing.

Following a vaginal delivery, the client tells the nurse that she intends to breastfeed her infant but she is very concerned about returning to her prepregnancy weight. On the basis of this interaction, the nurse would advise the client that: (Select all that apply.)

Even though more calories are needed for lactation, typically women who breastfeed lose weight more rapidly than women who bottle feed in the postpartum period. If breastfeeding, she should regulate her fluid consumption in response to her thirst level. Weight loss diets are not recommended for women who breastfeed. ......................................................................................................Weight loss diet plans are not recommended for women who are breastfeeding because they can lead to depletion of reserves and nutrient stores and decreased milk production. Breastfeeding mothers need to increase their caloric intake by 400-500 calories/day to ensure adequate nutritional stores and milk production. Breastfeeding women lose weight faster postpartum than women who bottle feed their infants. Regulating fluid consumption in response to her thirst level will ensure that a breastfeeding woman has adequate hydration without overhydration.

A woman gave birth to a 7-lb, 3-oz boy 2 hours ago. The nurse determines that the woman's bladder is distended because her fundus is now 3 cm above the umbilicus and to the right of the midline. What does the nurse identify as being the most serious complication based on this finding?

Excessive uterine bleeding.

The nurse helps a breastfeeding mother change the diaper of her 16-hour-old newborn after the first bowel movement. The mother expresses concern because the large amount of thick, sticky stool is very dark green, almost black. She asks the nurse whether something is wrong. Which of the following would be the best response offered by the nurse?

Explaining to the mother that this stool is called meconium and is expected for the first few bowel movements of all newborns. The majority of healthy term infants pass meconium during the first 12 to 24 hours after birth. Meconium is composed of amniotic fluid, intestinal secretions, shed mucosal cells, and possibly blood, resulting in the dark green to black color. At this early age this type of stool is typical of both bottle- and breastfed newborns. The mother's nutritional intake is not responsible for the appearance of a meconium stool. The nurse is fully capable of and responsible for teaching a new mother about the characteristics of her newborn, including expected stool patterns.

A nurse observes a postpartum client to have excessive blood loss. Which cause should the nurse identify as being the most common cause for this finding?

Failure of the uterine muscle to contract firmly.

A nurse suspects that the laboring client has ruptured membranes. Which test should the nurse perform?

Fern test

A nurse is reviewing factors leading to decreased variabilty. Which cause should the nurse determine as being the most common for decreased variability in the fetal heart rate that lasts 30 minutes or less?

Fetal sleep cycles.

A group of nursing students are discussing the condition and reconditioning of the urinary system after childbirth. Which statement should the nursing students identify as correct?

Fluid loss through perspiration and increased urinary output account for a weight loss of more than 2 kg during the puerperium. Excess fluid loss through other means occurs as well. Kidney function usually returns to normal in about a month. Diastasis recti abdominis is the separation of muscles in the abdominal wall; it has no effect on the voiding reflex. Bladder tone usually is restored 5 to 7 days after childbirth.

Which of the following findings would raise concern for the nurse who is monitoring a postpartum client who had a spontaneous vaginal delivery (SVD) of a 10-lb baby boy?

Fundus midline and firm with spurts of bright red blood upon fundal massage

A nurse is talking to parents about the adjustment of a new baby to the family unit. Which parent action should the nurse identify as facilitating the adjustement of other children to the new baby?

Having children at home choose or make a gift to give the new baby on his or her arrival home. Because the family is an interactive, open unit, the addition of a new family member affects everyone. Siblings have to assume new positions within the family hierarchy. Parents often face the task of caring for a new child while not neglecting others. Having the siblings choose or make a gift for their new brother or sister is a good way for them to feel included. Parents need to distribute their attention in an equitable manner. One way to ensure that this happens is to set aside special time just for the other children without interruption from the newborn. Someone other than the mother should carry the baby into the home so that she can give her full attention to the other children. Children should be actively involved in the care of the baby, according to their ability, without being overwhelmed.

A group of nurses are discussing opioids. Which opiate would the nurses indicate as causing euphoria, relaxation, drowsiness, and detachment from reality and has possible effects on the pregnancy, including preeclampsia, intrauterine growth restriction, and premature rupture of membranes?

