Chapters 21 22

The nurse is caring for a client who has given birth to twins. During which time period would the nurse instruct on the possibility of a late postpartum hemorrhage? 6 weeks to 6 months after birth 6 weeks to 3 months after birth 24 to 48 hours after birth 24 hours to 12 weeks after birth

24 hours to 12 weeks after birth Mothers who give birth to twins are instructed on postpartum hemorrhage at the same time as a mother with a single newborn. Delayed or late postpartum hemorrhages occur more than 24 hours but less than 12 weeks postpartum. Immediate, early, or primary postpartum hemorrhages occur within 24 hours of birth.

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 client is lying on her left side. Make sure the epidural medication is turned down. Check for a full bladder. Assess vital signs every 30 minutes.

Check for a full bladder. A full bladder can interfere with the progress of labor, so the nurse must be sure that the client has emptied her bladder.

A woman is admitted to the labor suite with contractions every 5 minutes lasting 1 minute. She is postterm and has oligohydramnios. What does this increase the risk of during birth? macrosomia shoulder dystocia cord compression fetal hydrocephalus

cord compression Oligohydramnios and meconium staining of the amniotic fluid are common complications of postterm pregnancy. Oligohydramnios increases the incidence of cord compression, which can lead to fetal distress during labor.

A woman is to undergo labor induction. The nurse determines that the woman requires cervical ripening if her Bishop score is: 7. 9. 5. 6.

5. A Bishop score less than 6 usually indicates that a cervical ripening method should be used before labor induction.

The nurse is caring for a client who required a forceps-assisted birth. For which potential factor should the nurse be alert? increased risk for cord entanglement increased risk for uterine rupture damage to the pregnant client's tissues potential lacerations and bleeding

potential lacerations and bleeding 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 pregnant client's tissues happens if the cup slips off the fetal head and the suction is not released during a vacuum-assisted birth.

A woman having contractions comes to the emergency department. She tells the nurse that she is at 34 weeks' gestation. The nurse examines her and finds that she is already effaced and dilated 2 cm. What is this woman demonstrating? preterm labor macrosomia normal labor dystocia

preterm labor Preterm labor is the occurrence of regular uterine contractions accompanied by cervical effacement and dilation before the end of the 37th week of gestation. It is not normal labor. Macrosomia is a large fetus. Dystocia is difficult or abnormal labor.

The nursing student demonstrates an understanding of dystocia with which statement? "Dystocia is diagnosed after labor has progressed for a time." "Dystocia is not diagnosed until after the birth." "Dystocia cannot be diagnosed until just before birth." "Dystocia is diagnosed at the start of labor."

"Dystocia is diagnosed after labor has progressed for a time." Nursing management of the woman with dystocia, regardless of etiology, requires patience. The nurse needs to provide physical and emotional support to the client and family. Dystocia is diagnosed not at the start of labor, but rather after it has progressed for a time.

A client has had a cesarean birth. Which amount of blood loss would the nurse document as a postpartum hemorrhage in this client? 1000 ml 500 ml 250 ml 750 ml

1000 ml Postpartum hemorrhage is defined as blood loss of 500 ml or more after a vaginal birth and 1000 ml or more after a cesarean birth.

A 29-year-old postpartum client is receiving anticoagulant therapy for deep venous thrombophlebitis. The nurse should include which instruction in her discharge teaching? Wear knee-high stockings when possible. Shortness of breath is a common adverse effect of the medication. Avoid iron replacement therapy. Avoid over-the-counter (OTC) salicylates.

Avoid over-the-counter (OTC) salicylates. Discharge teaching should include informing the client to avoid OTC salicylates, which may potentiate the effects of anticoagulant therapy. Iron will not affect anticoagulation therapy. Restrictive clothing should be avoided to prevent the recurrence of thrombophlebitis. Shortness of breath should be reported immediately because it may be a symptom of pulmonary embolism.

One of the primary assessments a nurse makes every day is for postpartum hemorrhage. What does the nurse assess the fundus for? Consistency, location, and place Content, lochia, place Consistency, shape, and location Location, shape, and content

Consistency, shape, and location Assess the fundus for consistency, shape, and location. Remember that the uterus should be firm, in the midline, and decrease 1 cm each postpartum day.

Which assessment on the third postpartum day would indicate to the nurse that a woman is experiencing uterine subinvolution? She experiences "pulling" pain while breastfeeding. Her uterus is 2 cm above the symphysis pubis. Her uterus is three finger widths under the umbilicus. Her uterus is at the level of the umbilicus.

Her uterus is at the level of the umbilicus. A uterus involutes at a rate of one finger width daily. On the third postpartum day, it is normally three finger widths below the umbilicus.

A 26-year-old primigravida has brought her doula to the birthing center for support during her labor and birth. The doula has been helping her through the past 16 hours of labor. The laboring woman is now 6 cm dilated. She continues to report severe pain in her back with each contraction. The client finds it comforting when her doula uses the ball of her hand to put counterpressure on her lower back. What is the likely cause of the woman's back pain? Breech presentation Nongynecoid pelvis Occiput posterior position Fetal macrosomia

Occiput posterior position A labor complicated by occiput posterior position is usually prolonged and characterized by maternal perception of increased intensity of back discomfort. The lay term for this type of labor is "back labor."

A woman experiences an amniotic fluid embolism as the placenta is delivered. The nurse's first action would be to: increase her intravenous fluid infusion rate. put firm pressure on the fundus of her uterus. administer oxygen by mask. tell the woman to take short, catchy breaths.

administer oxygen by mask. 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 17-year-old nulliparous client presents in active labor. It is discovered that she received no prenatal care. Which information would be important to collect first? coagulation studies HIV status urinalysis results STI status

coagulation studies Coagulation studies should be obtained immediately to determine her coagulation status to help eliminate potential bleeding problems. Her STI and HIV status and urinalysis results, although important, are not necessary emergently.

A woman is experiencing a postpartum hemorrhage due to uterine atony. Which risk factor would the nurse recognize as contributory to this specific problem? preeclampsia fetal demise placenta accreta multiparity

multiparity Risk factors for postpartum hemorrhage due to uterine atony include many factors, including multiparity. Placenta accreta is associated with placental issues, preeclampsia is seen in disruption of maternal clotting factors, and fetal demise can cause a disruption in maternal clotting factors, but not uterine atony.

In talking to a mother who is 6 hours post-delivery, the mother reports that she has changed her perineal pad twice in the last hour. What question by the nurse would best elicit information needed to determine the mother's status? "When did you last void?" "Are you in any pain with your bleeding?" "How much blood was on the two pads?" "What time did you last change your pad?"

"How much blood was on the two pads?" The nurse needs to determine the amount of bleeding the client is experiencing; therefore, the best question to ask the mother is the amount of blood noted on her perineal pads when she changes them. If she had an epidural, she may not feel any pain or discomfort with the bleeding. Although a full bladder can prevent the uterus from contracting, the nurse's main concern is the amount of lochia the mother is having.

The experienced labor and birth nurse knows to evaluate progress in active labor by using which simple rule? 1/2 cm/hour for cervical dilation 2 cm/hour for cervical dilation 1/4 cm/hour for cervical dilation 1 cm/hour for cervical dilation

1 cm/hour for cervical dilation In evaluating the progress in active labor, the nurse uses the simple rule of 1 cm/hour for cervical dilation.

A client is admitted to the unit in preterm labor. In preparing the client for tocolytic drug therapy, the nurse anticipates that the client's pregnancy may be prolonged for how long when this therapy is used? 4 to 8 days 2 to 7 days 6 to 10 days 1 to 5 days

2 to 7 days Tocolytic drugs may prolong the pregnancy for 2 to 7 days. During this time, steroids can be given to improve fetal lung maturity, and the woman can be transported to a tertiary care center.

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? Place the woman in Trendelenburg position. Administer oxygen at 10 L/min by face mask. Administer amnioinfusion. Assess fetal heart sounds.

