Chapters 21-24 OB Ricci

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The experienced labor and birth nurse knows to evaluate progress in active labor by using which simple rule?

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 nurse is assisting with the resuscitation of a preterm newborn. The nurse is giving ventilations to the newborn at which rate?

40 to 60 breaths per minute When performing newborn resuscitation, the nurse would ventilate at a rate of 40 to 60 breaths per minute.

A newborn is scheduled for casting to correct a talipes disorder. You would advise her parents that the cast will extend

Above the knee

A woman is going to have labor induced with oxytocin. Which statement reflects the induction technique the nurse anticipates the primary care provider will prescribe?

Administer oxytocin diluted as a "piggyback" infusion. Oxytocin is always infused in a secondary or "piggyback" infusion system so it can be halted quickly if overstimulation of the uterus occurs.

A client who gave birth 2 hours ago expresses concern about her baby developing jaundice. Which response from the nurse would be best?

"I understand your concern because as many as 50% of babies can develop jaundice."

A nurse is preparing to administer epinephrine intravenously to a preterm newborn. The newborn weighs 1,500 g, and the primary care provider prescribes 0.1 mL/kg. How much would the nurse administer?

0.15 mL The newborn weighs 1,500 g, which is equivalent to 1.5 kg. Calculating the dose based on 0.1 mL/kg, the nurse would administer 0.15 mL. p 848

A nurse is preparing to administer epinephrine intravenously to a preterm newborn. The newborn weighs 1,500 g and the physician orders 0.1 mL/kg. How much would the nurse administer? a) 0.25 mL b) 0.20 mL c) 0.15 mL d) 0.1 mL

0.15 mL Correct Explanation: The newborn weighs 1,500 g, which is equivalent to 1.5 kg. Calculating the dose based on 0.1 mL/kg, the nurse would administer 0.15 mL.

What percentage of neonates requires some type of assistance to transition to extrauterine life? a) 25% b) 10% c) 50% d) 5%

10% Correct Explanation: Most newborns transition to extrauterine life smoothly. About 10% of newborns need some type of assistance at birth.

100 mm Hg

A nursing student has learned that precipitous labor is when the uterus contracts so frequently and with such intensity that a very rapid birth will take place. This means the labor will be completed in which span of time? a) < 8 hours b) < 4 hours c) < 3 hours d) < 5 hours

< 3 hours Correct Explanation: Precipitous labor is completed in less than 3 hours.

One of the clinical manifestations seen in the child with hydrocephalus is which of the following? a) A partial to complete paralysis in the lower extremities b) An extremely large and rapidly growing head c) A membrane between the rectum and the anus d) Aprotruding sac that contains abdominal contents

An extremely large and rapidly growing head

A client's membranes have just ruptured. Her fetus is presenting breech. Which of the following should the nurse do immediately to rule out prolapse of the umbilical cord in this client? a) Administer amnioinfusion b) Assess fetal heart sounds c) Administer oxygen at 10 L/min by face mask d) Place the woman in Trendelenburg position

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.

Upon assessment, the nurse notes a postpartum client has increased vaginal bleeding. The client had a forceps birth that resulted in lacerations 4 hours ago. What should the nurse do next?

Assess for uterine contractions. The nurse needs to identify whether the bleeding is from lacerations or uterine atony. This can be done by looking for a well contracted uterus with bright-red vaginal bleeding. Lacerations commonly occur during forceps birth. In subinvolution of the uterus, there is inadequate contraction, resulting in bleeding. A boggy uterus with vaginal bleeding is seen in uterine atony. Once the nurse knows the cause of the bleeding, the condition can be treated.

On examining a woman who gave birth 5 hours ago, the nurse finds that the woman has completely saturated a perineal pad within 15 minutes. Which action by the nurse should be implemented first? a) Begin an IV infusion of Ringer's lactate solution. b) Assess the woman's vital signs. c) Assess the woman's fundus. d) Call the woman's health care provider.

Assess the woman's fundus. Correct Explanation: To have a suggested idea of the location of the bleeding, the nurse would need to assess the fundus of the patient first.

On examining a woman who gave birth 5 hours ago, the nurse finds that the woman has completely saturated a perineal pad within 15 minutes. Which action by the nurse should be implemented first? A) Call the woman's health care provider. B) Assess the woman's fundus. C) Assess the woman's vital signs. D) Begin an IV infusion of Ringer's lactate solution.

B) Assess the woman's fundus. To have a suggested idea of the location of the bleeding, the nurse would need to assess the fundus of the client first.

When discussing heat loss in newborns, placing a newborn on a cold scale would be an example of what type of heat loss? a) Conduction b) Convection c) Evaporation d) Radiation

Conduction Correct Explanation: A conduction heat loss results from direct contact with an object that is cooler.

Nursing assessment of the infant should include what important information that might indicate heart failure? a) Blood glucose level b) Color of hands and feet c) Diminished peripheral pulses d) Capillary refill time

Diminished peripheral pulses

A postpartal woman is developing a thrombophlebitis in her right leg. Which of the following assessments would you make to detect this? a) Ask her to raise her foot and draw a circle. b) Bend her knee and palpate her calf for pain. c) Blanch a toe and count the seconds it takes to color again. d) Dorsiflex her right foot and ask if she has pain in her calf.