Heroin The opiates include opium, heroin, meperidine, morphine, codeine, and methadone. The signs and symptoms of heroin use are euphoria, relaxation, relief from pain, detachment from reality, impaired judgment, drowsiness, constricted pupils, nausea, constipation, slurred speech, and respiratory depression. Possible effects on pregnancy include preeclampsia, intrauterine growth restriction, miscarriage, premature rupture of membranes, infections, breech presentation, and preterm labor. Alcohol, PCP, and cocaine are not opiates.

A nurse is reviewing care and management of the pregnant client who is diagnosed with appendicitis. What physical location factor would the nurse identify as making this harder to diagnose?

High and to the right. The appendix is not hidden by the uterus; rather, it is pushed upward and to the right from its usual anatomic location, making diagnosis of appendicitis difficult.

A nurse is reviewing metabolic functions occurring during the postpartum period. Which of the following changes would the nurse identify as being consistent with that timeframe?

Increased BMR in the immediate postpartum period BMR remains elevated for the first 2 weeks after birth and then returns to prepregnancy levels. Insulinase enzyme reverses the diabetogenic effects of pregnancy, leading to decreased glucose levels in the postpartum period. Decreases in hormones such as estrogen and cortisol are seen during the postpartum period.Blood sugar levels typically decrease in the postpartum period as a result of the reversal of diabetogenic effects of pregnancy. Thyroid hormones gradually decrease to prepregnant levels in the 4 weeks following delivery. Secretion of insulinase BMR remains elevated for the first 2 weeks after birth and then returns to prepregnancy levels. Insulinase enzyme reverses the diabetogenic effects of pregnancy, leading to decreased glucose levels in the postpartum period. Decreases in hormones such as estrogen and cortisol are seen during the postpartum period.Blood sugar levels typically decrease in the postpartum period as a result of the reversal of diabetogenic effects of pregnancy. Thyroid hormones gradually decrease to prepregnant levels in the 4 weeks following delivery. Decrease in estrogen and cortisol levels BMR remains elevated for the first 2 weeks after birth and then returns to prepregnancy levels. Insulinase enzyme reverses the diabetogenic effects of pregnancy, leading to decreased glucose levels in the postpartum period. Decreases in hormones such as estrogen and cortisol are seen during the postpartum period.Blood sugar levels typically decrease in the postpartum period as a result of the reversal of diabetogenic effects of pregnancy. Thyroid hormones gradually decrease to prepregnant levels in the 4 weeks following delivery.

While caring for the newborn, the nurse must be alert for any signs of cold stress. Which finding should the nurse anticpate?

Increased respiratory rate In an infant who is cold, the respiratory rate rises in response to the increased need for oxygen. Signs of cold stress include increased activity level and crying (increased basal metabolic rate [BMR] and heat production). A cold infant is at risk for hypoglycemia as the glucose stores are depleted. Newborns are unable to shiver as a means to increase heat production.

A nurse is reviewing possible etiologies for hyperbilirubinemia in the newborn. Which findings would the nurse expect to lead to increased bilirubin levels in the newborn? (Select all that apply.)

Initiation of newborn feedings delayed following birth Twin-to-twin transfusion syndrome Meconium passed after 24 hours Delay in passage of meconium or in newborn feedings could lead to increased bilirubin levels because of increased enterohepatic circulation. Twin-to-twin transfusion syndrome could lead to increased bilirubin levels as a result of an increased amount of hemoglobin. An increase in bilirubin levels would be seen if cord clamping were delayed following birth. Hypoglycemia could lead to increased bilirubin levels because of alterations in hepatic function and perfusion.

A group of nurses are discussing postpartum hemorrahge (PPH). Which PPH conditions would the nurses consider as medical emergencies that require immediate treatment?