Assess fetal heart sounds. 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 postpartum woman is developing a thrombophlebitis in her right leg. Which assessments would the nurse make to detect this? Assess for pedal edema. Blanch a toe, and count the seconds it takes to color again. Ask her to raise her foot and draw a circle. Bend her knee, and palpate her calf for pain.

Assess for pedal edema. Calf swelling, erythema, warmth, tenderness, and pedal edema may be noted and are caused by an inflammatory process and obstruction of venous return.

A nurse is assessing a client with postpartum hemorrhage; the client is presently on IV oxytocin. Which interventions should the nurse perform to evaluate the efficacy of the drug treatment? Select all that apply. Monitor the client's vital signs. Get a pad count. Assess the client's skin turgor. Assess deep tendon reflexes. Assess the client's uterine tone.

Assess the client's uterine tone. Monitor the client's vital signs. Get a pad count. A nurse should evaluate the efficacy of IV oxytocin therapy by assessing the uterine tone, monitoring vital signs, and getting a pad count. Assessing the skin turgor and assessing deep tendon reflexes are not interventions applicable to administration of oxytocin.

The nurse is caring for a client who has been diagnosed with a deep vein thrombosis. Which assessment finding should the nurse prioritize and report immediately? Dyspnea Edema Pyrexia Calf pain

Dyspnea A DVT is often suspected when an individual with an increased risk develops calf pain, pyrexia, and edema in one lower extremity. After the individual has been positively diagnosed with a DVT, any signs of dyspnea should be suspect of possible pulmonary embolism and should be handled as an emergency. The RN and/or primary care provider should be notified immediately so emergent care can be started, as this is often fatal.

A postpartum client is recovering from the birth and emergent repair of a cervical laceration. Which sign on assessment should the nurse prioritize and report to the health care provider? Weak and rapid pulse Warm and flushed skin Elevated blood pressure Decreased respiratory rate

Weak and rapid pulse : Excessive hemorrhage puts the client at risk for hypovolemic shock. Signs of impending shock include a weak and rapid pulse, decreased blood pressure, tachypnea, and cool and clammy skin. These findings should be reported immediately to the health care provider so that proper intervention for the client may be instituted.

A 25-year-old nulliparous client presents in active labor. She has had no prenatal care, and her coagulation status is determined. Which result would the nurse identify as placing the client at risk for postpartum hemorrhage? platelet count 350,000 international normalized ratio (INF) 1.0 prothrombin time 11 seconds activated partial thromboplastin time 60 seconds

activated partial thromboplastin time 60 seconds Activated partial thromboplastin time of 60 seconds is increased and suggestive of a coagulopathy. The platelet count, prothrombin time, and INR are within normal parameters.

The nurse suspects that a mother who delivered her infant 2 weeks ago is experiencing postpartum depression. What is the first line of treatment for this client? scheduling electroconvulsive therapy administrating a selective serotonin reuptake inhibitor telling the client that she has no need to be depressed talking to the client and reassuring her that she will feel better soon

administrating a selective serotonin reuptake inhibitor Selective serotonin reuptake inhibitors are the first-line drugs for postpartum depression and will help the new mother cope with the stresses of motherhood. They are also safe for breastfeeding mothers. Electroconvulsive therapy is used on women who are not responsive to medications. Minimizing the importance of the depression is counterproductive and not supportive of the mother.

The nurse is receiving shift handoff for a client with shoulder dystocia. Which nursing interventions are appropriate in the plan of care? Select all that apply. administration of a pain medication McRoberts maneuver bed rest in the side-lying position application of suprapubic pressure administration of a tocolytic

application of suprapubic pressure McRoberts maneuver Shoulder dystocia is the obstruction of fetal descent by the shoulders after the birth of the fetal head. The shoulders, and remainder of the fetus, fail to deliver spontaneously. McRoberts maneuver and the application of suprapubic pressure are common first interventions. If these do not work then the client may need a cesarean birth quickly. Administration of a tocolytic suppresses uterine contractions and the labor process. It is contraindicated during birth. Administering a pain medication may also be contraindicated, depending on the client's and fetus's status, whether or not the client received an epidural, and the type of pain medication already received. With shoulder dystocia, the client may be positioned onto hands and knees, not side-lying position.

Which measurement best describes postpartum hemorrhage? blood loss of 600 ml, occurring at least 24 hours after birth blood loss of 400 ml, occurring at least 24 hours after birth blood loss of 1,000 ml, occurring at least 24 hours after birth blood loss of 800 ml, occurring at least 24 hours after birth

blood loss of 1,000 ml, occurring at least 24 hours after birth Postpartum hemorrhage involves blood loss in excess of 1,000 mL within the first 24 hours of delivery.

A nurse is developing a plan of care for a postpartum woman with superficial venous thrombosis of the left leg. Which intervention would the nurse most likely include? applying cool compresses to the left leg administering opioids for pain relief encouraging elevation of the left leg administering intravenous anticoagulant therapy

encouraging elevation of the left leg For the woman with superficial venous thrombosis, administer nonsteroidal anti-inflammatory drugs (NSAIDs) for analgesia, provide for rest and elevation of the affected leg, apply warm compresses to the affected area to promote healing, and use antiembolism stockings to promote circulation to the extremities. Intravenous anticoagulant therapy would be used for a woman with deep vein thrombosis.

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 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.

The nurse is caring for a client in labor. The nurse realizes it is most common for labor dystocia to occur during which stage of labor? first stage of labor fourth stage of labor third stage of labor second stage of labor

first stage of labor Labor dystocia most often becomes apparent during the first stage of labor in the active labor phase.

What terminology would the nurse use to document a newborn who weighs 4,000 grams (8.8 lb) or more at birth? macrosomia meconium microsomia hydrocephalus

macrosomia Macrosomia, in which a newborn weighs 4,000 to 5,000 grams (8.8 to 11 lb) or more at birth, complicates approximately 10% of all pregnancies. Meconium is the first stool passed by a newborn. Hydrocephalus is a build-up of fluid inside the skull.

A fundal massage is sometimes performed on a postpartum woman. The nurse would perform this procedure to address which condition? uterine contraction uterine prolapse uterine subinvolution uterine atony

uterine atony Fundal massage is performed for uterine atony, which is failure of the uterus to contract and retract after birth. The nurse would place the gloved dominant hand on the fundus and the gloved nondominant hand on the area just above the symphysis pubis. Using a circular motion, the nurse massages the fundus with the dominant hand. Then the nurse checks for firmness and, if firm, applies gentle downward pressure to express clots that may have accumulated. Finally, the nurse assists the woman with perineal care and applying a new perineal pad.

The nurse is working with several clients who have recently delivered healthy newborns. Which statement by a mother would alert the nurse to further assess the mother for postpartum depression? "I seem to cry more each and every day that goes by." "I am hearing voices and sometimes want to harm myself and my newborn." "Life sure has changed since I had the newborn....I am so tired but it is worth it." "The first few days I was home, I was overwhelmed."

"I seem to cry more each and every day that goes by." The symptoms of postpartum depression are similar to the "baby blues" but worsen over time and do not lighten, so the nurse would further assess the mother who states she is crying more, not less. If the mother is in danger of harming herself or her newborn and hearing voices, she is likely experiencing postpartum psychosis, which is a psychiatric emergency. The mother who speaks of being tired and the mother who felt overwhelmed in the beginning are likely experiencing "baby blues."

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? 45 ml urine output in 2 hours hemoglobin of 13 g/dl (130 g/L) hematocrit of 36% (0.36) platelet count of 150,000 mm3

45 ml urine output in 2 hours 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 client arrives in the labor and delivery unit in the beginning early phase with the contractions 5 to 8 minutes apart and dilated 1 cm. Thirty minutes later the nurse finds the client in hard, active labor and 8 cm dilated. The nurse calls for assistance, prepares for a precipitate birth, and monitors the client for which priority assessment caused by a rapid birth? Check perineal area frequently for bleeding. Assess bladder for fullness. Assess and administer pain medication as needed. Assess the client's breathing and intervene if necessary.

