2300 U2 Reproduction
Neonate pulse range
110-160 bpm
Apgar: Pulse
Absent: 0 points Below 100 bpm: 1 point Over 100 bpm: 2 points
Jaundice appearing after 72 hours
Breastfeeding jaundice; breast milk jaundice; rare/congenital issues
Lochia alba
Day 10-6 weeks
Apgar: Grimace
Flaccid: 0 points Some flexion of extremities: 1 point Active motion: 2 points
Jaundice appearing within 24 hours
Hemolytic; infections
Jaundice appearing around 24-72 hours
Physiological or normal-very common
Lochia serosa
day 3/4-day 10
Lochia rubra
until day 3/4
Apgar: Activity
Absent: 0 points Arms and legs flexed: 1 point Active movement: 2 points
Jaundice appearing before 24 hours
Pathological
When is RhoGAM given
28 weeks gestation and 72 hours post delivery
Neonate respiration range
30-60 respirations per minute
Neonate temperature
97.7-99.5 F 36.5-37.5 C
While changing the neonate's diaper, the client asks the nurse about some red-tinged drainage from the neonate's vagina. Which of the following responses would be most appropriate? A) It's of no concern because it is such a small amount B) The cause is usually related to swallowing blood during the delivery C) Sometimes baby girls have this from hormones received from the mother D) This vaginal spotting is caused by hemorrhagic disease of the newborn
C (pseudomenstruation)
A 38 year old woman who is 36 weeks pregnant presents with HTN since age 34 and requires antihypertensive drugs. Prior to pregnancy, her BP was 130/70. During her 1st trimester: BP 120/60 and has risen in recent weeks to 150/95. She is complaining of worsening lower extremity edema. 24 hour urine shows 1500 mg of protein. Lab values for electrolytes, LFT, platelet counts are normal. What is likely the patient's diagnosis? A) Chronic essential HTN B) Eclampsia C) HELLP D) Preeclampsia
D
What is the significance of Newborns and Mothers Health Protection Act of 1996?
Hospital stay of 48 hours post vaginal birth and 72 hours post C-section
Neonate blood pressure
50-75/30-45
While making a home visit to a primiparous client and her 3 day old son, the nurse observes the mother changing the baby's disposable diaper. Before putting the new diaper on, the mother begins to apply baby powder to the infant's buttocks. Which statement about baby powder would the nurse make? A) It may cause pneumonia to develop B) It helps prevent diaper rash C) It keeps the diaper from adhering to the skin D) It can result in allergies late in life
A
Apgar: Respirations
Absent: 0 points Slow, irregular: 1 point Vigorous cry: 2 points
While making a home visit to a postpartum client on day 11, the nurse would anticipate that the client's lochia would be which of the following colors? A) Dark red B) Pink C) Brown D) White
D
While the nurse is preparing to assist the primiparous client to the bathroom to void 6 hours after a vaginal delivery under epidural anesthesia, the client says that she feels dizzy when sitting up on the side of the bed. The nurse explains that this is most likely caused by which of the following? A) Effects of the anesthetic during labor B) Hemorrhage during the delivery process C) Effects of analgesics used during labor D) Decreased blood volume in the vascular system
D
After instructing a primiparous client who is bottle feeding, which of the following client statements indicates that the client needs further teaching? A) I'll burp him after 15 minutes of feeding him formula B) After he takes 1/2 ounce of formula, I'll burp him C) I'll burp him while he is in an upright position D) I'll gently pat his back to get him to burp
A
Assessment of a term neonate at 2 hours after birth reveals a heart rate of 110 bpm. Periods of apnea approximately 25-30 seconds in length and mild cyanosis around the mouth. The nurse notifies the pediatrician based on the interpretation that these findings may lead to which condition? A) Respiratory arrest B) Bronchial pneumonia C) Intraventricular hemorrhage D) Epiglottitis
A
At which of the following locations would the nurse expect to palpate the fundus of a primiparous client 12 hours after delivery of a neonate? A) Halfway between the umbilicus and the symphysis pubis B) At the level of the umbilicus C) Just below the level of the umbilicus D) Above the level of the umbilicus