Inversion of the uterus and hypovolemic shock Inversion of the uterus and hypovolemic shock are considered medical emergencies. A hypotonic uterus can be managed with massage and oxytocin; coagulopathies should have been identified prior to delivery and treated accordingly. Although subinvolution of the uterus and ITP are serious conditions, they do not always require immediate treatment; ITP can be safely managed with corticosteroids or IV immunoglobulin. DIC and uterine atony are very serious obstetric complications but are not medical emergencies requiring immediate intervention.

To provide adequate postpartum care, the nurse should be aware that postpartum depression (PPD) with psychotic features:

Is typified by auditory or visual hallucinations. Hallucinations are present with this disorder; elements of delirium or disorientation, and extreme deficits in judgment accompanied by high levels of impulsivity may contribute to risks of suicide or infanticide. PPD is more likely to occur in first-time mothers. PPD with psychosis is a psychiatric emergency that requires hospitalization.

A nurse examining a newborn infant notes that the infant is jaundiced. Which observation would lead the nurse to continue to monitor but not to intervene and contact the physician?

Jaundice appeared on the third day of life. Physiologic jaundice can be seen in a large percentage of newborns, 60% of term and 80% of preterm, but typically resolves without immediate intervention. The critical factor here is the time of appearance, being within the first 24 hours of life. Jaundice appearing at this time is considered pathological and requires further investigation. The timing in C combined with prematurity also requires further investigation.

A nurse is taking care of a client in labor who is experiencing back pain. What action should the nurse implement?

Lean over a birth ball with her knees on the floor.

A nurse has provided client teaching to a breastfeeding mother. Which action if observed by the nurse would indicate the need for further instruction?

Leans forward to bring breast toward the baby. To maintain a comfortable, relaxed position, the mother should bring the baby to the breast, not the breast to the baby. The mother would need further demonstration and teaching to correct the ineffective action. The other actions described are correct.

A male infant at 26 weeks of gestation arrives from the delivery room intubated. 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 saturation values of 80%. The prescribed saturation value is 92%. What is the most appropriate nursing action?

Listen to breath sounds and ensure the patency of the endotracheal tube, increase oxygen, and notify a physician. The actions described in A are appropriate nursing interventions to assist in optimal O2 saturation of the infant. Oxygenation of the infant is crucial. O2 saturation should be maintained at more than 92%, and the nurse should delay other tasks to stabilize the infant. The action described in D is not appropriate. Further assessment and intervention are warranted prior to determination of fetal status.

As part of the postpartum assessment, the nurse examines the breasts of a primiparous breastfeeding woman 1 day postpartum. What should the nurse identify as an expected finding?

Little if any change.

A nurse is reviewing the clinical diagnosis of adult respiratory distres syndrome (ARDS) during pregnancy. Which clinical factor would the nurse associate as being present during pregnancy in the presence of ARDS?

Magnesium sulfate The use of tocolytics, such as magnesium sulfate, can be associated with the development of ARDS. Pitocin induction, cholecystitis, and hyperemesis gravidarum are not associated with ARDS.

A nurse is caring for a woman with mitral stenosis who is in the active stage of labor. Which action should the nurse take to promote cardiac function?

Maintain the woman in a side-lying position with the head and shoulders elevated to facilitate hemodynamics. The side-lying position with the head and shoulders elevated helps facilitate hemodynamics during labor. A vaginal delivery is the preferred method for a woman with cardiac disease because it sustains hemodynamics better than a cesarean section. The use of supportive care, medication, and narcotics or epidural regional analgesia is not contraindicated for a woman with heart disease. Using the Valsalva maneuver during pushing in the second stage should be avoided because it reduces diastolic ventricular filling and obstructs left ventricular outflow.

The nurse examines a woman 1 hour after birth. The woman's fundus is boggy, midline, and 1 cm below the umbilicus. Her lochial flow is profuse, with two plum-sized clots. What is the nurse's intial action?

Massage her fundus A boggy or soft fundus indicates that uterine atony is present. This is confirmed by the profuse lochia and passage of clots. The first action is to massage the fundus until firm.The physician can be called or methylergonovine administered after the fundus massage, especially if the fundus does not become or remain firm with massage. There is no indication of a distended bladder, so having the woman urinate will not alleviate the problem.

