Chapter 19, T/C II Exam 3
At 37 weeks' gestation, a woman presents to labor and delivery complaining of intense, knife-like abdomen pain that started suddenly about 1 hour ago and has not subsided. On palpation, the abdomen is rigid and board-like and no vaginal bleeding is evident. What should the nurse do next?
Assess fetal heart rate
A nurse in the maternity triage unit is caring for a client with a suspected ectopic pregnancy. Which nursing intervention should the nurse perform first?
Assess the client's vital signs.
What can help with fetal lung development in preterm labor?
Betamethasone steroid
causes of possterm pregnancy
Cause is largely unknown, genetics, obesity, primiparity
Nuchal cord
Cord around the baby's neck:
If a patient presents with bright red painless bleeding and states she has had no prenatal care, what do you NOT do?
Vaginal / cervical exam, because this could be a placenta previa and you could stick your fingers through the placenta and cause a huge problem, like more bleeding.
A nurse is conducting a refresher program for a group of perinatal nurses. Part of the program involves a discussion of HELLP. The nurse determines that the group needs additional teaching when they identify which aspect as a part of HELLP?
elevated lipoproteins
postterm pregnancy
gestation of the fetus that extends beyond 42 weeks (294 days since last menstrual period)
Placental abruption
premature separation of the placenta from the uterus Complete or partial after 20 weeks
Placenta previa risk factors
previous previa, scar tissue, AMA, multiple gestation, smoking
When assessing a pregnant woman with vaginal bleeding, the nurse would suspect a threatened abortion based on which finding?
slight vaginal bleeding
symptoms of placental abruption
Sudden onset of intense LOCALIZED PAIN with dark red vaginal bleeding, uterine tenderness and firmness, hypertonic UC's, hypovolemic shock
Premature Rupture of Membranes (PROM)
a rupture (breaking open) of the membranes (amniotic sac) before labor begins (one hour or more)
Nuchal cord treatment
can be manually reduced or cut on perineum
Risk factors for Cervical insufficiency
cervical trauma, D&C
A client has been admitted with abruptio placentae. She has lost 1,200 mL of blood, is normotensive, and ultrasound indicates approximately 30% separation. The nurse documents this as which classification of abruptio placentae?
grade 2
A nurse is caring for a newborn who has hydrocephalus. Which of the following manifestations should the nurse expect to find? Over-riding suture lines Dilated scalp veins Hypertension A backward sloping appearance of the forehead.
Dilated scalp veins Manifestations of hydrocephalus in newborns include dilated scalp veins, separated sutures, and, in late infancy, frontal enlargement.
A 25-year-old client at 22 weeks' gestation is noted to have proteinuria and dependent edema on her routine prenatal visit. Which additional assessment should the nurse prioritize and alert the RN or health care provider?
Initial BP 100/70 mm Hg; current BP 140/90 mm Hg
What meds are used to ripen the cervix and dilate it?
Misoprostol or Prostaglandins
hypotonic labor patterns
hypotonic contractions -Irregular contractions -Lack intensity -Less than 1 cm dilatation per hour usually caused by Cephalopelvic Disproportion (CPD) or Malposition
A woman of 16 weeks' gestation telephones the nurse because she has passed some "berry-like" blood clots and now has continued dark brown vaginal bleeding. Which action would the nurse instruct the woman to do?
"Come to the health facility with any vaginal material passed."
A nurse is caring for a client who has rubella at the time of delivery and asks why her newborn is being placed in isolation. Which of the following responses by the nurse is appropriate? "The newborn might be actively shedding the virus." "The newborn is at risk for developing a TORCH infection." "The child might develop encephalitis, a complication of rubella." "Exposure to rubella will suppress the newborn's immune response."
"The newborn might be actively shedding the virus." Infants born to mothers who have rubella will continue to shed the rubella virus for up to 18 months postdelivery.
tachysystole labor pattern
-uterine hyperstimulation: greater than 5 contractions per 10 minutes -this is bad and it is dysfunctional
3 things magnesium sulfate does for the pregnant woman
1. prevent seizures (lowers seizure threshold) 2. protect baby's brain at time of delivery 3. slows down labor process
An RN from the maternal-newborn unit is being floated to a medical surgical unit. Which of the following clients should the charge nurse plan to assign to RN? A client who has terminal end-stage renal disease A client who has acute pancreatitis A client who is one-day postoperative following a total abdominal hysterectomy A client who had a stroke and is to be admitted
A client who is one-day postoperative following a total abdominal hysterectomy The nurse who floats to another unit must have the skills to provide safe care to clients. This client is stable. This is an appropriate assignment for the RN.
A nurse is reviewing a newborn's laboratory results. Which of the following findings is the nurse's priority? Platelets 200,000/mm3 Bilirubin 19 mg/dL Blood glucose 45 mg/dL Hemoglobin 22 g/dL
Bilirubin 19mg/dL Bilirubin 19 mg/dL is above the expected reference range for a newborn at 4 hr of age. A bilirubin level greater than 15 mg/dL or an increase by more than 6 mg/dL in 24 hr is pathologic or nonphysiologic jaundice. Pathologic jaundice is a result of an underlying disease and occurs before 24 hr of age; therefore, this is the nurse's priority finding.
Before calling the health care provider to report a slow progression or an arrest of labor, several assessments need to be made. What other maternal assessment does the nurse need to make prior to calling the health care provider? Make sure the epidural medication is turned down. Assess vital signs every 30 minutes. Make sure the client is lying on her left side. Check for a full bladder.
Check for a full bladder. Explanation: A full bladder can interfere with the progress of labor, so the nurse must be sure that the client has emptied her bladder.
A nurse is planning care for a preterm newborn. Which of the following nursing interventions to promote development should be included in the plan of care? A. Position the newborn to promote extension of muscles B. Use fingertips when calming newborn C. Cluster the newborn's care activities D. Keep the newborn I a well-lit nursery
Cluster the newborn's care activities. By clustering activities and organizing care, the nurse prevents excessive interruptions and allows the newborn extended periods of rest and energy conservation that promote development.
Placental abruption risk factors
HTN (causes vasoconstriction that alerts the placenta to separate), trauma (seatbelts in MVC), drug use, previous abruption, smoking, PROM, multifetal pregnancy
A nurse is preparing to administer an injection of Rh(D) immunoglobulin. The nurse should understand that the purpose of this injection is to prevent which of the following newborn complications? Hydrops fetalis Hypobilirubinemia Biliary atresia ?Transient clotting difficulties
Hydrops fetalis
A nurse is caring for a term macrosomic newborn whose mother has poorly controlled type 2 diabetes. The newborn has respiratory distress syndrome. The nurse should be aware that the most likely cause of respiratory distress is which of the following? Hyperinsulinemia Increased deposits of fat in the chest and shoulder area Brachial plexus injury Increased blood viscosity
Hyperinsulinemia High levels of maternal glucose increase the production of fetal insulin. High fetal insulin levels interfere with the production of surfactant.
A nurse is caring for a client who is scheduled for a maternal serum alpha-fetoprotein test at 15 weeks of gestation. The nurse provides which of the following explanations about this test to the client? This test assesses fetal lung maturity. It assesses various markers of fetal well-being. This test identifies an Rh incompatibility between the mother and fetus. It is a screening test for spinal defects in the fetus.
It is a screening test for spinal defects in the fetus.
The nurse is caring for a pregnant client with severe preeclampsia. Which nursing intervention should a nurse perform to institute and maintain seizure precautions in this client?
Keep the suction equipment readily available.
The nurse is caring for a client suspected to have a uterine rupture. The nurse predicts the fetal monitor will exhibit which pattern if this is true? Late decelerations Variable decelerations Early decelerations Mild decelerations
Late decelerations Explanation: When the fetus is being deprived of oxygen the fetus will demonstrate late decelerations on the fetal monitoring strip. This is an indication the mother is in need of further assessment. Early decelerations are a normal finding. Variable decelerations usually coincide with cord compression.