B
A 6 lb 8 oz neonate was delivered vaginally at 38 weeks gestation. At 5 minutes of life, the neonate has the following signs: Heart rate 110 bpm, intermittent grunting with respiratory rate of 70, flaccid tone, no response to stimulus, overall pale white in color. The Apgar score is: A) 2 B) 3 C) 4 D) 6
B
Apgar: Appearance
Blue, pale: 0 points Body pink, acrocyanosis: 1 point Completely pink: 2 points
A client is in the first hour of her recovery after a vaginal delivery. During an assessment, the lochia is moderate, bright red, and is trickling from the vagina. The nurse locates the fundus at the umbilicus: it is firm and midline with no palpable bladder. The client vital signs remain at their baseline. Based on this information, the nurse would implement which of the following actions? A) Increase the IV rate B) Recheck the admission hematocrit and hemoglobin levels C) Report the finding to the health care provider D) Document the findings as normal
C
Approximately 90 minutes after birth the nurse encourages the mother of a term neonate to do which of the following? A) Feed the neonate B) Allow the neonate to sleep C) Get to know the neonate D) Change the neonate's diaper
B
While performing a complete assessment of a term neonate, which of the following findings would alert the nurse to notify the pediatrician? A) Red reflect in the eyes B) Expiratory grunt C) Respiratory rate of 45 breaths/minute D) Prominent xiphoid process
B
A primiparous client who underwent a C-section delivery 30 minutes ago is a candidate for Rho(D) immune globulin (RhoGAM). The nurse anticipates administering this ordered medication within which of the following time frames after delivery? A) 8 hours B) 24 hours C) 72 hours D) 96 hours
C
Initial assessment of a term female neonate about 4 hours old reveals a normal anterior fontanel. The nurse documents its shape as which of the following? A) Oval B) Square C) Diamond shaped D) Triangular
C
The nurse is caring for a postpartum client who delivered vaginally 4 hours ago and has not voided since delivery. Feeling has returned to her perineal area, and she has ambulated to the bathroom and attempted to void twice. SHe has ice on her edematous perineum. Her uterus is 3 fingerbreadths above the umbilicus, to the right of midline, and boggy. What would be the priority nursing actions? A) Evaluate the client with a bladder scan B) Insert a foley catheter C) Medicated the client with NSAID D) Massage the fundus until it is firm and perform a one-time catheterization on the client
D
36 week pregnant woman presents complaining of mid-epigastric tenderness, nausea, and vomiting. She looks unwell. Her BP is 146/100, lab test shows normal renal function, low platelet count, AST level of 80 IU/L (elevated liver enzymes), and hemolysis with a microangiopathic blood smear. She is diagnosed with HELLP. Which of the following is the most important initial therapeutic intervention for this patient? A) Bedrest until fetus reaches 40 weeks B) immediate delivery C) Platelet infusion to prevent bleeding D) Right upper quadrant ultrasound
B
When instilling erythromycin ointment into the eyes of a neonate 1 hour old, the nurse would explain to the parents that the medication is used to prevent which of the following? A) chorioretinitis from cytomegalovirus B) Blindness secondary to gonorrhea C) Cataracts from beta-hemolytic streptococcus D) Strabismus resulting from neonatal maturation
B
When developing the plan of care for a primiparous client during the first 12 hours after vaginal delivery, which of the following concerns of the client should be the nurse's primary focus of care? A) The neonate B) The family C) The client's own comfort D) The client's significant other
C
2 hours after vaginally delivering a viable male neonate under epidural anesthesia, the client with a midline episiotomy ambulates to the bathroom to void. After voiding, the nurse assesses the client's bladder, finding it distended. The nurse interprets this finding based on the understanding that the client's bladder distention is most likely caused by which of the following? A) Prolonged first stage of labor B) Urinary tract infection C) Pressure of the uterus on the bladder D) Edema in the lower urinary tract area