During rounds, a nurse suspects that a client who has recently delivered via vaginal route is having excessive postpartum bleeding. Which intervention would be the priority action taken by the nurse at this time?

Massage the uterine fundus. Massaging of the uterine fundus would be a priority action to help expel clots and stimulate uterine contractions to constrict blood flow. The other actions described, as well as catheterization (if bladder distention is noted) and lochia flow monitoring, may be needed, but none of them is the priority action required at this time.

On examining a woman who gave birth 5 hours ago, the nurse finds that the woman has completely saturated a perineal pad within 15 minutes. What is the first action to be taken by the nurse?

Massage the woman's fundus.

A nurse is caring for a first-time mother who is breastfeeding. Which postpartum infection would the nurse identify as being most often contracted by this client type?

Mastitis Mastitis is infection in a breast, usually confined to a milk duct. Most women who get it are first-timers who are breastfeeding. Endometritis is the most common postpartum infection. Its incidence is higher after a cesarean birth, not in first-time mothers. Wound infections are also a common postpartum complication. Sites of infection include both a cesarean incision and the episiotomy or repaired laceration. The gravidity of the mother and her feeding choice are not factors in the development of a wound infection. UTIs occur in 2% to 4% of all postpartum women. Risk factors include catheterizations, frequent vaginal exams, and epidural anesthesia.

Nurses must be cognizant of the growing problem of methamphetamine use during pregnancy. When caring for a woman who uses methamphetamines, it is important for the nurse to be aware of which factor related to the abuse of this substance?

Methamphetamine users are extremely psychologically addicted. "Meth" users are extremely psychologically addicted. Typically these women display poor control over their behavior and a low threshold for pain. This substance is relatively inexpensive and easy to obtain. Methamphetamine is a stimulant and a vasoconstrictor. The rate of relapse for methamphetamine users is very high.

A nurse caring for a woman in labor understands that increased variability of the fetal heart rate might be caused by:

Methamphetamines.

A pregnant woman with cystic fibrosis (CF) wants to breastfeed her infant. Which assessments by the nurse would have to be performed in order to make sure that the breastfeedings were safe and effective? (Select all that apply.)

Monitor total fat levels in breast milk Monitor infant growth pattern Monitor sodium levels in breast milk Breast milk should be monitored for sodium, total fat, and chloride levels in order to establish its safety. Monitoring of the infant's growth pattern would provide evidence that breastfeeding is adequate. Maternal weight monitoring and urinalysis would not be indicated with regard to the safety of breastfeeding in this case.

A nurse is working with a postpartum client who is experiencing after birth pains. Which statement should the nurse identify as being accurate with regard to afterbirth pains?

More noticeable in births in which the uterus was overdistended.

While evaluating the reflexes of a male newborn, the nurse notes that with a loud noise, the newborn symmetrically abducts and extends his arms, his fingers fan out and form a "C" with the thumb and forefinger, and he has a slight tremor. The nurse documents this finding as a positive:

Moro reflex response The characteristics displayed by the infant are associated with a positive Moro reflex response. The tonic neck reflex occurs when the infant extends the leg on the side to which the infant's head simultaneously turns. The glabellar reflex is elicited by tapping on the infant's head while the eyes are open; a characteristic response is blinking for the first few taps. The Babinski reflex occurs when the sole of the foot is stroked upward along the lateral aspect of the sole and then across the ball of the foot; a positive response occurs when all the toes hyperextend, with dorsiflexion of the big toe.

The nurse is reviewing concepts related to healthy-parent infants bonding. The nurse recognizes that the process in which the infant's behaviors and characteristics call forth a corresponding set of maternal behaviors and characteristics is called:

Mutuality. Bonding is the process through which over time parents form an emotional attachment to their infant. Mutuality refers to a shared set of behaviors that is a part of the bonding process. Like mutuality, acquaintance is part of attachment. It describes how parents get to know their baby during the immediate postpartum period through eye contact, touching, and talking. Claiming is the process by which parents identify their new baby in terms of likeness to other family members, the differences, and the baby's uniqueness.

A nurse is working with a Hispanic client. Which statement accurately reflects an after childbirth ritual?