A nurse is caring for a newborn who has myelomeningocele. Which of the following nursing goals has the priority in the care of this infant? A. educate the parents about the defect B. provide age-appropriate stimulation C. promote maternal-infant bonding D. maintain the integrity of the sac
Maintain the integrity of the sac. Myelomeningocele is a congenital disorder that causes the spine and spinal canal to not close prior to birth, which results in the spinal cord, meninges, and nerve roots protruding out of the child's back in a fluid-filled sac. Before surgery, the infant must be handled carefully to reduce damage to the exposed spinal cord and to maintain the integrity of the sac.
The nurse is caring for a pregnant client with fallopian tube rupture. Which intervention is the priority for this client?
Monitor the client's vital signs and bleeding.
A woman presents at Labor and Delivery very upset. She reports that she has not felt her baby moving for the last 6 hours. The nurse listens for a fetal heart rate and cannot find a heartbeat. An ultrasound confirms fetal death and labor induction is started. What intervention by the nurse would be appropriate for this mother at this time? Offer to take pictures and footprints of the infant once it is delivered. Recommend that she not hold the infant after it is delivered so as to not upset her more. Explain to her that there was probably something wrong with the infant and that is why it died. Call the hospital chaplain to talk to the parents.
Offer to take pictures and footprints of the infant once it is delivered. Explanation: When parents are faced with a fetal death, they need comfort and support without being intrusive. Taking pictures, footprints and gathering other mementos are very important in helping the family deal with the death. The mother is encouraged to hold the infant after delivery and name it. Telling the parents that the infant was probably defective is hurtful and not supportive to them. Calling the hospital chaplain is something that can be offered but should not be done without the parent's approval.
symptoms of placenta previa
Painless Bright red vaginal bleeding Soft uterus Normal fetal hr
A nurse is planning care for a newborn who has spina bifida. Which of the following actions should be included in the plan of care? Obtain rectal temperatures. Place the newborn in the prone position. Cover the lesion with a dry dressing. Apply snug, clean diapers.
Place the newborn in the prone position. Placing the newborn in the prone position prevents trauma to the lesion. The newborn's knees should be assessed for evidence of skin breakdown.
A client at 27 weeks' gestation is admitted to the OB unit afer reporting headaches and edema of her hands. Review of the prenatal notes reveals BP consistently above 136/90 mm Hg. The nurse anticipates the health care provider will order magneisum sulfate to accomplish which primary goal?
Prevent maternal seizures
The following hourly assessments are obtained by the nurse on a client with preeclampsia receiving magnesium sulfate: 97.3oF (36.2oC), HR 88, RR 1, BP 148/110 mm Hg. What other priority physical assessments by the nurse should be implemented to assess for potential toxicity?
Reflexes
Risks of preterm rupture of membranes
Risks to mom include intra-amniotic infection, postpartum infection, endometritis, and death.
A nurse is caring for a client who is 5 hr postpartum following a vaginal birth of a newborn weighing 9 lb 6 oz (4252g). The nurse should recognize that this client is at risk for which of the following postpartum complications? A. Puerperal infections B. Retained placental fragments C. Thrombophlebitis D. Uterine atony
Uterine atony A uterus that is over distended, such as from a macrosomic fetus, has an increased risk of uterine atony.
uterine rupture risk factors
Who is at risk- prior C-sections, large babies, contractions too close to each other, multiple babies, rapid labor, prior abortion/uterine manipulation with window or scarring in uterus.
A nurse is teaching a client who is at 23 weeks of gestation about immunizations. Which of the following statements should the nurse include in the teaching? "You should not receive the rubella vaccine while breastfeeding." "You should receive a varicella vaccine before you deliver." "You can receive an influenza vaccination during pregnancy." "You cannot receive the Tdap vaccine until after you deliver."
You can receive an influenza vaccination during pregnancy.
There are several women in active labor on the unit. Which woman is at highest risk for developing hypotonic contractions and therefore will need frequent nursing assessments? a 37-year-old G2P1 woman being induced whose last ultrasound at 36 weeks' gestation showed oligohydramnios a G4P3 client who is having twins and wants to experience a "natural birth" a 17-year-old primipara requesting more pain medication every 15 to 30 minutes (and not receiving it) even though there is an epidural catheter in place that is working effectively a 21-year-old primipara woman who does not have a support person with her and is very anxious
a G4P3 client who is having twins and wants to experience a "natural birth" Explanation: Hypotonic contractions occur during the active phase of labor and tend to occur after the administration of analgesia in a uterus that is overstretched by a multiple gestation or polyhydramnios, or in a uterus that is lax from grand multiparty. Anxiety is not listed as a cause for hypotonic contractions.
Uterine Rupture
a tear in the wall of the uterus Obstetric emergency; onset marked by sudden fetal bradycardia
A woman experiences an amniotic fluid embolism as the placenta is delivered. The nurse's first action would be to: administer oxygen by mask. increase her intravenous fluid infusion rate. tell the woman to take short, catchy breaths. put firm pressure on the fundus of her uterus.
administer oxygen by mask. Explanation: An amniotic embolism quickly becomes a pulmonary embolism. The woman needs oxygen to compensate for the sudden blockage of blood flow through her lungs.
A pregnant woman is admitted to the hospital with a diagnosis of placenta previa. Which action would be the priority for this woman on admission?
assessing fetal heart tones by use of an external monitor
Subchorionic hemorrhage
bleeding behind the placenta that can sometimes cause miscarriages
A fetus is experiencing shoulder dystocia during birth. The nurse would place priority on performing which fetal assessment postbirth? assess for cleft palate brachial plexus assessment monitor for a cardiac anomaly extensive lacerations
brachial plexus assessment Explanation: The nurse should identify nerve damage as a risk to the fetus in cases of shoulder dystocia. Other fetal risks include asphyxia, clavicle fracture, central nervous system injury or dysfunction, and death. Extensive lacerations is a poor maternal outcome due to the occurrence of shoulder dystocia, which should be assessed and treated. Cleft palate and cardiac anomalies are not related to shoulder dystocia.
The nurse plays a major role in assessing the progress of labor. The nurse integrates understanding of the typical rule for monitoring labor progress. Which finding would the nurse correlate with this rule? fetus descends 1 cm per hour cervix dilates 1 cm per hour cervix dilates 2 cm per hour fetus descends 2 cm per hour
cervix dilates 1 cm per hour Explanation: A simple rule for evaluating the progress of labor is expecting 1 cm per hour of cervical dilation (dilatation). If the cervix fails to respond to uterine contractions by dilating and effacing, then dysfunctional labor must be ruled out.
Leading cause of preterm labor
cigarette smoking
The nurse is monitoring the uterine contractions of a woman in labor. The nurse determines the woman is experiencing hypertonic uterine dysfunction based on which contraction finding? well coordinated. poor in quality. brief. erratic.
erratic Explanation: Hypertonic contractions occur when the uterus never fully relaxes between contractions, making the contractions erratic and poorly coordinated because more than one uterine pacemaker is sending signals for contraction. Hypotonic uterine contractions are poor in quality, brief, and lack sufficient intensity to dilate and efface the cervix.
A client at 38 weeks' gestation has an ultrasound performed at a routine office visit and learns that her fetus has not moved out of a breech position. Which intervention does the nurse anticipate for this client? vacuum extraction external cephalic version trial labor forceps birth
external cephalic version Explanation: External cephalic version is the turning of a fetus from a breech to a cephalic position before birth. It may be done as early as 34 to 35 weeks, although the usual time is 37 to 38 weeks of pregnancy. A trial birth is performed when a woman has a borderline (just adequate) inlet measurement and the fetal lie and position are good and involves allowing labor to take its normal course as long as descent of the presenting part and dilation (dilatation) of the cervix continue to occur. Forceps, which are not commonly used anymore, and vacuum extraction are used to facilitate birth when other complications are present, but they would be less likely to be used with a fetus in breech position.
A client at 35 weeks' gestation is now in stable condition after being admitted for vaginal bleeding. Which assessment should the nurse prioritize? fetal heart tones signs of shock infection uterine stabilization
fetal heart tones Explanation: When a client is admitted for vaginal bleeding and is stable, the next priority assessment is to determine if the fetus is viable. The other options are not a higher priority than fetal heart tones.