Check perineal area frequently for bleeding. Precipitous dilation (dilatation) is cervical dilation that occurs at a rate of 5 cm or more per hour in a primipara or 10 cm or more per hour in a multipara. Contractions can be so forceful they lead to premature separation of the placenta (placental abruption) or lacerations of the perineum, placing the client at risk for hemorrhage. The other interventions are appropriate, but the priority is assessing for bleeding/hemorrhage.

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 strength of uterine contractions Increased risk for placental abruption Decreased fetal oxygenation

Decreased fetal oxygenation 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.

A woman is 2 weeks postpartum when she calls the clinic and tells the nurse that she has a fever of 101°F (38.3°C). She reports abdominal pain and a "bad smell" to her lochia. The nurse recognizes that these symptoms are associated with which condition? Episiotomy infection Endometritis Mastitis Subinvolution

Endometritis The woman with endometritis typically looks ill and commonly develops a fever of 100.4°F (38°C) or higher (more commonly 101°F [38.3°C], possibly as high as 104°F [40° C]) on the third to fourth postpartum day. The rise in temperature at this specific time is the most significant finding. The woman exhibits tachycardia, typically a rise in pulse rate of 10 beats per minute for each rise in temperature of one degree. In addition, the woman may report chills, anorexia, and general malaise. She also may report abdominal cramping and pain, including strong afterpains. Fundal assessment reveals uterine subinvolution and tenderness. Lochia typically increases in amount and is dark, purulent, and foul-smelling. However, with certain microorganisms, her lochia may be scant or absent.

A client in their third trimester comes to the clinic reporting vaginal bleeding that started this morning. The nurse performs an assessment to determine the underlying cause of the bleeding. Assessment reveals fundal height appropriate for expected gestational age, uterine pain 10 out of 10 on scale 0 to 10, and bright red vaginal bleeding. Vital signs include a heart rate of 110 beats/min and a blood pressure reading of 90/50 mm Hg. For each finding, click to specify if the finding indicates placenta previa or placental abruption. Each finding may support more than one classification. Finding Placental Abruption Placenta Previa Pain increased heart rate uterine tenderness decreased hemoglobin decreased blood pressure bright red blood fundal height greater than expected gestational age Note: Each column must have at least 1 response option selected.

Placental Abruption Pain increased heart rate uterine tenderness decreased hemoglobin decreased blood pressure bright red blood Placenta Previa increased heart rate decreased hemoglobin decreased blood pressure bright red blood fundal height greater than expected gestational age Placenta previa presents with painless bright red blood, and a fundal height greater than expected for gestational age. Depending on blood loss, the client's hemoglobin and hematocrit may be decreased; as a result, the blood pressure would also be decreased with an elevated heart rate. Placental abruption presents with painful, bright red bleeding; a boardlike, tender uterus; a fundal height at a height expected for gestational age; decreased hemoglobin, hematocrit, and blood pressure; and an elevated heart rate. Placenta previa does not present with a painful, tender uterus. In placenta previa, the fundal height would be higher than expected for gestational age. In placental abruption, the fundal height would be at a height expected for gestational age.

A nurse is caring for a postpartum client whose most recent assessment reveals a large, purplish area of edema on the left side of the perineum. What action will the nurse take? Document the expected finding and reassess frequently. Report the finding promptly to the primary health care provider. Apply an ice pack and reassess in 30 minutes. Provide a hot pack and administer analgesia as prescribed.

Report the finding promptly to the primary health care provider. This client's presentation is consistent with a hematoma, which indicates a hemorrhage and which must be treated promptly. Because this is a large hematoma, reporting this change in status is priority. If the hematoma had been small in size, hot and/or cold treatments will likely be used. This is not an expected finding; thus, the nurse needs to intervene.

The nurse is assigned to care for a postpartum client with a deep vein thrombosis (DVT) who is prescribed anticoagulation therapy. Which statement will the nurse include when providing education to this client? "It is appropriate for you to sit with your legs crossed over each other." "You can breastfeed your newborn while taking any anticoagulation medication." "It is expected for you to have minimal blood in your urine during therapy." "You need to avoid medications which contain acetylsalicylic acid."

"You need to avoid medications which contain acetylsalicylic acid." The nurse should caution the client to avoid products containing acetylsalicylic acid, or aspirin, and other nonsteroidal anti-inflammatory medications while on anticoagulation therapy. These medications inhibit the synthesis of clotting factors and can further prolong clotting time and precipitate bleeding. The nurse should instruct the client to avoid crossing the legs as a preventive measure. Hematuria is not expected and indicates internal bleeding. The client would be instructed to notify the primary health care provider for any prolonged bleeding. The client may not be able to breastfeed while taking anticoagulation medications. Warfarin is not thought to be excreted in breastmilk; however, most medications are excreted in breast milk. Therefore, breastfeeding is generally not recommended for the client on anticoagulation therapy.

The nurse is conducting discharge teaching with a postpartum woman. What would be an important instruction for this client? Call her caregiver if lochia moves from rubra to serosa. Call her caregiver if lochia moves from serosa to alba. Call her caregiver if lochia moves from serosa to rubra. Call her caregiver if amount of lochia decreases.

Call her caregiver if lochia moves from serosa to rubra. Most cases of late postpartum hemorrhage occur after the woman leaves the health care or birthing facility. Therefore, client education before discharge about expected changes and danger signs and symptoms is crucial. Instruct the woman to call her primary care provider if she experiences any signs of infection, such as fever greater than 100.4°F (38°C), chills, or foul-smelling lochia. She should also report lochia that increases (versus decreasing) in amount, or reversal of the pattern of lochia (i.e., moves from serosa back to rubra).

The health care provider has determined that the source of dystocia for a woman is related to the fetus size. The nurse understands that macrosomia would indicate the fetus would weigh: 4,000 g to 4500 g 3,000 g to 3500 g 2500 to 3000 g 3,500 g to 4000 g

4,000 g to 4500 g Macrosomia, in which a newborn weighs 4,000 to 4,500 g (8.1 to 9.9 lb) or more at birth, complicates approximately 10% of all pregnancies The excessive fetal size and abnormalities contribute to labor and birth dysfunctions.

The nurse is caring for a mother within the first four hours after a cesarean birth. Which nursing intervention would be most appropriate to prevent thrombophlebitis in the mother? Ambulate the client as soon as her vital signs are stable. Assist client in performing leg exercises every 2 hours. Roll a bath blanket or towel and place it firmly behind the knees. Limit oral intake of fluids for the first 24 hours to prevent nausea.

Ambulate the client as soon as her vital signs are stable. The best prevention for thrombophlebitis is ambulation as soon as possible after recovery. Ambulation requires blood movement throughout the cardiovascular system, decreasing thrombophlebitis risks. Placing a bath blanket behind the knees interrupts circulation and could cause a thrombus. Fluids are encouraged not limited. Leg exercises may put strain on the abdominal incision.

A nurse is caring for a postpartum client diagnosed with von Willebrand disease. What should be the nurse's priority for this client? Assess the fundal height. Assess the temperature. Check the lochia. Monitor the pain level.

Check the lochia. The nurse should assess the client for prolonged bleeding time. von Willebrand disease is a congenital bleeding disorder, inherited as an autosomal dominant trait, that is characterized by a prolonged bleeding time, a deficiency of von Willebrand factor, and impairment of platelet adhesion. A fever of 100.4° F (38° C) after the first 24 hours following birth and pain indicate infection. A client with a postpartum fundal height that is higher than expected may have subinvolution of the uterus.

A client who had an emergency cesarean birth for fetal distress 3 days ago is preparing for discharge. When reviewing the home care instructions with the nurse, the client reveals she is saddened about her cesarean and feels let down that she was not able to have a vaginal birth. When questioned further, the client states she feels "weepy about everything" and cannot stop crying. What nursing action is indicated first? Discuss the client's potential depression with her family members. Contact the primary care provider to report the client's deteriorating mental status. Document the conversation. Ask the client to elaborate on her feelings.