Naming of the child can not be done until the 40 day period has been met. Hispanic women do not name their infant until the 40 day confimennt period ends following birth. Breastfeeding is not started until after the mother's milk has come in. Restrictions are placed and cultural beliefs are aligned with periods of time rather than the indication of being a good mother.

The nurse is evaluating the fetal monitor tracing of a client, who is in active labor. Suddenly the fetal heart rate (FHR) drop from its baseline of 125 down to 80. The nurse repositions the mother, provides oxygen, increases IV fluid, and performs a vaginal exam. The cervix has not changed. Five minutes have passed, and the FHR remains in the 80s. What additional measures should the nurse take?

Notify the primary health care provider immediately.

Nurses are getting ready for bedside reporting at change of shift. What benefit do the nurses identify for this type of change of shift report?

Nurses are able to visualize their client's directly at the time of report leading to better client satisfaction. Using a bedside report technique helps the nurse directly visualize the client in question so as to improve his/her understanding of each client's clinical situation. The transparency of information is not a benefit of bedside reporting. A bedside report is a change-of-shift report between nurses involved in the delivery of health care to a client and/or group of clients; it is not mediated by client questioning. Also, it is not all inclusive because client care continues and is evolving over the course of the client's hospitalization. Thus, additional information will be needed.

Which statement regarding Postpartum Depression (PPD) is essential for the nurse to be aware of when attempting to formulate a nursing diagnosis?

PPD can easily go undetected. PPD can go undetected because parents do not voluntarily admit to this type of emotional distress out of embarrassment, fear, or guilt. PPD symptoms range from mild to severe, with women having good days and bad days. Screening should be done for mothers and fathers, because PPD may also occur in new fathers. The nurse should include information on PPD and how to differentiate this from the baby blues for all clients on discharge. Nurses also can urge new parents to report symptoms and seek follow-up care promptly if they occur.

A nurse is assessing a client who is 12 hours postpartum. Which finding would be a source of concern if observed by the nurse?

Pain in left calf with dorsiflexion of left foot These findings indicate presence of Homans sign, are suggestive of thrombophlebitis, and should be investigated. Postural hypotension is an expected finding related to circulatory changes after birth. A heart rate of 55 beats/min is an expected finding in the initial postpartum period. A temperature of 38° C in the first 24 hours most likely indicates dehydration, which is easily corrected by increasing oral fluid intake.

A nurse is caring for a postpartum client who is experiencing profuse postpartum bleeding. What is the priority intervention to be performed by the nurse?

Palpate the uterus and massage it if it is boggy. The initial management of excessive postpartum bleeding is firm massage of the uterine fundus to stop the bleeding. This is the most important nursing intervention. Then the primary health care provider should be notified or the nurse can delegate this task to another staff member. Administering an oxytocic and ascertaining vital signs are appropriate after assessment has been made and immediate steps have been taken to control the bleeding.

A nurse is monitoring an obstetrical client. Which test result would provide evidence to the nurse that there is fetal blood in maternal circulation?

Positive Kleihauer-Betke test result A Kleihauer-Betke test determines the presence of fetal blood in maternal circulation.A positive fern test result would indicate the presence of amniotic fluid, noting that membranes had ruptured. A positive Coombs test result would indicate that the mother has Rh antibodies, and a negative result would indicate no presence of Rh antibodies.

A nurse is advising a pregnant client who has a substance abuse problem about a contingency management program. Which statement would the nurse identify as being an aspect of this type of program?

Pregnant woman are given motivational incentives as a primary approach to stop their drug abuse problem. A contingency management program utilizes a motivational incentive approach with clients to support their efforts to maintain abstinence. The incentives may include small cash amounts, privileges, or prizes. Contingency management programs are not limited to inclient settings and do not involve biofeedback modalities or medication nutritional programs.

A nurse is reviewing the 4 Ps-Plus screening tool. Which of the following would the nurse identify as not being included in the tool?

Present The first P is Parents: The woman should be asked, "Did either of your parents have a problem with alcohol or drugs?" The second P is Partner: "Does your partner have a problem with alcohol or drugs?" The third P is Past: "Have you ever had any beer, wine, or liquor?" The fourth P is 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?"