A client has arrived to the birthing center in labor, requesting a VBAC. After reading the client's previous history, the nurse anticipates that the client would be a good candidate based on which finding? had prior transfundal uterine surgery had previous lower abdominal incision had prior classic uterine incision has a contracted pelvis
had previous lower abdominal incision Explanation: The choice of a vaginal or repeat cesarean birth can be offered to women who have had a lower abdominal incision. Contraindications to VBAC include a prior classic uterine incision, prior transfundal uterine surgery, uterine scar other than low-transverse ("bikini cut") cesarean scar, contracted pelvis, and inadequate staff at the facility if an emergency cesarean birth is required.
A nurse is caring for a newborn who has macrosomia and whose mother has diabetes mellitus. The nurse should recognize which of the following newborn complications as the priority focus of care? hypoglycemia hypomagnesemia hyperbilirubinemia hypocalcemia
hypoglycemia Newborns of mothers who have diabetes are at high risk for hypoglycemia due to the loss of high levels of glucose after the umbilical cord is cut. This results in fetal hyperinsulinemia. It can take several days for the newborn to adjust to secreting appropriate amounts of insulin for the lower level of blood glucose. Because severe hypoglycemia can lead to cyanosis and seizures, prevention of hypoglycemia becomes the nurse's priority focus of care.
A pregnant woman has just found out that she is having twin girls. She asks the nurse the difference between fraternal and identical twins. The nurse explains that with one set of twins there is fertilization of two ova, and with the other set one fertilized ovum splits. What type of twins result from the split ovum? identical both types can result from the split ovum neither type results from a split ovum fraternal
identical Explanation: The incidence of twins is about 1 in 30 conceptions, with about 2/3 being from the fertilization of two ova (fraternal) and about 1/3 from the splitting of one fertilized ovum (identical).
Cervical insufficiency
passive and painless dilation of the cervix leading to recurrent preterm births during the second trimester in the absence of other causes
main difference between placentral abruption and placenta previa
placental abruption: abdominal pain with bleeding, uterine tenderness, firm uterus placental previa: no pain at all, bleeding, soft uterus, normal FHR
A woman at 8 weeks' gestation is admitted for ectopic pregnancy. She is asking why this has occurred. The nurse knows that which factor is a known risk factor for ectopic pregnancy?
use of IUD for contraception
cerclage
used for incompetent cervixes. suturing of the cervix to prevent it from dilating prematurely during pregnancy, thus decreasing the chance of a spontaneous abortion
A woman in active labor has just had her membranes ruptured to speed up labor. The nurse is concerned the woman is experiencing a prolapse of the umbilical cord when the nurse notices which pattern on the fetal heart monitor? variable deceleration pattern early deceleration with each contraction late deceleration with late recovery following contraction fetal heart rate (FHR) increase to 200 beats/min
variable deceleration pattern Explanation: Umbilical cord prolapse can be seen after the membranes have ruptured, when the FHR is displaying a sudden variable deceleration FHR pattern on a fetal monitor. It is not uncommon for FHR to increase following a procedure. Early deceleration with each contraction is seen when the fetal head is being compressed through the pelvic opening. Late deceleration with late recovery following contraction is associated with uteroplacental insufficiency (UPI).
Prolapsed Cord
when a fetus's umbilical cord slips through the cervix and into the vagina after a mother's water breaks and before the baby descends into the birth canal
A nurse is caring for a preterm newborn who is in an incubator to maintain a neutral thermal environment. The father of the newborn asks the nurse why this is necessary. Which of the following responses should the nurse make? A. "Preterm newborns have a smaller body surface area than normal newborns." B. "The added brown fat layer in a preterm newborn reduces his ability to generate heat." C. "Preterm newborns lack adequate temperature control mechanisms." D. "The heat in the incubator rapidly dries the sweat of preterm newborns."
C. "Preterm newborns lack adequate temperature control mechanisms." Preterm newborns have poor body control of temperature and need support to avoid losing heat. They require an external heat source, such as an incubator.
A nurse is caring for a client who is postpartum. The client tells the nurse that the newborn's maternal grandmother was born deaf and asks how to tell if her newborn hears well. Which of the following statements should the nurse make? A. "There is no need to worry about that. Most forms of hearing loss are not inherited." B. "Look at how she looks at you when you speak. That's a good sign." C. "We do routine hearing screenings on newborns. You'll know the results before you leave the hospital." D. "The best way to determine if your baby can hear is to clap your hands loudly and see if she startles."
C. "We do routine hearing screenings on newborns. You'll know the results before you leave the hospital." Most states mandate hearing screening for all newborns. The two tests in use do not diagnose hearing loss, but determine whether or not a newborn requires further evaluation.
Interventions for Prolapsed Cord
Call for help immediately !!! Notify provider Apply pressure with 2 fingers to the fetal presenting part to elevate it off the cord Reposition pt to Trendelenburg or knee-chest Administer high-flow oxygen Wrap exposed cord with sterile saline-soaked gauze *** Prepare for immediate birth (likely by C-section)
Cord compression
Can reduce blood flow from the placenta to the fetus Causes: abnormal presentation, inadequate pelvis, presenting part at a high station, multiple gestations, prematurity, PROM, and Polyhydramnios Can cause fetal asphyxia
A woman in her 20s has experienced a miscarriage at 10 weeks' gestation and asks the nurse at the hospital what went wrong. She is concerned that she did something that caused her to lose her baby. The nurse can reassure the woman by explaining that the most common cause of spontaneous miscarriage in the first trimester is related to which factor?
Chromosomal defects in the fetus
A nurse is instructing a woman who is contemplating pregnancy about nutritional needs. To reduce the risk of giving birth to a newborn who has a neural tube defect, which of the following information should the nurse include in the teaching? Limit alcohol consumption. Increase intake of iron-rich foods. Consume foods fortified with folic acid. Avoid foods containing aspartame.
Consume foods fortified with folic acid. Increased consumption of folic acid in the 3 months prior to conception, as well as throughout the pregnancy, reduces the incidence of neural tube defects in the developing fetus.
The nurse assesses that a fetus is in an occiput posterior position. The nurse predicts the client will experience which situation related to this assessment? Need to have the baby manually rotated Shorter dilation (dilatation) stage of labor Experience of additional back pain Necessity for vacuum extraction for birth
Experience of additional back pain Explanation: Most women whose fetus is in a posterior position experience back pain while in labor. Pressure against the back by a support person often reduces this type of pain. An occiput posterior position does not make for a shorter (dilation) dilatation stage of labor. OP position does not indicate the need to have the baby manually rotated, nor does it indicate a necessity for a vacuum extraction birth.
A nurse is providing teaching about expected gestational changes to a client who is at 12 weeks of gestation. Which of the following statements by the client indicates a need for further teaching? "I will reduce my stress level." "I will tell my doctor before using home remedies for nausea." "I will monitor my weight gain during the remaining months." "I will use only nonprescription medications while pregnant."
I will use only nonprescription medications while pregnant.
What is often the cause of preterm rupture of membranes?
Infection in the uterus
A nurse is planning care for a newborn who is small for gestational age (SGA). Which of the following is the priority intervention the nurse should include in the newborn's plan of care? Monitor I&O. Monitor axillary temperature. Monitor blood glucose levels. Monitor weight.
Monitor blood glucose levels. Decreased stores of glycogen and a lower rate of gluconeogenesis place newborns who are SGA at higher risk for hypoglycemia. Monitoring of blood glucose levels is a priority intervention.
A nurse is caring for a newborn who has respiratory depression. Which of the following medications should the nurse anticipate administering? Flumazenil Physostigmine Terbutaline Naloxone
Naloxone Naloxone is an opioid antagonist and is administered to reverse opioid toxicity or reverse neonatal respiratory depression. Dosage for a newborn is 0.01 mg/kg, and is repeated every 2 to 3 min until adequate respiratory function returns.
postterm pregnancy risks for neonates
Neonate: meconium aspiration, hypoglycemia, poor fetal growth, poor placental perfusion, shoulder dystocia, macrosomia & stillbirth
What can you give to help with preterm labor contractions to help stop contractions?
Nifedipine (PO calcium channel blocker) and Magnesium Sulfate (IV)
A nurse is caring for a client who is at 40 weeks of gestation and is in labor. The clients ultrasound examination indicates that the fetus is small for gestational age. Which of the following interventions should be included in the newborns plan of care? Observe for meconium in respiratory secretions. Monitor for hyperglycemia. Identify manifestations of anemia. Monitor for hyperthermia.