Ask the client to elaborate on her feelings. The client's affect is consistent with postpartum blues, a transient source of sadness experienced during the first week after birth. The nurse should offer support to the client and encourage her to discuss her concerns and feelings. The client's emotional state is normal and contacting the care provider is not indicated. Discussing the client's feelings with family members is a violation of confidentiality and is not an appropriate action. Documenting the interaction is indicated but should take place after the encounter is completed.

The nurse observes an ambulating postpartum woman limping and avoiding putting pressure on her right leg. Which assessments should the nurse prioritize in this client? Assess for warmth, erythema, and pedal edema. Ask the client to raise the foot and draw a circle. Blanch a toe, and count the seconds it takes to color again. Bend the knee and palpate the calf for pain.

Assess for warmth, erythema, and pedal edema. This client is demonstrating potential symptoms of DVT, but is avoiding putting pressure on the leg and limping when ambulating. DVT manifestations are caused by inflammation and obstruction of venous return and can be assessed by the presence of calf swelling, warmth, erythema, tenderness, and pedal edema. The client would not need to bend the knee to assess for pain in the calf. Asking the client to raise her toe and draw a circle is assessing reflexes, and blanching a toe is assessing capillary refill (which may be affected by the DVT but is not indicative of a DVT).

The nurse is caring for a postpartum woman who exhibits a large amount of bleeding. Which areas would the nurse need to assess before the woman ambulates? Attachment, lochia color, complete blood cell count Blood pressure, pulse, reports of dizziness Height, level of orientation, support systems Degree of responsiveness, respiratory rate, fundus location

Blood pressure, pulse, reports of dizziness Continue to monitor the woman's vital signs for changes. If she reports dizziness or light-headedness when getting up, obtain her blood pressure while lying, sitting, and standing, noting any change of 10 mm Hg or more.

It is discovered that a new mother has developed a postpartum infection. What is the most likely expected outcome that the nurse will identify for this client related to this condition? Client's temperature remains below 100.4°F (38.8°C) orally. Fundus remains firm and midline with progressive descent. Client maintains a urinary output greater than 30 ml per hour. Lochia discharge amount is 6 inches or less on a perineal pad in 1 hour.

Client's temperature remains below 100.4°F (38.8°C) orally. As fever would accompany a postpartum infection, a likely expected outcome would be to reduce the client's temperature and keep it in a normal range. The other expected outcomes do not pertain as directly to postpartum infection as does the reduced temperature.

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. Apply pressure to the fundus. Use McRoberts maneuver.

Use McRoberts maneuver. 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.

Which statement describes why hypertonic contractions tend to become very painful? More than one contraction may begin at the same time, as receptor points in the myometrium act independently of each other. The myometrium becomes sensitive from the lack of relaxation and anoxia of uterine cells. The number of uterine contractions is very low or infrequent. There is an increase in the length of labor because so many contractions are needed to achieve cervical dilation (dilatation).

Uterine rupture 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 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 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 nurse is caring for a client who has had an intrauterine fetal death with prolonged retention of the fetus. For which signs and symptoms should the nurse watch to assess for an increased risk of disseminated intravascular coagulation? Select all that apply. acute kidney injury hypertension tachycardia bleeding gums lochia less than usual

bleeding gums tachycardia acute kidney injury The nurse should monitor for bleeding gums, tachycardia, and acute kidney injury to assess for an increased risk of disseminated intravascular coagulation in the client. The other clinical manifestations of this condition include petechiae, ecchymosis, and uncontrolled bleeding during birth. Hypotension and amount of lochia greater than usual are findings that might suggest a coagulopathy or hypovolemic shock.

A fetus is experiencing shoulder dystocia during birth. The nurse would place priority on performing which fetal assessment postbirth? assess for cleft palate extensive lacerations monitor for a cardiac anomaly brachial plexus assessment

brachial plexus assessment 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.

Various medications are available to help control hemorrhage in the postpartum client. When reviewing the client's history, the nurse notes the client's history of asthma. Which medication if prescribed would the nurse question? methylergonovine dinoprostone oxytocin carboprost

carboprost Carboprost is contraindicated with asthma due to the risk of bronchial spasms. Oxytocin should be given undiluted as a bolus injection, and methylergonovine should not be given to a woman who is hypertensive. Dinoprostone and methylergonovine can be used in pregnant clients with asthma, although should be used cautiously. Dinoprostone may cause hypotension, nausea/vomiting, diarrhea and temperature elevation.

Which intervention would be most important when caring for the client with breech presentation confirmed by ultrasound? applying suprapubic pressure against the fetal back auscultating the fetal heart rate at the level of the umbilicus noting the space at the maternal umbilicus continuing to monitor maternal and fetal status

continuing to monitor maternal and fetal status 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 client in preterm labor is receiving magnesium sulfate IV and appears to be responding well. Which finding on assessment should the nurse prioritize? bradycardia elevated blood glucose tachypnea depressed deep tendon reflexes

depressed deep tendon reflexes The nurse should assess the woman at least once hourly and report any dyspnea (not tachypnea), tachycardia (not bradycardia), productive cough, adventitious breath sounds, and absent or decreased deep tendon reflexes in a client receiving magnesium sulfate; these are all signs of possible magnesium toxicity. Elevated blood glucose is a potential adverse reaction if the woman is receiving terbutaline.

The nurse is assisting a primary care provider to attempt to manipulate the position of the fetus in utero from a breech to cephalic position. What does the nurse inform the client the procedure is called? external cephalic version vaginal manipulation external rotation internal rotation

external cephalic version External cephalic version is the process of manipulating the position of the fetus in order to try to turn the fetus to a cephalic presentation.

The nurse provides education to a postterm pregnant client. What information will the nurse include to assist in early identification of potential problems? "Continue to monitor fetal movements daily." "Increase your fluid intake to prevent dehydration." "Monitor your bowel movements for constipation." "Be sure to measure 24-hour urine output daily."

"Continue to monitor fetal movements daily." 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.

The nurse is administering a postpartum woman an antibiotic for mastitis. Which statement by the mother indicates that she understood the nurse's explanation of care? "I will stop breastfeeding until I finish my antibiotics." "I can continue breastfeeding my infant, but it may be somewhat uncomfortable." "I am able to pump my breast milk for my baby and throw away the milk." "When breastfeeding, it is recommended to begin nursing on the infected breast first."

"I can continue breastfeeding my infant, but it may be somewhat uncomfortable." Breastfeeding on antibiotics for mastitis is fine, and the mother is encouraged to empty the infected breast to prevent milk stasis. However, the nurse should prepare the mother for the process being somewhat painful because the breast is tender. It is recommended to start the infant nursing on the uninvolved breast first as vigorous sucking may increase the mother's pain. Unless contraindicated by the antibiotic, the breast milk will be stored for later if the mother needs to pump her breasts; she does not need to throw the milk away.

During active labor, the nurse notes a decrease in the baby's fetal heart rate and consults with the health care provider. The provider concurs and prescribes application of oxygen via mask, increase in IV fluids, and repositioning. The nurse should communicate which piece of information to the woman when she protests about being "tied down" in bed with IVs? "Remember, the goal is to increase the FHR so a healthy infant can be born." "Changing your position to side lying can prevent hypotension from inferior vena cava compression." "Increasing your oxygen level will also increase the infant's oxygen level." "An IV line will assist the staff if your baby shows signs of distress."

"Remember, the goal is to increase the FHR so a healthy infant can be born." If a woman develops a complication of labor or birth, actions to increase the fetal heart rate (FHR) or to strengthen uterine contractions are a priority and possibly an emergency. Interventions must be planned and performed efficiently and effectively, based on the individual circumstances. Focusing on IV lines, rationale for oxygen placement, or educating about changing position does not put the focus on the priority—a healthy baby.

The nurse is caring for several women in the postpartum clinic setting. Which statement(s), when made by one of the clients, would alert the nurse to further assess that client for postpartum psychosis? Select all that apply. "The newborn is not really mine emotionally, since I was never pregnant and do not have children." "When the newborn is sleeping, I can see his thoughts projected on my phone and I do not like the thoughts." "I believe my newborn is losing weight because I will not feed him because my milk was poisoned by the health care provider." "I am sad because I am not spending as much time with my toddler now that my newborn is here." "Sometimes I get tired of being with only the newborn, so I call my mom and sister to come visit."