A nurse is preparing to educate a group of postpartum clients. Which description of postpartum restoration or healing times should the nurse identify as being accurate?

Rugae reappear within 3 to 4 weeks. Rugae are never again as prominent as in a nulliparous woman. Localized dryness may occur until ovarian function resumes. The cervix regains its form within days; the cervical os may take longer. Most episiotomies take 2 to 3 weeks to heal. Hemorrhoids can take up to 6 weeks to decrease in size.

The nurse observes several interactions between a postpartum woman and her new son. What behavior, if exhibited by this woman, does the nurse identify as a possible maladaptive behavior regarding parent-infant attachment?

Seldom makes eye contact with her son The woman should be encouraged to hold her infant in the in face position and make eye contact with him. Talking and cooing to her son, cuddling, and sharing her son's success at feeding are all normal infant-parent interactions or actions.

A nurse is reviewing phases of maternal postpartum adjustment. Which behaviors should the nurse identify as being exhibited during the letting-go phase of maternal role adaptation? (Select all that apply.)

Sexual intimacy relationship continuing Emergence of family unit Defining one's individual roles Emergence of family unit, sexual intimacy relationship continuing, and defining one's individual roles represent interdependent behaviors associated with the letting-go phase. Dependent behaviors are exhibited in the taking-in phase. Being talkative and excited about becoming a mother represents the taking-hold phase and is an example of dependent-independent behaviors.

A nurse is reviewing the concept of lochia. Which statement should the nurse identify as correct?

Should smell like normal menstrual flow unless an infection is present.

A client has just delivered a healthy newborn. Which action should the nurse peform based on evidence-based care practice in the immediate newborn period?

Skin-to-skin contact of mother and baby should be encouraged.

A nurse is reviewing the concept of weaning with regard to infant care. Which statement should the nurse identify as correct?

Weaning can be mother or infant initiated. Weaning is initiated by the mother or the infant. With infant-led weaning, the infant moves at his or her own pace in omitting feedings, which leads to a gradual decrease in the mother's milk supply. In mother-led weaning, the mother decides which feedings to drop. Infants can be weaned directly from the breast to a cup. Bottles are usually offered to infants younger than 6 months. If the infant is weaned prior to 1 year of age, iron-fortified formula rather than cow's milk should be offered. The feeding of least interest to the baby or the one through which the infant is likely to sleep should be eliminated first. Every few days thereafter the mother drops another feeding. Gradual weaning over a period of weeks or months is easier for both the mother and the infant than an abrupt weaning.

A nurse is caring for a client who is bottle-feeding but has engorged breasts. What action should the nurse implement?

Wear a snug, supportive bra.

A nurse is reviewing the concept of Category X substances. Which of these medications would the nurse classify as a Category X substance that is not to be used during pregnancy?

Temazepam (Restoril) Restoril is classified as a Category X drug and is contraindicated during pregnancy on the basis of clinical studies. Ativan, Xanax, and Librium are classified as Category D drugs and as such would not be given during pregnancy unless a benefits to risks ratio was established.

A nurse is examining a newborn male, who is estimated to be 39 weeks of gestation. Which physical finding should the nurse anticipate to be present?

Testes descended into the scrotum. A full-term male infant has both testes descended into his scrotum and rugae appear on the anterior portion. A full-term infant's good muscle tone results in a more flexed posture when at rest. A full-term infant exhibits only a moderate amount of lanugo, usually on the shoulders and back. Preterm infants have an abundance of lanugo over the entire body. The muscle tone of a full-term newborn prevents him from being able to move his elbow past midline.

The nurse is using intermittent auscultation (IA) to assess uterine activity. Which statement should the nurse identify as correct?

The examiner's hand should be placed over the fundus before, during, and after contractions.

A nurse is caring is administering a gavage feeding to an infant. What should the nurse document each time?

The infant's response to the feeding 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. Some older infants may be learning to suck, but the important factor to document is the infant's response to the feeding (including attempts to suck). Abdominal circumference is not measured after a gavage feeding. Vital signs may be obtained prior to feeding, but the infant's response is more important.