Observe for meconium in respiratory secretions. When a fetus is SGA, there is an increased risk for intrauterine hypoxia due to the presence of meconium in the amniotic fluid. The nurse should observe for meconium in respiratory secretions when suctioning the newborn at delivery. Newborns who are SGA are at risk for perinatal asphyxia due to the stress of labor and are often depressed. They require careful resuscitation and suctioning at delivery.
The nurse is admitting a client in labor. The nurse determines that the fetus is in a transverse lie by performing Leopold maneuvers. What intervention should the nurse provide for the client? Administer an analgesic to the client. Prepare the client for a cesarean birth. Prepare for a precipitous vaginal birth. Prepare to assist the care provider with an amniotomy.
Prepare the client for a cesarean birth. Explanation: If a transverse lie persists, the fetus cannot be born vaginally. Thus, the nurse will prepare the client for a caesarean birth. There is no indication the client will have precipitous labor. Amniotomy, artificial rupture of the membranes, is not indicated when preparing from a caesarean birth. The nurse would not administer analgesic before surgery unless prescribed by the health care provider.
A nurse in a prenatal clinic is caring for a client who believes that she might be pregnant because she feels the baby moving. Which of the following statements should the nurse make? "This is a presumptive sign of pregnancy." "This is a probable sign of pregnancy." "This is a possible sign of pregnancy." "This is a positive sign of pregnancy."
This is a presumptive sign of pregnancy.
Placenta previa
abnormal implantation over or near the cervical OS Complete or partial, marginal or low-lying
Which intervention would be most important when caring for the client with breech presentation confirmed by ultrasound? auscultating the fetal heart rate at the level of the umbilicus applying suprapubic pressure against the fetal back noting the space at the maternal umbilicus continuing to monitor maternal and fetal status
continuing to monitor maternal and fetal status Explanation: Once a breech presentation is confirmed by ultrasound, the nurse should continue to monitor the maternal and fetal status when the team makes decisions about the method of birth. The nurse usually plays an important role in communicating information during this time. Applying suprapubic pressure against the fetal back is the nursing intervention for shoulder dystocia and may not be required for breech presentation. Noting the space or dip at the maternal umbilicus and auscultating the fetal heart rate at the umbilicus level are assessments related to occipitoposterior positioning of the fetus.
A nurse is providing care to a client who has been diagnosed with a common benign form of gestational trophoblastic disease. The nurse identifies this as:
hydatidiform mole.
precipitus labor
labor that lasts less than 2 hours
What would be the physiologic basis for a placenta previa?
low placental implantation
When caring for a client requiring a forceps-assisted birth, the nurse would be alert for: increased risk for uterine rupture. damage to the maternal tissues. potential lacerations and bleeding. increased risk for cord entanglement.
potential lacerations and bleeding. Explanation: Forcible rotation of the forceps can cause potential lacerations and bleeding. Cervical ripening increases the risk for uterine rupture in a client attempting vaginal birth after undergoing at least one previous cesarean birth. There is an increased risk for cord entanglement in multiple pregnancies. Damage to the maternal tissues happens if the cup slips off the fetal head and the suction is not released.
The nursing student doing a rotation in obstetrics is talking to her preceptor about dystocia. She asks what is meant by the term "expulsive forces," better known as the "powers." The preceptor correctly tells her that the "powers" include which factors? Select all that apply. fetal development analgesia mother's age position presentation
presentation position fetal development Explanation: Dystocia can result from problems or abnormalities involving the expulsive forces (known as the "powers"): presentation, position, and fetal development. The others are not included in the "powers."
A nursing instructor is conducting a session exploring the signs and symptoms of eclampsia to a group of student nurses. The instructor determines the session is successful after the students correclty choose which signs indicating eclampsia? Select all that apply.
proteinuria hypereflexia blurring of vision
A nurse is teaching about crib safety with the parent of a newborn. Which of the following statements by the client indicates understanding of the teaching? "I will place my baby on his stomach when he is sleeping." "I should remove extra blankets from my baby's crib." "I should pad the mattress in my baby's crib so that he will be more comfortable when he sleeps." "I should place my baby's crib next to the heater to keep him warm during the winter."
"I should remove extra blankets from my baby's crib." Loose bedding such as sheets and blankets could cover the baby's head and lead to suffocation.
A nurse is teaching about nutrition guidelines to a parent of a newborn. Which of the following statement by the parent indicates understanding of the teaching? "I should start solid foods when my baby is 3 months old." "I should introduce cow's milk when my baby is 9 months old." "I should wait to give fruit juice until my baby is 6 months of age." "I should wait to begin fluoride supplements until my baby is 4 months of age."
"I should wait to give fruit juice until my baby is 6 months of age." Fruit juice provides minimal nutritional value to the infant's diet. Therefore, fruit juices should be limited and not offered until the infant is 6 months of age.
After a regular prenatal visit, a pregnant client asks the nurse to describe the differences between abruptio placentae and placenta previa. Which statement should the nurse include in the teaching?
"Placenta previa causes painless, bright red bleeding during pregnancy due to an abnormally implanted placenta that is too close to or covers the cervix; abruptio placentae is associated with dark red painful bleeding caused by premature separation of the placenta from the wall of the uterus before the end of labor."
A nurse in the emergency department is admitting a client who is at 40 weeks of gestation, has ruptured membranes, and the nurse observes the newborns head is crowning. The client tells the nurse she wants to push. Which of the following statements should the nurse make? "You should go ahead and push to assist the delivery." "You should try to pant as the delivery proceeds." "You should try to perform slow-paced breathing." "You should take a deep, cleansing breath and breathe naturally."
"You should try to pant as the delivery proceeds." Panting allows uterine forces to expel the fetus and permits controlled muscle expansion to avoid rapid expulsion of the fetal head.
A nurse is providing teaching to the mother of a newborn born small for gestational age. Which of the following should the nurse include as a possible cause of this condition? A. Placental insufficiency B. Preterm delivery C. Fetal hyperinsulinemia D. Perinatal asphyxia
A. Placental insufficiency Placental insufficiency is a cause of small for gestational age. It can result from maternal infections, embryonic placental deficiency, teratogens, or chromosomal abnormalities.
A nurse is assessing a newborn who has developmental dysplasia of the hip (DDH). Which of the following findings should the nurse expect? Absent plantar reflexes Lengthened thigh on the affected side Inwardly turned foot on the affected side Asymmetric thigh folds
Asymmetric thigh folds. Gluteal and thigh skin folds that are not equal and symmetric is a sign of DDH.
The nurse is required to assess a pregnant client who is reporting vaginal bleeding. Which nursing action is the priority?
assessing the amount and color of the bleeding
Placental abruption risks
Significant maternal and fetal morbidity and mortality; can lead to DIC
The nurse provides education to a postterm pregnant client. What information will the nurse include to assist in early identification of potential problems? "Be sure to measure 24-hour urine output daily." "Monitor your bowel movements for constipation." "Increase your fluid intake to prevent dehydration." "Continue to monitor fetal movements daily."
"Continue to monitor fetal movements daily." Explanation: The nurse will teach the postterm client to monitor fetal movements (kick counts) daily to help determine if the fetus is experiencing distress. A 24-hour urine is needed for postterm clients; however, this is not collected daily. Although all pregnant clients should avoid dehydration, there is no indication this client needs to increase her fluid intake and this will not help identify potential problems. Monitoring bowel movements for constipation is not needed.
A nurse is teaching a group of clients who are in their first trimester about exercise during pregnancy. Which of the following statements should the nurse include in the teaching? "Refrain from exercises that include stretching." "Moderate exercise improves circulation." "It is recommended to increase your weight-bearing exercises." "It is recommended to rest for 30 minutes before each new exercise."
"Moderate exercise improves circulation." Improving circulation is just one of the many benefits of moderate exercise during pregnancy. It enhances well-being, promotes rest and relaxation, and improves muscle tone.
A woman has been in labor for the past 8 hours, and she has progressed to the second stage of labor. However, after 2 hours with no further descent, the provider diagnoses "arrest of labor." The woman asks, "Why is this happening?" Which response is the best answer to this question? "It is likely that your body has not secreted enough hormones to soften the ligaments so your pelvic bones can shift to allow birth of the baby." "More than likely you have cephalopelvic disproportion (CPD) where baby's head cannot make it through the canal." "Maybe your uterus is just tired and needs a rest." "Maybe your baby has developed hydrocephaly and the head is too swollen."