"The newborn is not really mine emotionally, since I was never pregnant and do not have children." "When the newborn is sleeping, I can see his thoughts projected on my phone and I do not like the thoughts." "I believe my newborn is losing weight because I will not feed him because my milk was poisoned by the health care provider." Postpartum psychosis is a serious and emergent condition in which the new mother has lost touch with reality and needs immediate psychiatric intervention. Visual hallucinations such as seeing the newborn's thoughts projected on her phone is a sign of postpartum psychosis. Denying the pregnancy or that the newborn is hers is a sign of postpartum psychosis. The delusion that her milk is poisoned is a sign of postpartum psychosis. Being concerned about time with the toddler is a sign of postpartum blues or possibly depression. Reaching out for family to visit is a positive coping skill.

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 amniotic fluid embolism placental separation

amniotic fluid embolism 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.

A nurse is assessing the perineum of several postpartum clients using the REEDA score. The nurse initiates interventions to minimize the risk for postpartum infection for the client with which score? 9 5 3 7

9 The nurse would implement measures to minimize the risk for postpartal infection for the woman with a REEDA score of 9. The acronym REEDA is frequently used for assessing a woman's perineum status. It is derived from five components that have been identified to be associated with the healing process of the perineum. These include: redness, edema, ecchymosis, discharge and approximation of skin edges. Each category is assessed and a number assigned (0 to 3 points, with 0 indicating none or intact and 3 indicating more significant problems). The total REEDA score ranges from 0 to 15. Higher scores indicate increased tissue trauma predisposing the woman to an increased risk for infection and a greater risk for postpartal hemorrhage. Therefore the woman with a total score of 9 is at greatest risk for problems.

The nursing student doing a clinical obstetrics rotation correctly picks which term to label a pregnancy that continues past the end of the 42nd week of gestation? term pregnancy post-term pregnancy preterm pregnancy none of the above

post-term pregnancy A term pregnancy usually lasts 38 to 42 weeks. A post-term pregnancy continues past the end of the 42nd week of gestation. A preterm pregnancy ends before the 34th week of gestation.

The nurse in a busy L & D unit is caring for a woman beginning induction via oxytocin drip. Which prescription should the nurse question with regard to titrating the infusion upward for adequate contractions? After one hour, titrate the infusion upward by 1 to 2 mu/min until contractions are adequate. Start oxytocin drip, piggyback to main IV line to port closest to client. Begin infusion at 10 milliunits (mu)/min and titrate every 15 minutes upward by 5 mu/min. Discontinue infusion if contractions are every 2 minutes lasting 60 to 90 seconds each.

Begin infusion at 10 milliunits (mu)/min and titrate every 15 minutes upward by 5 mu/min. Hyperstimulation is usually defined as five or more contractions in a 10-minute period or contractions lasting more than 2 minutes in duration or occurring within 60 seconds of each other. The surest method to relieve hyperstimulation is to immediately discontinue the oxytocin infusion. The rate should not be increased by more than 2 milliunits at a time. When the infusion is administered, the oxytocin solution should be "piggybacked" to a maintenance IV solution such as Ringer's lactate and the piggyback added to the main infusion at the port closest to the woman. Infusions are usually begun at a rate of 1 to 2 milliunits/min. If there is no response, the infusion is gradually increased every 30 to 60 minutes by small increments of 1 to 2 milliunits/min until contractions begin.

The nurse is monitoring a woman who is receiving IV oxytocin to assist with uterine irritability. Which action should the nurse prioritize if the woman's contractions are determined to be 80 seconds in length after 1 hour of administration of the oxytocin? Increase the flow rate of the main line infusion. Continue to monitor contraction duration every 2 hours. Discontinue the oxytocin infusion. Slow the infusion to under 10 gtts per minute.

Discontinue the oxytocin infusion. If uterine contractions lengthen beyond 70 seconds, there is apt to be an interference with fetal circulation. Discontinuing the infusion allows contractions to shorten in length and allow fetal nourishment. The nurse would not increase the flow rate of the main line infusion or slow the infusion without the health care provider's prescription. Uterine contractions are monitored continuously.

The perinatal educator is instructing on various emotions commonly experienced during labor. Which complication of anxiety is most important to stress? Fetal tachycardia Gestational hypertension Shortness of breath Dystocia

Dystocia 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.

The nurse collects a urine specimen for culture from a postpartum woman with a suspected urinary tract infection. Which organism would the nurse expect the culture to reveal? Staphylococcus aureus Gardnerella vaginalis Klebsiella pneumoniae Escherichia coli

Escherichia coli E. coli is the most common causative organism for urinary tract infections. S. aureus is the most common causative organism for mastitis. G. vaginalis is a common cause of metritis. K. pneumoniae is a common cause of endometritis, but some species of Klebsiella may cause urinary tract infections.

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? Mild decelerations Late decelerations Variable decelerations Early decelerations

Late decelerations 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 client is diagnosed with a postpartum infection. The nurse is most correct to provide which instruction? Apply ice to the perineum to decrease pain of a perineal infection. Drink plenty of fluids to decrease a bladder infection. Change the perineal pad every 3 to 4 hours to decrease the uterine infection. Finish all antibiotics to decrease a genital tract infection.

Finish all antibiotics to decrease a genital tract infection. A postpartum infection is an infection of the genital tract after delivery through the first 6 weeks postpartum. It is most important to include finishing all antibiotics in nursing instructions. Endometritis is an infection of the mucous membrane or endometrium of the uterus. Cystitis is an infection of the bladder. Infection of the perineum or episiotomy is a localized infection and not inclusive of the entire genital tract.

The nurse palpates a postpartum woman's fundus 2 hours after birth and finds it located to the right of midline and somewhat soft. What is the correct interpretation of this finding? The uterine placement is normal. The uterus is filling up with blood. There is an infection inside the uterus. The bladder is distended.

The bladder is distended. If a postpartum client's bladder becomes full, the client's uterus is displaced to the side. The client should be taught to void on demand to prevent the uterus from becoming soft and increasing the flow of lochia.

What medication would the nurse administer to a client experiencing uterine atony and bleeding leading to postpartum hemorrhage? Magnesium sulfate Calcium gluconate Domperidone Oxytocin

Oxytocin Oxytocin causes the uterus to contract to improve uterine tone and reduce bleeding. Magnesium sulfate is administered to clients with preeclampsia or eclampsia or hypertension problems. Domperidone is used to increase lactation in women. Calcium gluconate is an antagonist used in clients experiencing side effects of magnesium sulfate.

The nurse is assessing a client who is 14 hours postpartum and notes very heavy lochia flow with large clots. Which action should the nurse prioritize? Assess her blood pressure. Palpate her fundus. Have her turn to her left side. Assess her perineum.

Palpate her fundus. The nurse should assess the status of the uterus by palpating the fundus and determining its condition. If it is boggy, the nurse would then initiate fundal massage to help it contract and encourage the passage of the lochia and any potential clots that may be in the uterus. Assessing the blood pressure and assessing her perineum would follow if indicated. It would be best if the woman is in the semi-Fowler position to allow gravity to help the lochia to drain from the uterus. The nurse would also ensure the bladder was not distended

The nurse is examining a client at 37 weeks' gestation who came to labor and delivery with severe cramps and vaginal spotting. While listening to the fetal heart rate the nurse observes a reddened area of the side of the client's abdomen. When the nurse asks about the area, the client says "I got hit with a broom." The nurse asks who hit her, but the client does not respond. A vaginal examination reveals the cervix is 50% effaced and dilated 1 cm, membranes are intact, no bleeding and the presenting part is floating. Based on the nurse's assessment, the client is admitted to the observation unit to be monitored for which obstetrical condition? Placenta previa Preeclampsia Placental abruption (abruptio placentae) Premature labor

Placental abruption (abruptio placentae) Trauma to the abdomen increases the risk for placenta abruption (abruptio placentae). The client's presentation with severe cramps is consistent with a potential for placental abruption. A client would be monitored for preeclampsia if she presented with elevated blood pressure, proteinuria, headache, and edema of the fingers or face. The client is at 37 weeks' gestation so she is not in premature labor. A placenta previa would present with painless vaginal bleeding.