In follow-up appointments or visits with parents and their new baby, it may be useful if the nurse can identify parental behaviors that can either facilitate or inhibit attachment. Which of the following should the nurse identify as a facilitating behavior?

The parents hover around the infant, directing attention to and pointing at the infant. Hovering over the infant, as well as obviously paying attention to the baby, is a facilitating behavior. The other choices are inhibiting behaviors.

When assessing a multiparous woman who has just given birth to an 8-pound boy, the nurse notes that the woman's fundus is firm and has become globular. A gush of dark red blood comes from her vagina. How does the nurse interpret this finding?

The placenta has separated.

The nurse is monitoring a client during labor. Which observation if noted by the nurse would indicate fetal well-being?

The response of the fetal heart rate (FHR) to uterine contractions (UCs).

A nurse is providing instruction to a postpartum client regarding perineal care technique. When evaluating the postpartum woman's perineal care technique, the nurse would recognize the need for further instruction if the woman:

Uses the peribottle to rinse upward into her vagina.

A nurse is making a home visit to a postpartum woman 1 week after childbirth. Which client observation should the nurse expect?

Vacillate between the desire to have her own nurturing needs met and the need to take charge of her own care and that of her newborn. One week after birth the woman should exhibit behaviors characteristic of the dependent-independent or taking-hold stage. She still has needs for nurturing and acceptance by others. Wanting to discuss the events of her labor and delivery are characteristics of the taking-in stage, as are a limited readiness to learn and reduced attention span; this stage lasts from the first 24 hours until 2 days after delivery. Having reestablished her role as a spouse reflects the letting-go stage, which indicates that psychosocial recovery is complete.

A nurse is reviewing the clinical manifestation of fetal bradycardia. What indication should the nurse identify as being the most common cause?

Viral infection.

A nurse caring for a newborn should be aware that the sensory system least mature at the time of birth is:

Vision. The visual system continues to develop for the first 6 months. As soon as the amniotic fluid drains from the ear (minutes), the infant's hearing is similar to that of an adult. Newborns have a highly developed sense of smell and can distinguish and react to various tastes.

A nurse is working with parents who have a sensory impairment. Which statement should the nurse identify as being inaccurate?

Visually impaired mothers cannot overcome the infant's need for eye-to-eye contact. Other sensory output can be provided by the parent, other people can participate, and other coping devices can be used. The skepticism, open or hidden, of health care professionals throws up an additional and unneeded hurdle for the parents. After the parents' capabilities have been assessed (including some the nurse may not have expected), the nurse can help find ways to assist the parents that play to their strengths. The Internet affords an extra teaching tool for the deaf, as do videos with subtitles or nurses signing. A number of electronic devices can turn sound into light flashes to help a pick up a child's cry. Sign language is acquired readily by young children.

The nurse taught new parents the guidelines to follow regarding the bottle feeding of their newborn who will be using formula from a can of concentrate. Which action if observed by the nurse would indicate that the parents correctly understand the nurse's instruction?

Wash the top of can and can opener with soap and water before opening the can. Washing the top of the can and can opener with soap and water before opening the can of formula is a good habit for parents to get into to prevent contamination. Directions on the can for dilution should be followed exactly and not adjusted according to weight gain to prevent nutritional and fluid imbalances. Honey is not necessary and could contain botulism spores. The formula should be warmed in a container of hot water because a microwave can easily overheat it.

A nurse is assisting a breastfeeding mother with positioning of the baby. Which finding should the nurse be aware of?

Whatever the position used, the infant is held in direct skin with the mother. The infant inevitably faces the mother, belly to belly and should be in direct skin contact. The football position usually is preferred after cesarean birth. Women with perineal pain and swelling prefer the side-lying position because they can rest while breastfeeding. The mother should never push on the back of the head, because doing so might cause the baby to bite, hyperextend the neck, or develop an aversion to being brought near the breast.

A nurse is working on the labor and delivery unit. Under which circumstance would a nurse not perform a vaginal examination on a client in labor?

When accelerations of the fetal heart rate (FHR) are noted