"More than likely you have cephalopelvic disproportion (CPD) where baby's head cannot make it through the canal." Explanation: Arrest of labor results when no descent has occurred for 2 hours in a nullipara or 1 hour in a multipara. The most likely cause for arrest of descent during the second stage is CPD. Rest should allow the uterine contractions to be more efficient. The hormones secreted during pregnancy allow ligaments to soften so bones can shift to allow birth. Ultrasound would have previously been diagnosed prior to the onset of labor.
A nurse is providing teaching about phenylketonuria (PKU) testing to the parent of a newborn. Which of the following statements by the parent indicates a need for additional teaching? "My baby will be placed under special lights if the test result is positive." "My baby needs to be on formula or breast milk before the test can be done." "This test checks for a genetic disorder that can be managed by diet." "Sometimes the test is repeated in the doctor's office at the baby's 2-week check-up."
"My baby will be placed under special lights if the test result is positive."
.A nurse is caring for a client who delivered a healthy term newborn via cesarean birth. The client asks the nurse, "Is there a chance that I could deliver my next baby without having a cesarean section?" Which of the following responses should the nurse provide? "The primary consideration is what type of incision was performed this time." "There are so many variables that you'll have to ask your obstetrician." "It's too soon for you to be worrying about this now." "A repeat cesarean birth is safer for both you and your baby."
"The primary consideration is what type of incision was performed this time." Rationale: The most common type of incision during a cesarean birth is transverse, which is made across the lower, thinner part of the uterus. It is the primary criteria that permits a vaginal birth after a cesarean (VBAC). Other types of incisions increase the risk of uterine rupture. Additional criteria for VBAC include an adequate maternal pelvis, no uterine scars or history of rupture, the availability of a provider to monitor labor, and personnel to perform a cesarean birth if needed.
A client in her first trimester arrives at the emergency room with reports of severe cramping and vaginal spotting. On examination, the health care provider informs her that no fetal heart sounds are evident and orders a dilatation and curettage. The client looks frightened and confused and states that she does not believe in abortion. Which statement by the nurse is best?
"Unfortunately, the pregnancy is already lost. The procedure is to clear the uterus to prevent further complications."
The nurse is comforting and listening to a young couple who just suffered a miscarriage. When asked why this happened, which reason should the nurse share as a common cause?
Chromosomal abnormality
A nurse in a prenatal clinic is reviewing the health record of a client who is at 28 weeks of gestation. The history includes one pregnancy, terminated by elective abortion at 9 weeks; the birth of twins at 36 weeks; and a spontaneous abortion at 15 weeks. According to the GTPAL system, which of the following describes the client's current status? 4-0-1-2-2 3-0-2-0-2 2-0-0-2-0 4-2-0-2-2
4-0-1-2-2
During pregnancy a woman's blood volume increases to accommodate the growing fetus to the point that vital signs may remain within normal range without showing signs of shock until the woman has lost what percentage of her blood volume?
40%
The nurse is caring for a client after experiencing a placental abruption (abruptio placentae). Which finding is the priority to report to the health care provider? hematocrit of 36% (0.36) 45 ml urine output in 2 hours platelet count of 150,000 mm3 hemoglobin of 13 g/dl (130 g/L)
45 ml urine output in 2 hours Explanation: The nurse knows a placental abruption places the client at high risk of hemorrhage. A decreased urine output indicates decreased perfusion from blood loss. The hematocrit, hemoglobin, and platelet counts are all within expected levels.
A nurse is caring for a newborn and observes signs of diaphoresis, jitteriness, and lethargy. Which of the following actions should the nurse take? A. Obtain blood glucose by heel stick. B. Initiate phototherapy. C. Monitor the newborn's blood pressure. D. Place the newborn in a radiant warmer.
A. Obtain blood glucose by heel stick. The newborn is exhibiting early signs of hypoglycemia. The nurse should obtain blood by heel stick to check glucose. A therapeutic serum glucose level for a newborn is 40 to 60 mg/dL. Less than 40 mg/dL indicates hypoglycemia. Other findings of hypoglycemia include poor feeding, tremors, hypothermia, flaccid muscle tone, irregular respirations, apnea, cyanosis, and a weak, shrill cry. Early breastfeeding also should be encouraged to prevent hypoglycemia.
The nurse is planning to contact the provider regarding the newborn's status. Which of the following prescriptions should the nurse anticipate? Select 3. Swaddle the newborn. Encourage the birthing parent to breastfeed. Continue NAS scoring as prescribed. Administer naloxone for NAS scores greater than 24. Administer oral morphine.
Administer oral morphine. Swaddle the newborn. Continue NAS scoring as prescribed. Administer oral morphine is correct. The nurse should administer oral morphine to assist with decreasing the withdrawal findings in the newborn. The dosage of the medication is adjusted based on the NAS scores of the newborn. Encourage the birthing parent to breastfeed is incorrect. The nurse should not allow the client to breastfeed because of their heroin use. However, if the client was prescribed methadone the nurse should encourage the client to breastfeed on demand because the newborn is experiencing neonatal abstinence syndrome (NAS). Swaddle the newborn is correct. The nurse should swaddle the newborn and reduce the environmental stimuli for newborns with NAS to assist with decreasing the manifestations the newborn is experiencing. Administer naloxone for NAS scores greater than 24 is incorrect. The nurse should not administer naloxone to a newborn who has a diagnosis of NAS. Naloxone is contraindicated in newborns born with opioid toxicity and can cause severe manifestations including seizures. Continue NAS scoring as prescribed is correct. The nurse should continue conducting NAS scoring as prescribed in order to evaluate the newborn's clinical findings and status. The score obtained will assist with determining the dosage of morphine to administer.
A primigravida 28-year-old client is noted to have Rh negative blood and her husband is noted to be Rh positive. The nurse should prepare to administer RhoGAM after which diagnostic procedure?
Amniocentesis
A client's membranes have just ruptured. Her fetus is presenting breech. Which action should the nurse do immediately to rule out prolapse of the umbilical cord in this client? Administer oxygen at 10 L/min by face mask. Place the woman in Trendelenburg position. Administer amnioinfusion. Assess fetal heart sounds.
Assess fetal heart sounds. Explanation: To rule out cord prolapse, always assess fetal heart sounds immediately after rupture of the membranes whether this occurs spontaneously or by amniotomy, as the fetal heart rate will be unusually slow or a variable deceleration pattern will become apparent when cord prolapse has occurred. The other answers refer to therapeutic interventions to implement once cord prolapse has been confirmed.
A nurse is caring for a client who is beginning to breastfeed her newborn after delivery. The new mother states, "I don't want to take anything for pain because I am breastfeeding." Which of the following statements should the nurse make? A. "You need to take pain medications so you are more comfortable." B. "We can time your pain medication so that you have an hour or two before the next feeding." C. "All medications are found in breast milk to some extent." D. "You have the option of not taking pain medication if you are concerned."
B. "We can time your pain medication so that you have an hour or two before the next feeding." This answer provides the client an option that allows for administration of pain medication but minimizes the effect it will have on the newborn while breastfeeding.
A nurse is caring for a newborn 4 hr after birth. Which of the following actions should the nurse include in the plan of care to prevent jaundice? A. Begin phototherapy B. Initiate early feeding C. Suction excess mucus with bulb syringe D. Prepare for an exchange blood transfusion
B. Initiate early feeding Prevention of jaundice can be facilitated best by early and frequent feeding, which stimulates intestinal activity and passage of meconium. Jaundice occurs due to elevated serum bilirubin, which is excreted primarily in the newborn's stool. Physiologic jaundice manifests after 24 hr and is considered benign. However, bilirubin may accumulate to hazardous levels and lead to a pathologic condition.
A nurse is reinforcing teaching about newborn care with a postpartum client. Which of the following statements by the client indicates a need for further teaching? "I will use mild soap." "I will use a basin during bathing." "Baby powder will help prevent a diaper rash." "I will test the water on my wrist for temperature before bathing."