The father of a 2-week-old infant presents to the clinic with his disheveled wife for a postpartum visit. He reports his wife is acting differently, is extremely talkative and energetic, sleeping only 1 or 2 hours at a time (if at all), not eating, and appears to be totally neglecting the infant. The nurse should suspect the client is exhibiting signs and symptoms of which disorder? Postpartum blues Maladjustment Postpartum depression Postpartum psychosis

Postpartum psychosis Postpartum psychosis in a client can present with extreme mood changes and odd behavior. Her sudden change in behavior from normal, along with a lack of self-care and care for the infant, are signs of psychosis and need to be assessed by a provider as soon as possible. Postpartum depression affects the woman's ability to function; however, her perception of reality remains intact. Postpartum blues is a transitory phase of sadness and crying common among postpartum women.

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? With the client in lithotomy position, hold her legs and sharply flex them toward her shoulders. Place the client in Trendelenburg position and gently attempt to reinsert the cord. Contact the health care provider and prepare the client for an emergent vaginal birth. Put the client in bed immediately, call for help, and lift the presenting part of the fetus off the cord.

Put the client in bed immediately, call for help, and lift the presenting part of the fetus off the cord. 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 pregnatn client asks about experiencing a vaginal birth after cesarean (VBAC). After reading the client's history, the nurse anticipates that the client mayu be a good candidate based on which finding? The previous cesarean used a lower abdominal incision. Client has a contracted pelvis. Client underwent prior transfundal uterine surgery. The previous cesarean used the classic uterine incision.

The previous cesarean used a lower abdominal incision. The choice of a vaginal or repeat cesarean birth can be offered to a client who had a previous cesarean birth using a lower abdominal incision. Contraindications to vaginal birth after cesarean (VBAC) include a prior cesarean using the classic uterine incision, prior transfundal uterine surgery, uterine scar other than low-transverse ("bikini cut") scar from a previous cesarean birth, contracted pelvis, and inadequate staff at the facility if an emergency cesarean birth is required.

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? Apply pressure to the fundus. Attempt to push in one of the fetus's shoulders. Use Zavanelli maneuver. Use McRoberts maneuver.

Use McRoberts maneuver. 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.

Which intervention would be helpful to a client who is bottle feeding her infant and experiencing hard, engorged breasts? applying ice restricting fluids administering bromocriptine applying warm compresses

applying ice Women who do not breastfeed often experience moderate to severe engorgement and breast pain when no treatment is applied. Ice promotes comfort by decreasing blood flow (vasoconstriction), numbing the area, and discouraging further letdown of milk. Restricting fluids does not reduce engorgement and should not be encouraged. Warm compresses will promote blood flow and hence, milk production, worsening the problem of engorgement. Bromocriptine has been removed from the market for lactation suppression.

For a client in precipitous labor, within which span of time should the nurse expect the birth to occur? approximately 3 hours approximately 5 hours approximately 4 hours approximately 6 hours

approximately 3 hours A labor that lasts 3 hours or less from the onset of regular contractions until fetal expulsion is classified as precipitous

Which finding would lead the nurse to suspect that the fetus of a woman in labor is in hypertonic uterine dysfunction? reports of severe back pain lack of cervical dilation past 2 cm fetal buttocks as the presenting part contractions most forceful in the middle of uterus rather than the fundus

contractions most forceful in the middle of uterus rather than the fundus Contractions that are more forceful in the midsection of the uterus rather than in the fundus suggest hypertonic uterine dysfunction. Reports of severe back pain are associated with a persistent occiput posterior position due to the pressure of the fetal head on the woman's sacrum and coccyx. Cervical dilation (dilatation) that has not progressed past 2 cm is associated with dysfunctional labor. A breech position is one in which the fetal presenting part is the buttocks or feet.

A client is giving birth when shoulder dystocia occurs in the fetus. The nurse recognizes that which condition in the client is likely to increase the risk for shoulder dystocia? preterm birth diabetes pendulous abdomen nullipara

diabetes Shoulder dystocia is most apt to occur in women with diabetes, in multiparas, and in postdate pregnancies. A pendulous abdomen is associated with the transverse lie fetal position not with shoulder dystocia.

A postpartum client with a history of deep vein thrombosis is being discharged on anticoagulant therapy. The nurse teaches the client about the therapy and measures to reduce her risk for bleeding. Which statement by the client indicates the need for additional teaching? "If I get a cut, I need to apply direct pressure for about 5 minutes or more." "If my lochia increases, I need to call my health care provider." "I should brush my teeth vigorously to stimulate the gums." "I need to avoid using any aspirin-containing products."

"I should brush my teeth vigorously to stimulate the gums." The client is at risk for bleeding and as such should gently brush her teeth with a soft toothbrush to prevent injury. An increase in lochia warrants notification of the health care provider. Aspirin and aspirin-containing products should be avoided. If the client experiences a cut that bleeds, she should apply direct pressure to the site for 5 to 10 minutes.

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? "Maybe your uterus is just tired and needs a rest." "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." "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."

"More than likely you have cephalopelvic disproportion (CPD) where baby's head cannot make it through the canal." 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.

The nurse is providing education to a postpartum woman who has developed a uterine infection. Which statement by the woman indicates that further instruction is needed? "I will change my perineal pad regularly to remove the infected drainage." "If my abdomen becomes firm, or if I don't urinate as much, I need to call the doctor." "I will take frequent walks around my home to promote drainage." "When I am sleeping or lying in bed, I should lie flat on my back."

"When I am sleeping or lying in bed, I should lie flat on my back." With a uterine infection, the client needs to be in a semi-Fowler position to facilitate drainage and prevent the infection from spreading. Changing the perineal pads regularly; walking to promote drainage; and contacting the doctor if her uterus becomes rigid (or if she notes a decrease in urinary output) are all correct actions.

A client is experiencing postpartum hemorrhage shortly after the birth of the infant. Which nursing intervention(s) would be appropriate for this client? Select all that apply. Begin uterine massage with both hands on the fundus of the uterus. Turn the client on the side and inspect the area under the buttocks for blood. Encourage increased fluid intake. Monitor vital signs every 15 minutes. Encourage the client to breastfeed the infant, if she is breastfeeding.

Encourage the client to breastfeed the infant, if she is breastfeeding. Begin uterine massage with both hands on the fundus of the uterus. Turn the client on the side and inspect the area under the buttocks for blood. Encourage increased fluid intake. Monitor vital signs every 15 minutes. If a client is experiencing a postpartum hemorrhage, the nurse needs begin uterine massage and increase her fluid intake. If eating and drinking are not advisable due to the client's status, IV fluids are started. Breastfeeding releases oxytocin, which aids in uterine contractions. The nurse should always turn the client over to check for pooled blood under the buttocks to get a more accurate assessment of blood loss. Since hemorrhaging can result in tachycardia and hypotension from hypovolemia, frequent monitoring of the client's vital signs is imperative.

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. 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.

The nurse is monitoring a client in labor who has had a previous birth via cesarean and is trying a vaginal birth with an epidural. The nurse observes a sudden drop in blood pressure, increased heart rate, and deep variable deceleration on the fetal monitor. The client reports severe pain in the abdomen and shoulder. What should the nurse prepare to do? Place the client in a knee-chest position. Turn the client on their left side. Prepare the client for a cesarean birth. Bolus the client with another dose of medication through the epidural.

Prepare the client for a cesarean birth. The findings are consistent with uterine rupture. An abrupt change in the fetal heart rate pattern is often the most significant finding associated with uterine rupture. Other findings are reports of pain in the abdomen, shoulder, or back in a laboring client who had previous effective pain relief from epidural anesthesia. Falling blood pressure and rising pulse may be associated with hypovolemia caused by occult bleeding. The treatment is immediate cesarean birth.