D
A 26 year old primiparous client is seen in the urgent care clinic 2 weeks after delivering a viable female neonate. The client, who is breast feeding, is diagnosed with infectious mastitis of the right breast. The client asks the nurse, "can I continue breast feeding?" Which of the following responses would be most appropriate? A) You can continue to breastfeed, feeding your baby more frequently B) You can continue once your symptoms begin to decrease C) You must discontinue breastfeeding until antibiotic therapy is completed D: You must stop breastfeeding because the breast is contaminated
A
The nurse makes a home visit to 3 day old full term neonate who weighed 8 lb 10 oz at birth. Today the neonate who is being bottle-fed weighs 7 lb 14 oz. Which of the following instructions would the nurse most likely give to the mother? A) Continue feeding every 3-4 hours since weight loss is normal B) Contact the physician if the weight loss continues over the next few days C) Switch to a soy-based formula because the current one seems inadequate D) Change to a higher-calorie formula to prevent further weight loss
A
A primiparous client who is bottle feeding her neonate at 12 hours after birth asks the nurse, "when will my menstrual cycle return?": Which of the following responses by the nurse would be most appropriate? A) Your menstrual cycle will return in 3-4 weeks B) It will probably be 6-10 weeks before it starts again C) You can expect your menses to start in 12-14 weeks D) Your menses will return in 16-18 weeks
B
Which of the following observations would the nurse expect when assessing the gestational age of a neonate delivered at term? A) Ear lying flat against the head B) Absence of rugae in the scrotum C) Sole creases covering the entire foot D) Square window sign angle of 90 degress
C
A 27 year old female 30 weeks pregnant presents to her MD for routine follow-up: BP 150/105 Hg. She was previously normotensive. Urinalysis reveals 1+ proteinuria. Serum uric acid level is 5.0 mg/dL.. Platelet count and liver function tests are normal. 24 hour urine collections shows 1.1 g protein. Which of the following does this patient most likely have? A) Chronic hypertension B) Gestational hypertension C) Normal blood pressure for pregnancy D) Pre-eclampsia
D
A client delivered vaginally 2 hours ago and has a 3rd degree laceration. There is ice in place on her perineum. However, her pain rated 6/10. Which nursing intervention would be the most appropriate at this time? A) Begin sitz baths B) Administer pain medication per order C) Replace ice packs to the perineum D) Initiate anesthetic sprays to the perineum
B
A viable female neonate delivered vaginally at term has Apgar scores of 9 at 1 minute and 10 at 5 minutes after birth. Immediately postpartum, the nurse keeps the infant under a radiant warmer away from the cooling ducts in the room to prevent heat loss by which of the following mechanisms? A) Evaporation B) Convection C) Conduction D) Radiation
B
After instructing a primiparous client about episiotomy care which of the following client statements indicates a successful teaching? A) I'll use hot, sudsy water to clean the episiotomy area B) I wipe the area from front to back using a blotting motion C) Before bedtime, I'll use a cold water sitz bath D) I can use ice packs for 3-4 days after delivery
B
The nurse is assessing a cesarean section client who delivered 12 hours ago. Findings include a distended abdomen with faint bowel sounds x1 quadrant, fundus firm at the umbilicus, lochia scant, rubra, and pain 4/10. The IV and Foley catheter have been discontinued and the client was medicated 3 hours ago for pain. When planning care for this client, what should the nurse identify as the highest priority interventions? A) Medicate the client B) Incentive spirometry C) Ambulate the client D) Encourage caring for infant
C
Vitamin K is used to prevent which of the following? A) Hypoglycemia B) Hyperbilirubinemia C) Hemorrhage D) Polycythemia
C