Baby powder will help prevent a diaper rash. Lotions, creams, oils, or powders can alter a newborn's skin and provide a medium for bacterial growth or cause an allergic response. Powders can be inhaled, leading to respiratory distress. This statement requires the nurse to clarify instruction on newborn care.
A nurse is preparing to assess a newborn who is postmature. Which of the following findings should the nurse expect? SATA Cracked, peeling skin Positive Moro reflex Short, soft fingernails Abundant lanugo Vernix in the folds and creases
Cracked, peeling skin positive Moro reflex Cracked, peeling skin is correct. Physical findings that indicate postmaturity in a newborn (gestational age of greater than 42 weeks) include cracked, peeling skin .Positive Moro reflex is correct. Reflexes that are present in a postmature newborn are the same as those that are present in a mature newborn. These reflexes include a positive Moro reflex.
A nurse is assessing a newborn who was born at 42.5 weeks of gestation. Which of the following findings should the nurse expect? A. Copious vernix B. Scant scalp hair C. Increased subcutaneous fat D. Dry, cracked skin
D. Dry, cracked skin A newborn who is postmature has dry, cracked skin.
A nurse is caring for a young woman who is in her 10th week of gestation. She comes into the clinic reporting vaginal bleeding. Which assessment finding best correlates with a diagnosis of hydatidiform mole?
Dark red, "clumpy" vaginal discharge
A client's membranes rupture. The nurse observes the fetal heart rate drop from 156 to 110. The nurse inspects the client's perineum and sees a loop of umbilical cord. What is the nurse's priority concern in this situation? Increased risk for infection Decreased fetal oxygenation Increased risk for placental abruption Decreased strength of uterine contractions
Decreased fetal oxygenation Explanation: When there is a cord prolapse the cord becomes compressed, blood flow is interrupted, and there is decreased oxygen available to the fetus resulting in fetal distress. There is a slight increased risk for postbirth infection, but it is not the priority at this time. A cord prolapse does not increase the risk for placental abruption nor does it decrease the strength of uterine contractions.
Bishop score
Determines maternal readiness for labor by evaluating whether the cervix is favorable by rating cervical dilation, effacement, consistency, position, and station High score of 13 and low of 0. Score of 8 or greater is desired for Induction of Labor
A graduate nurse (GN) is caring for a client being induced via oxytocin infusion. The client is currently reporting a headache and is vomiting. The graduate nurse thinks that the client is getting near the end of labor. However, the GNs preceptor intervenes by performing which interventions immediately after hearing this report? Select all that apply. administering IV ondansetron for the nausea/vomiting discontinuing the oxytocin infusion increasing IV fluid rate notifying the health care provider immediately calling respiratory therapy to obtain ABGs on this client
Discontinuing the oxytocin infusion notifying the health care provider immediately Explanation: A second side effect of oxytocin is that it can result in decreased urine flow, possibly leading to water intoxication. This is first manifested by a headache and vomiting. If the nurse observes these danger signs in a client during induction of labor, the client should report them immediately and halt the infusion. Ondansetron may be appropriate but is not the priority. The headache and vomiting are due to water intoxication, so fluids should be decreased not increased. At this point, ABGs are not the priority intervention.
The perinatal educator is instructing on various emotions commonly experienced during labor. Which complication of anxiety is most important to stress? Shortness of breath Gestational hypertension Fetal tachycardia Dystocia
Dystocia Explanation: Many women experience an array of emotions during labor, which may include fear, anxiety, helplessness, desire to be alone, and weariness. These emotions can lead to psychological stress, which indirectly can cause dystocia. Dystocia is a prolonged labor as the tense woman is fighting against the labor process. Shortness of breath may occur with a panic attack. Gestational hypertension occurs during pregnancy. Fetal tachycardia is not commonly associated with maternal anxiety.
A 28-year-old client with a history of endometriosis presents to the emergency department with severe abdominal pain and nausea and vomiting. The client also reports her periods are irregular with the last one being 2 months ago. The nurse prepares to assess for which possible cause for this client's complaints?
Ectopic pregnancy
A nurse in a prenatal clinic is caring for client who asks what her estimated date of delivery will be if her last menstrual period was May 4, 2015. Which of the following is the appropriate response by the nurse? February 11, 2016 February 27, 2016 April 27, 2016 April 11, 2016
February 11, 2016.
A nurse is completing an assessment of a 1 month old newborn. Which of of the following developmental skills is an expected finding? Displays a social smile Follows movements of objects with eyes Reacts to sounds by turning head Makes babbling sounds
Follows movements of objects with eyes A 1-month-old infant is able to follow movements with their eyes.
A nurse is assessing a newborn who has a coarctation of the aorta. Which of the following should the nurse recognize is a clinical manifestation of coartation of the aorta? Increased blood pressure in the arms with decreased blood pressure in the legs Decreased blood pressure in the arms with increased blood pressure in the legs Increased blood pressure in both the arms and the legs Decreased blood pressure in both the arms and the legs
Increased blood pressure in the arms with decreased blood pressure in the legs There is a narrowing next to the ductus arteriosus that results in an increased pressure proximal to the defect, with a decreased pressure distal to the obstruction. Therefore, an increased blood pressure in the arms with a decreased blood pressure in the legs would be a clinical manifestation of a coarctation of the aorta.
A pregnant woman has been admitted to the hospital due to severe preeclampsia. Which measure will be important for the nurse to include in the care plan?
Institute and maintain seizure precautions.
A nurse is completing a health history for a client who is at 6 weeks of gestation. The client informs the nurse that she smokes one pack of cigarattes per day. The nurse should advise the client that smoking places the client's newborn at risk for which of the following complications? Hearing loss Intrauterine growth restriction Type 1 diabetes mellitus Congenital heart defects
Intrauterine growth restriction
A nurse is completing a health hx for a client who is at 6 weeks gestation. The client informs the nurse that she smokes one pack of cigarettes per day. The nurse should advice the client that smoking places the clients newborn at risk for which of the following complications? Hearing loss Intrauterine growth restriction Type 1 diabetes mellitus Congenital heart defects
Intrauterine growth restriction. Clients who smoke place their newborns and themselves at risk for diverse complications, including fetal intrauterine growth restriction, placental abruption, placenta previa, preterm delivery, and fetal death.
A woman who is 10 weeks' pregnant calls the physician's office reporting "morning sickness" but, when asked about it, tells the nurse that she is nauseated and vomiting all the time and has lost 5 pounds. What interventions would the nurse anticipate for this client?
Lab work will be drawn to rule out acid-base imbalances.
What do you not want to happen with a placenta previa?
Labor, because it tears the placenta, so we do not want to allow any signs of labor to progress
postterm pregnancy risks for mothers
Maternal: longer labor, injury to the perineum, C-section, dystocia, birth trauma, postpartum hemorrhage, and infection
A nurse is completing the admission assessment of a newborn. Which of the following anatomical landmarks should the nurse use when measuring the newborn's chest circumference? Sternal notch Nipple line Xiphoid process Fifth intercostal space
Nipple Line Rationale: The nurse should measure the newborn's chest circumference at the nipple line.
nursing care for postterm pregnancy
Nursing care includes good labor management with careful fetal assessment, assist with amnioinfusion for meconium, early skin-to-skin and feeding of newborn, monitor newborn for hypoglycemia
A woman at 34 weeks' gestation presents to labor and delivery with vaginal bleeding. Which finding from the obstetric examination would lead to a diagnosis of placental abruption?
Onset of vaginal bleeding was sudden and painful
A 32-year-old gravida 3 para 2 at 36 weeks' gestation comes to the obstetric department reporting abdominal pain. Her blood pressure is 164/90 mm/Hg, her pulse is 100 beats per minute, and her respirations are 24 per minute. She is restless and slightly diaphoretic with a small amount of dark red vaginal bleeding. What assessment should the nurse make next?
Palpate the fundus, and check fetal heart rate.
A woman in labor suddenly reports sharp fundal pain accompanied by slight dark red vaginal bleeding. The nurse should prepare to assist with which situation?