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? Apply pressure to the client's lower back with a fisted hand. Assist with nitrazine and fern tests. Prepare to assist with external version. Include a set of piper forceps when the table is prepped.

Prepare to assist with external version. 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 woman arrives at the office for her 4-week postpartum visit. Her uterus is still enlarged and soft, and lochial discharge is still present. Which nursing diagnosis is most likely for this client? Risk for infection related to microorganism invasion of episiotomy Risk for impaired breastfeeding related to development of mastitis Ineffective peripheral tissue perfusion related to interference with circulation secondary to development of thrombophlebitis Risk for fatigue related to chronic bleeding due to subinvolution

Risk for fatigue related to chronic bleeding due to subinvolution Subinvolution is incomplete return of the uterus to its prepregnant size and shape. With subinvolution, at a 4- or 6-week postpartal visit, the uterus is still enlarged and soft. Lochial discharge usually is still present. The symptoms in the scenario are closest to those of subinvolution.

The nurse is caring for a postpartum woman who is diagnosed with endometritis. Which position should the nurse encourage the client to maintain? Trendelenburg On her left side Semi-Fowler Flat in bed

Semi-Fowler A semi-Fowler position encourages lochia to drain so it will not become stagnant and cause further infection. Placing the woman flat in bed, on her left side, or in the Trendelenburg position would not accomplish this goal and could result in the infection spreading to other parts of the body.

Which recommendation should be given to a client with mastitis who is concerned about breastfeeding her neonate? She should stop breastfeeding until completing the antibiotic. She should supplement feeding with formula until the infection resolves. She should continue to breastfeed; mastitis will not infect the neonate. She should not use analgesics because they are not compatible with breastfeeding.

She should continue to breastfeed; mastitis will not infect the neonate. The client with mastitis should be encouraged to continue breastfeeding while taking antibiotics for the infection. No supplemental feedings are necessary because breastfeeding does not need to be altered and actually encourages resolution of the infection. Analgesics are safe and should be administered as needed.

The nurse is caring for a client in active labor. Which assessment finding should the nurse prioritize and report to the team? Unrelieved pain Bradycardia Sudden shortness of breath Bradypnea

Sudden shortness of breath Sudden shortness of breath can be a sign of amniotic fluid embolism and requires emergent intervention. This can occur suddenly during labor or immediately after. The woman usually develops symptoms of acute respiratory distress, cyanosis, and hypotension. It must be reported to the care team so proper interventions may be taken. Other symptoms can include hypotension, cyanosis, hypoxemia, uterine atony, seizures, tachycardia, coagulation failure, DIC, and pulmonary edema.

A 39-year-old multigravida with diabetes presents at 32 weeks' gestation reporting she has not felt movement of her fetus. Assessment reveals the fetus has died. The nurse shares with the mother that the institution takes pictures after the birth and asks if she would like one. What is the best response if the mother angrily says no and starts crying? Apologize and tell her that the photos will be destroyed immediately. Tell her that once she gets over her shock and grief, she will probably be happy to have the photos. Console her with the fact that she has other children. Tell her that the hospital will keep the photos for her in case she changes her mind.

Tell her that the hospital will keep the photos for her in case she changes her mind. Emotional care of the woman is complex, especially one who has suffered the loss of a child. The woman will need time to move through the stages of grief and the responses of grief vary from person to person. The mother may request the items later and they should be stored or kept for a year after the birth. There is no need to apologize to the client. It would be inappropriate to console her with the fact that she has other children. It negates her feelings and is not supportive of the woman at this time.

The nurse recognizes that the postpartum period is a time of rapid changes for each client. What is believed to be the cause of postpartum affective disorders? preexisting conditions in the client medications used during labor and birth drop in estrogen and progesterone levels after birth lack of social support from family or friends

drop in estrogen and progesterone levels after birth Plummeting levels of estrogen and progesterone immediately after birth can contribute to postpartum mood disorders. It is believed that the greater the change in these hormone levels between pregnancy and postpartum, the greater the change for developing a mood disorder. Lack of support, medications, and preexisting conditions may contribute but are not the main etiology.

The nursing student correctly identifies which risk factors for developing dystocia? Select all that apply. multiple gestation shoulder dystocia high fetal station at complete cervical dilation maternal diabetes excessive analgesia epidurals maternal exhaustion

epidurals excessive analgesia multiple gestation maternal exhaustion high fetal station at complete cervical dilation shoulder dystocia Early identification and prompt interventions for dystocia are essential to minimize risk to the woman and fetus. Factors associated with increased risk for dystocia include epidurals, excessive analgesia, multiple gestations, maternal exhaustion, ineffective pushing technique, longer first stage of labor, fetal birth weight, maternal age of >35, ineffective uterine contractions, and high fetal station at complete cervical dilation (dilatation).

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? fraternal both types can result from the split ovum neither type results from a split ovum identical

identical 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).

A client in her seventh week of the postpartum period is experiencing bouts of sadness and insomnia. The nurse suspects that the client may have developed postpartum depression. What signs or symptoms are indicative of postpartum depression? Select all that apply. decreased interest in life inability to concentrate loss of confidence bizarre behavior manifestations of mania

inability to concentrate loss of confidence decreased interest in life The nurse should monitor the client for symptoms such as inability to concentrate, loss of confidence, and decreased interest in life to verify the presence of postpartum depression. Manifestations of mania and bizarre behavior are noted in clients with postpartum psychosis.

A client presents to her postpartum appointment with vague reports. The nurse suspects postpartum depression based on which assessment finding? She is over her interest in her baby. She feels like eating all the time. extreme periods of elation lack of pleasure

lack of pleasure Some signs and symptoms of postpartum depression include feeling restless, worthless, guilty, hopeless, moody, sad, overwhelmed; crying a lot; exhibiting a lack of energy and motivation; experiencing a lack of pleasure; changes in appetite, sleep, or weight; withdrawing from friends and family; feeling negatively toward her baby; or showing lack of interest in her baby.

A primary care provider prescribes intravenous tocolytic therapy for a woman in preterm labor. Which agent would the nurse expect to administer? indomethacin betamethasone magnesium sulfate nifedipine

magnesium sulfate Magnesium sulfate is only given intravenously for preterm labor. Nifedipine and indomethacin are given orally for preterm labor. Betamethasone is given by intramuscular injection to help promote fetal lung maturity by stimulating surfactant production. It is not a tocolytic agent.

A nurse is conducting a class for nurses working in the postpartum unit about ways to reduce the risk of postpartum infections. The nurse determines that the teaching was effective when the group identifies which preventive measure as essential? fluid intake limitations meticulous handwashing unlimited visitation from family and friends use of clean gloves for invasive procedures

meticulous handwashing Meticulous handwashing is essential for preventing postpartum infections, including before and after each client care activity. Aseptic technique, not clean gloves, are needed when performing invasive procedures. All visitors should be screened for any signs of active infection to reduce the risk for exposure. Adequate hydration, not fluid limitations, would be appropriate.

A nurse is caring for a client in the clinic. The client reports burning during urination for the past few days. Assessment reveals cloudy urine, with the presence of white blood cells (WBCs). Vital signs: temperature, 101.4°F (38.5°C); heart rate, 101 beats/min; blood pressure, 100/64 mm Hg. Complete the following sentence(s) by choosing from the lists of options. The priority actions of the nurse should be to first Select... administer antibiotics obtain a culture recheck the client's temperature followed by Select... initiate antibiotics encourage intake of fluids administer nonsteroidal anti-inflammatory drug (NSAID)

obtain a culture initiate antibiotics The nurse should first obtain a culture for sensitivity before administering antibiotics. Once the culture has been obtained, the nurse should administer a broad-spectrum antibiotic per provider prescription. Rechecking the client's temperature is not necessary. An antibiotic should not be administered until a culture has been obtained. The priorities for this client would be to first obtain a culture, then administer a broad-spectrum antibiotic. The nurse will encourage fluid intake, but this is not the priority. A nonsteroidal anti-inflammatory drugs (NSAID) can be administered for fever, but the priority is to obtain a culture and start the client on a broad-spectrum antibiotic to start treating the infection.