Premature separation of the placenta
The nurse is assessing a multipara client who presents to the hospital after approximately 2 hours of labor and notes the fetus is in a transverse lie. After notifying the RN and primary care provider, which action should the LPN prioritize? Prepare to assist with external version. Apply pressure to the client's lower back with a fisted hand. Assist with nitrazine and fern tests. Include a set of piper forceps when the table is prepped.
Prepare to assist with external version. Explanation: Transverse lie is a fetal malposition and is a cause for labor dystocia. The fetus would need to be turned to the occipital position using external version or be born via cesarean birth. Piper forceps are used in the birth of a fetus that is in the breech position. Nitrazine and fern tests are done to assess if amniotic fluid is leaking from the sac into the vagina. Counterpressure applied to the lower back with a fisted hand sometimes helps the client to cope with the "back labor" that is characteristic of occiput posterior (OP) positioning.
A nurse is assessing a newborn. Which of the following should the nurse understand is a clinical manifestation of pyloric stenosis? Absent bowel sounds Increased sodium levels Projectile vomiting after feedings Golf ball-sized mass over the left quadrant
Projectile vomiting after feedings. Pyloric stenosis is a narrowing and thickening of the pyloric canal between the stomach and the duodenum, resulting in projectile vomiting.
A G3P2 woman at 39 weeks' gestation presents highly agitated, reporting something "came out" when her membranes just ruptured. Which action should the nurse prioritize after noting the umbilical cord is hanging out of the vagina? Contact the health care provider and prepare the client for an emergent vaginal birth. Place the client in Trendelenburg position and gently attempt to reinsert the cord. Put the client in bed immediately, call for help, and lift the presenting part of the fetus off the cord. With the client in lithotomy position, hold her legs and sharply flex them toward her shoulders.
Put the client in bed immediately, call for help, and lift the presenting part of the fetus off the cord. Explanation: The nurse must put the woman in a bed immediately, while calling for help, and holding the presenting part of the fetus off the cord to ensure its safety. Umbilical cord prolapse occurs when the umbilical cord slips down in front of the presenting part, which can result in the presenting part compressing the cord, cutting off oxygen and nutrients to the baby, and the baby is at risk of death. This is an emergency. When a prolapsed cord is evident the nurse does not put the woman in lithotomy position, and cannot attempt to reinsert the cord. A vaginal birth is contraindicated in this situation.
A client at 37 weeks' gestation presents to the emergency department with a BP 150/108 mm Hg, 1+ pedal edema, 1+ proteinuria, and normal deep tendon reflexes. Which assessment should the nurse prioritize as the client is administered magnesium sulfate IV?
Respiratory rate
A nurse is intitiating the newborn's plan of care. Complete the following sentence by using the list of options. The nurse should first address the client's ____________ followed by the client's ___________________.
Respiratory status Temperature
A nurse is caring for an antepartum client whose laboratory findings indicate a negative rubella titer. Which of the following is the correct interpretation of this data? The client is not experiencing a rubella infection at this time. The client is immune to the rubella virus. The client requires a rubella vaccination at this time. The client requires a rubella immunization following delivery.
The client requires a rubella immunization following delivery. A negative rubella titer indicates that the client is susceptible to the rubella virus and needs vaccination following delivery. Immunization during pregnancy is contraindicated because of possible injury to the developing fetus. Following rubella immunization, the client should be cautioned not to conceive for 1 month.
A nurse is observing a new mother bathing her newborn son for the first time. For which of the following actions should the nurse intervene? The mother cleans the newborn's eyes from the inner canthus outwards. The mother cleans the umbilical cord with tap water. The mother leaves the yellow exudate on the circumcision site. The mother plans to use a cotton-tipped swab to clean the nares.
The mother plans to use a cotton-tipped swab to clean the nares.
A nurse is caring for a new mother who is concerned that her newborn's eyes cross. Which of the following statement is a therapeutic response by the nurse? "I will call your primary care provider to report your concerns." "I will take your baby to the nursery for further examination." "This occurs because newborns lack muscle control to regulate eye movement." "This is a concern, but strabismus is easily treated with patching."
This occurs because newborns lack muscle control to regulate eye movement This addresses the client's concerns because it provides information that addresses her concerns. The eyes of newborns are structurally incomplete and muscle control is not fully developed for 3 months.
A young woman presents at the emergency department reporting lower abdominal cramping and spotting at 12 weeks' gestation. The primary care provider performs a pelvic examination and finds that the cervix is closed. What does the care provider suspect is the cause of the cramps and spotting?
Threatened abortion
A young mother gives birth to twin boys who shared the same placenta. What serious complication are they at risk for?
Twin-to-twin transfusion syndrome (TTTS)
The nurse is assisting with a G2P1, 24-year-old client who has experienced an uneventful pregnancy and is now progressing well through labor. Which action should be prioritized after noting the fetal head has retracted into the vagina after emerging? Use Zavanelli maneuver. Attempt to push in one of the fetus's shoulders. Use McRoberts maneuver. Apply pressure to the fundus.
Use McRoberts maneuver. Explanation: McRoberts maneuver intervention is used with a large baby who may have shoulder dystocia and requires assistance. The legs are sharply flexed by a support person or nurse, and the movement will help to open the pelvis to the widest diameter possible. Zavanelli maneuver is performed when the practitioner pushes the fetal head back in the birth canal and performs an emergency cesarean birth. Fundal pressure is contraindicated with shoulder dystocia. It is outside the scope of practice for the LPN to attempt birth of the fetus by pushing one of the fetus' shoulders in a clockwise or counterclockwise motion.
A G2P1 woman is in labor attempting a VBAC, when she suddenly complains of light-headedness and dizziness. An increase in pulse and decrease in blood pressure is noted as a change from the vital signs obtained 15 minutes prior. The nurse should investigate further for additional signs or symptoms of which complication? Uterine rupture Umbilical cord compression Placenta previa Hypertonic uterus
Uterine rupture Explanation: The client with any prior history of uterus surgery is at increased risk for a uterine rupture. A falling blood pressure and increasing pulse is a sign of hemorrhage, and in this client a uterine rupture needs to be a first consideration. The scenario does not indicate a hypertonic uterus, a placenta previa, or umbilical cord compression.
A woman in labor with a history of drug and alcohol addiction and no prenatal care has arrived in the emergency department in active labor with cervix 5 cm dilated. An ultrasound shows the fetus in a breech presentation. As a nurse prepares to care for this woman, which assessments indicate the fetus is in distress and needs immediate help to survive? Select all that apply. minimal movement as the fetus descends into the pelvic opening variable deceleration FHR pattern noted on monitor fetal heart rate decreasing into the 80s premature rupture of membranes with yellow-green color fluid that smells foul meconium staining noted on fluid seeping from vagina
Variable deceleration FHR pattern noted on monitor Fetal heart rate decreasing into the 80s Explanation: Variable deceleration fetal heart rate pattern noted on the monitor signifies a possible prolapsed cord. Low fetal heart rate can be a sign of hypoxia. Meconium staining occurs because of cervical pressure on the buttocks and rectum, not because of fetal anoxia, so it is not a sign of fetal distress. It is normal for the fetus to slow in movement as it makes its way through the birth canal.
A nurse is assisting with the care of a newborn immediately following birth. Which of the following medications should the nurse anticipate administering? (Select all that apply) Vitamin K injection Hepatitis B immunization Antibiotic ointment to both eyes Lidocaine gel to the umbilical stump Haemophilus influenza type b immunization (Hib)
Vitamin K injection Hepatitis B immunization Antibiotic ointment to both eyes Vitamin K injection is correct. Vitamin K is administered by a single intramuscular injection of 0.5 to 1 mg soon after birth to prevent hemorrhagic disease of the newborn. Vitamin K is not present in the gastrointestinal tract of the newborn, but production will begin at about 7 days of age as bacteria begin to form in the intestines. Hepatitis B immunization is correct. Hepatitis B immunization is recommended at birth, 1 to 2 months, and between 6 to 18 months. It is injected intramuscularly soon after birth. For newborns born to hepatitis-infected mothers, hepatitis B immune globin (HBIG) also should be administered within 12 hr of birth. The vastus lateralis is the preferred site of intramuscular injections in newborns, and no more than 0.5 mL should be administered in one injection. Parental consent must first be obtained prior to the administration of this immunization. Antibiotic ointment to both eyes is correct. Due to the risk of eye infections to newborns born to women who have vaginal infections (e.g., chlamydia, gonorrhea), the instillation of prophylactic antibiotics is mandatory in the United States. The medication used is dependent upon facility protocols but is usually erythromycin or tetracycline ophthalmic ointment. It is administered into both eyes within 1 to 2 hr after birth. It should be applied from inner canthus to outer canthus, being careful not to touch the eye. After 1 min, the excess ointment can be wiped off.
A nurse is caring for a newborn who is small for gestational age (SGA). Which of the following findings is associated with this condition? Moist skin Protruded abdomen Gray umbilical cord Wide skull sutures
Wide skull sutures Newborns who are SGA have wide skull sutures due to inadequate bone growth. Head circumference is smaller than in a normal newborn and there is reduced brain capacity.
Preterm Premature Rupture of Membrane (PPROM)
a rupture of the membranes before labor begins if PROM occurs before 37 wks pregnancy
A nurse assesses a client in labor and suspects dysfunctional labor (hypotonic uterine dysfunction). The woman's membranes have ruptured and fetopelvic disproportion is ruled out. Which intervention would the nurse expect to include in the plan of care for this client? providing a comfortable environment with dim lighting encouraging the woman to assume a hands-and-knees position preparing the woman for an amniotomy administering oxytocin
administering oxytocin Explanation: Oxytocin would be appropriate for the woman experiencing dysfunctional labor (hypotonic uterine dysfunction). Comfort measures minimize the woman's stress and promote relaxation so that she can work more effectively with the forces of labor. An amniotomy may be used if the membranes were intact. It may also be used with hypotonic uterine dysfunction to augment labor. A hands-and-knees position helps to promote fetal head rotation with a persistent occiput posterior position.
Immediately after giving birth to a full-term infant, a client develops dyspnea and cyanosis. Her blood pressure decreases to 60/40 mm Hg, and she becomes unresponsive. What does the nurse suspect is happening with this client? aspiration congestive heart failure placental separation amniotic fluid embolism
amniotic fluid embolism Explanation: With amniotic fluid embolism, symptoms may occur suddenly during or immediately after labor. The woman usually develops symptoms of acute respiratory distress, cyanosis, and hypotension.
After teaching a review class to a group of perinatal nurses about various methods for cervical ripening, the nurse determines that the teaching was successful when the group identifies which method as surgical? breast stimulation amniotomy laminaria prostaglandin
amniotomy Explanation: Amniotomy is considered a surgical method of cervical ripening. Breast stimulation is considered a nonpharmacologic method for ripening the cervix. Laminaria is a hygroscopic dilator that mechanically causes cervical ripening. Prostaglandins are pharmacologic methods for cervical ripening.
A woman whose fetus is in the occiput posterior position is experiencing increased back pain. Which is the best way for the nurse to help alleviate this back pain? applying a heating pad to the back applying ice to the back applying counterpressure to the back performing acupuncture on the back
applying counterpressure to the back Explanation: Counterpressure applied to the lower back with a fisted hand sometimes helps the woman cope with "back labor" associated with occiput-posterior positioning. The others are not recommended or used techniques for a woman in labor with back pain.
A woman is being closely monitored and treated for severe preeclampsia with magnesium sulfate. Which finding would alert the nurse to the development of magnesium toxicity in this client?
diminished reflexes
A nurse is monitoring a client with PROM who is in labor and observes meconium in the amniotic fluid. What does the observation of meconium indicate?
fetal distress related to hypoxia
A client has come to the office for a prenatal visit during her 22nd week of gestation. On examination, it is noted that her blood pressure has increased to 138/90 mm Hg. Her urine is negative for proteinuria. The nurse recognizes which factor as the potential cause?
gestational hypertension
A novice nurse asks to be assigned to the least complex antepartum client. Which condition would necessitate the least complex care requirements?
gestational hypertension
At 31 weeks' gestation, a 37-year-old client with a history of preterm birth reports cramps, vaginal pain, and low, dull backache accompanied by vaginal discharge and bleeding. Assessment reveals cervix 2.1 cm long; fetal fibronectin in cervical secretions, and cervix dilated 3 to 4 cm. Which interactions should the nurse prepare to assist with? hospitalization, tocolytic, and corticosteroids bed rest and hydration at home an emergency cesarean birth careful monitoring of fetal movement (kick) counts
hospitalization, tocolytic, and corticosteroids Explanation: At 31 weeks' gestation, the goal would be to maintain the pregnancy as long as possible if the client and fetus are tolerating the continuation of the pregnancy. Stopping the contractions and placing the client in the hospital allows for monitoring in a safe place if the client continues and gives birth. Administration of corticosteroids may help to develop the lungs and prepare for early preterm birth. Sending the client home is contraindicated in the scenario described. An emergency cesarean birth is not indicated at this time. Monitoring fetal movement (kick) counts is typically done with a postterm pregnancy.
A nursing student working with a client in preterm labor correctly identifies which medication as being used to relax the smooth muscles of the uterus and for seizure prophylaxis and treatment in clients with preeclampsia? betamethasone nifedipine magnesium sulfate indomethacin
magnesium sulfate Explanation: The drug used to relax the uterine muscles and for seizure prophylaxis is magnesium sulfate. Betamethasone promotes fetal lung maturity, indomethacin inhibits uterine activity to arrest preterm labor, and nifedipine blocks calcium movement into the muscle cells and inhibits preterm labor.
The nurse is admitting a client at 23 weeks' gestation in preparation for induction and delivery after it was determined the fetus had died secondary to trauma. When asked by the client to explain what went wrong, the nurse can point out which potential cause for this loss? placental abruption genetic abnormality preeclampsia premature rupture of membranes
placental abruption Explanation: The most common cause of fetal death after a trauma is placental abruption (abruptio placentae), where the placenta separates from the uterus, and the fetus is not able to survive. Genetic abnormalities typically cause spontaneous abortion (miscarriage) in the first trimester. Trauma does not cause preeclampsia (which is related to various issues in the mother) nor does trauma usually cause PROM.
A woman in week 35 of her pregnancy with severe hydramnios is admitted to the hospital. The nurse recognizes that which concern is greatest regarding this client?
preterm rupture of membranes followed by preterm birth
A 24-year-old client presents in labor. The nurse notes there is an order to administer RhoGAM after the birth of her infant. When asked by the client the reason for this injection, which reason should the nurse point out?
prevent maternal D antibody formation.
A 19-year-old nulliparous woman is in early labor with erratic contractions. An assessment notes that she is remaining at 3 cm. There is also a concern that the uterus is not fully relaxing between contractions. The nurse suspects which complication? cephalopelvic disproportion precipitate labor reduced oxygen to the fetus ruptured uterus
reduced oxygen to the fetus Explanation: Hypertonic uterine dysfunction occurs when the uterus never fully relaxes between contractions. Placental perfusion becomes compromised, thereby reducing oxygen to the fetus. This occurs in early labor and affects nulliparous women more than multiparous women. A ruptured uterus is a potential complication; however, hypoxia to the fetus would occur first. Cephalopelvic disproportion is usually associated with hypotonic uterine dysfunction. Precipitate labor is one that is completed in less than 3 hours from the start of contractions to birth.
Neonatal risks of preterm rupture of membranes
respiratory distress syndrome, sepsis, intraventricular hemorrhage, and death.
A pregnant woman has arrived to the office reporting vaginal bleeding. Which finding during the assessment would lead the nurse to suspect an inevitable abortion?
strong abdominal cramping
A client with a pendulous abdomen and uterine fibroids (uterine myomas) has just begun labor and arrived at the hospital. After examining the client, the primary care provider informs the nurse that the fetus appears to be malpositioned in the uterus. Which fetal position or presentation should the nurse most expect in this woman? occipitoposterior position anterior fetal position cephalic presentation transverse lie
transverse lie Explanation: A transverse lie, in which the fetus is more horizontal than vertical, occurs in the following instances: women with pendulous abdomens; uterine fibroids (uterine myomas) that obstruct the lower uterine segment; contraction of the pelvic brim; congenital abnormalities of the uterus; or hydramnios. Anterior fetal position and cephalic presentation are normal conditions. Occipitoposterior position tends to occur in women with android, anthropoid, or contracted pelvis.