Manual manipulation is used to reposition the uterus of a client experiencing uterine inversion. After the repositioning, which type of medication would the nurse administer as prescribed to the client? indomethacin oxytocin agent nifedipine magnesium sulfate

oxytocin agent The nurse should administer a prescribed oxytocin agent to the client after repositioning the uterine fundus because it causes uterine contractions preventing reinversion and decreasing blood loss. The nurse should administer prescribed medications such as magnesium sulfate, indomethacin, and nifedipine, which are uterine relaxants that help in the repositioning of the uterus. These drugs are administered during the repositioning of the uterus and not after in case of uterine inversion.

A woman presents to her first postpartum visit reporting she does not feel well. Which findings would lead the nurse to suspect that she has developed endometritis? Select all that apply. odorless lochia hematuria leukocytosis flank pain pain on both sides of the abdomen

pain on both sides of the abdomen leukocytosis Signs and symptoms of endometritis include lower abdominal tenderness or pain on one or both sides, foul-smelling lochia, and leukocytosis. Hematuria and flank pain would be associated with a urinary tract infection.

The fetus of a client in labor is determined to be in a persistent occiput posterior position. Which intervention will the nurse prioritize? immediate cesarean birth pain relief measures oxytocin administration side-lying position

pain relief measures Intense back pain is associated with persistent occiput posterior position. Therefore, a priority is to provide pain relief measures. Counterpressure and back rubs may be helpful. Position changes that can promote fetal head rotation are important and can help to relieve some of the pain. Additionally, the client's ability to cooperate and participate in these position changes is enhanced when they are experiencing less pain. Immediate cesarean birth is not indicated unless there is evidence of fetal distress. Oxytocin would add to the client's already high level of pain.

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? premature rupture of membranes placental abruption genetic abnormality preeclampsia

placental abruption 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 nurse is caring for a client in the postpartum period. When observing the client's condition, the nurse notices that the client tends to speak incoherently. The client's thought process is disoriented, and the client frequently indulges in obsessive concerns. The nurse notes that the client has difficulty in relaxing and sleeping. The nurse interprets these findings as suggesting which condition? postpartum depression postpartum psychosis postpartum blues postpartum panic disorder

postpartum psychosis The client's signs and symptoms suggest that the client has developed postpartum psychosis. Postpartum psychosis is characterized by clients exhibiting suspicious and incoherent behavior, confusion, irrational statements, and obsessive concerns about the baby's health and welfare. Delusions, specific to the newborn, are present. Sudden terror and a sense of impending doom are characteristic of postpartum panic disorders. Postpartum depression is characterized by a client feeling that life is rapidly tumbling out of control. The client thinks of oneself as an incompetent parent. Emotional swings, crying easily—often for no reason—and feelings of restlessness, fatigue, difficulty sleeping, headache, anxiety, loss of appetite, decreased ability to concentrate, irritability, sadness, and anger are common findings are characteristic of postpartum blues.

A client presents to the emergency department reporting regular uterine contractions. Examination reveals that her cervix is beginning to efface. The client is in her 36th week of gestation. The nurse interprets the findings as suggesting which condition is occurring? normal labor preterm labor dystocia precipitate labor

preterm labor Preterm labor is the occurrence of regular uterine contractions accompanied by cervical effacement and dilation (dilatation) before the end of the 37th week of gestation. If not halted, it leads to preterm birth. Normal labor can occur after the 37th week. Dystocia refers to a difficult labor. Precipitate labor is one that is completed in less than 3 hours from the start of contraction to birth.

A woman is experiencing dystocia that appears related to psyche problems. Which intervention would be most appropriate for the nurse to initiate? providing a comfortable environment with dim lighting preparing the woman for an amniotomy administering oxytocin encouraging the women to change positions frequently

providing a comfortable environment with dim lighting Comfort measures minimize the woman's stress and promote relaxation so that she can work more effectively with the forces of labor. This action is consistent with assisting a woman experiencing problems with the psyche. Oxytocin would be appropriate for the woman experiencing hypotonic uterine dysfunction (problem with the powers). An amniotomy may be used with hypertonic uterine dysfunction to augment labor. Frequent position changes would be appropriate for a woman with persistent occiput posterior position (problem with the passenger).

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? reduced oxygen to the fetus precipitate labor cephalopelvic disproportion ruptured uterus

reduced oxygen to the fetus 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.

A nurse is assessing the following antenatal clients. Which client is at highest risk for having a multiple gestation? the 19-year-old client diagnosed with polycystic ovary syndrome the 27-year-old client who gave birth to twins 2 years ago the 41-year-old client who conceived by in vitro fertilization the 38-year-old client whose spouse is a triplet

the 41-year-old client who conceived by in vitro fertilization The nurse should assess infertility treatment as a contributor to the increased probability of multiple gestations. Multiple gestations do not occur with an adolescent birth; instead, chances of multiple gestations are known to increase due to the increasing number of women giving birth at older ages.

A young woman experiencing contractions arrives at the emergency department. After examining her, the nurse learns that the client is at 33 weeks' gestation. What treatment can the nurse expect this client to be prescribed? tocolytic therapy anti-anxiety therapy bronchodilators muscle relaxants

tocolytic therapy Tocolytic therapy is most likely prescribed if preterm labor occurs before the 34th week of gestation in an attempt to delay birth and thereby reduce the severity of respiratory distress syndrome and other complications associated with prematurity.

A pregnant client at 28 weeks' gestation in preterm labor has received a dose of betamethasone IM today at 1400. The client is scheduled to receive a second dose. At which time would the nurse expect to administer that dose? tomorrow at 1400 tomorrow at 1800 tomorrow at 1200 tomorrow at 0800 today at 2200

tomorrow at 1400 Betamethasone is given as two intramuscular injections, given 24 hours apart. Because the woman got her first dose at 1400 today, then her second dose would be given at 1400 tomorrow. Corticosteroids given to the mother in preterm labor can help prevent or reduce the frequency and severity of respiratory distress syndrome in premature infants delivered between 24 and 34 weeks' gestation.

A client who gave birth several hours ago is experiencing postpartum hemorrhage. She had a cesarean birth and received deep, general anesthesia. She has a history of postpartum hemorrhage with her previous births. The blood is a dark red. Which cause of the hemorrhage is most likely in this client? cervical laceration uterine atony disseminated intravascular coagulation retained placental fragment

uterine atony Uterine atony, or relaxation of the uterus, is the most frequent cause of postpartum hemorrhage; it tends to occur most often in Asian or Hispanic woman. Conditions that contribute to uterine atony include having received deep anesthesia or analgesia and a prior history of postpartum hemorrhage. A cervical laceration is less likely because the blood is dark, not bright red, and bleeding from such a laceration usually occurs immediately after detachment of the placenta. Disseminated intravascular coagulation is typically associated with premature separation of the placenta, a missed early miscarriage, or fetal death, none of which is evident in this scenario. A retained placental fragment is possible, and could contribute to the atony, but there is no evidence for this in the scenario.

A client in active labor with a history of two previous cesarean births is being monitored frequently as they try to have a vaginal birth. Suddenly, the client grabs the nurse's hand and states, "Something inside me is tearing." The nurse notes the client's blood pressure is 80/50 mm Hg, pulse rate is 130 beats/min and weak, the skin is cool and clammy, and the fetal monitor shows bradycardia. The nurse activates the code team because the nurse suspects the client may be experiencing which complication? uterine rupture undiagnosed abdominal aorta aneurysm amniotic embolism to the lungs compression on the inferior vena cava

uterine rupture If a uterus should rupture, the client experiences a sudden, severe pain during a strong labor contraction, which the client may report as a "tearing" sensation. Because the uterus at the end of pregnancy is such a vascular organ, uterine rupture is an emergency. Signs of hypotensive shock begin, including a rapid, weak pulse; falling blood pressure; cold and clammy skin; and dilation of the nostrils from air starvation. Fetal heart sounds fade and then are absent.