Dorsiflex her right foot and ask if she has pain in her calf.

A nurse is caring for a 38-year-old overweight client 24-hours post cesarean birth. The client is reporting calf tenderness. Which should the nurse do first?

Have the client rest with the extremity elevated. The client is probably experiencing a deep vein thrombosis (DVT). The nurse would maintain bed rest with the effected extremity elevated until the diagnosis could be confirmed. Once the diagnosis is confirmed, and anticoagulant may be prescribed. It is not priority to determine the severity of the pain or a respiratory rate.

Which assessment finding would best validate a problem in a small-for-gestational age newborn secondary to meconium in the amniotic fluid? a) Respiratory rate of 60-70 bpm b) Total bilirubin level of 15 c) Heart rate of 162 bpm d) Hematocrit of 44%

Heart rate of 162 bpm

In addition to newborns of diabetic mothers being at risk for hypoglycemia, these newborns are also at risk for which of the following? a) Hypermagnesemia b) Hypobilirubinemia c) Hypocalcemia d) Hyperkalemia

Hypocalcemia

A nurse is assessing vital signs for a postpartum patient 48 hours after delivery. The vital signs are: T 101.2°F; HR 82; RR 18; BP 125/78. How will the nurse interpret the vital signs? a) Dehydration b) Normal vital signs c) Infection d) Shock

Infection

The nurse is performing a postpartum check on a 40-year-old client. Which nursing measure is appropriate? a) Perform the examination as quickly as possible b) Instruct the client to empty her bladder before the examination c) Wear sterile gloves when assessing the pad and perineum d) Place the client in a supine position with her arms overhead for the examination of her breasts and fundus

Instruct the client to empty her bladder before the examination Explanation: An empty bladder facilitates the examination of the fundus. The client should be in a supine position with her arms at her sides and her knees bent. The arms-overhead position is unnecessary. Clean gloves should be used when assessing the perineum; sterile gloves aren't necessary. The postpartum examination shouldn't be done quickly. The nurse can take this time to teach the client about the changes in her body after delivery.

While assessing a postpartum woman, the nurse palpates a contracted uterus. Perineal inspection reveals a steady stream of bright-red blood trickling out of the vagina. The woman reports mild perineal pain. She just voided 200 mL of clear yellow urine. Which of the following would the nurse suspect? a) Laceration b) Hematoma c) Uterine atony d) Uterine inversion

Laceration Correct Explanation: Lacerations typically present with a firm contracted uterus and a steady stream of unclotted bright-red blood. Hematoma would present as a localized bluish bulging area just under the skin surface in the perineal area, accompanied by perineal or pelvic pain and difficulty voiding. Uterine inversion would present with the uterine fundus at or through the cervix. Uterine atony would be manifested by a noncontracted uterus.

Which action could the nurse initiate to reduce the discomfort of a woman in labor whose fetus is in an occiput posterior position?

Massage her lower back. Counterpressure against the woman's back by a support person can be helpful in reducing this type of pain.

A 26-year-old primigravida has brought her doula to the birthing center for support during her labor and delivery. 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 patient 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? a) Breech presentation b) Occiput posterior position c) Nongynecoid pelvis d) Fetal macrosomia

Occiput posterior position Correct Explanation: 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."

It would be best to place an infant with a myelomeningocele in which position prior to surgery? a) Supine with the head elevated b) On the stomach (prone) c) Semi-Fowler's in an infant chair d) On the left side with the head dependent

On the stomach (prone)

A ventilated 33 weeks' gestation newborn in the neonatal intensive care unit (NICU) receives surfactant therapy. Which would the nurse expect to assess as a positive response to this therapy?

Oxygen saturation levels are at 98%.

The small-for-gestation neonate is at increased risk for which complication during the transitional period? a) Hyperthermia due to decreased glycogen stores b) Polycythemia probably due to chronic fetal hypoxia c) Hyperglycemia due to decreased glycogen stores d) Anemia probably due to chronic fetal hypoxia

Polycythemia probably due to chronic fetal hypoxia Correct Explanation: The small-for-gestation neonate is at risk for developing polycythemia during the transitional period in an attempt to decrease hypoxia. This neonate is also at increased risk for developing hypoglycemia and hypothermia due to decreased glycogen stores

When caring for a client requiring a forceps-assisted birth, the nurse would be alert for which of the following? a) Potential lacerations and bleeding b) Increased risk for uterine rupture c) Damage to the maternal tissues d) Increased risk for cord entanglement

Potential lacerations and bleeding Correct 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 nurse enters the room and notices that the infant is in the crib against the window. What type of heat loss may this infant suffer? a) Radiation b) Convection c) Evaporation d) Conduction

Radiation Correct Explanation: Radiation heat loss results from the transfer of heat in an environment from warmer to cooler objects that are not in direct contact with each other.

Which nursing diagnosis would be most appropriate for a client with a postpartum hematoma? a) Risk for impaired urinary elimination b) Deficient fluid volume c) Ineffective tissue perfusion d) Impaired tissue integrity

Risk for impaired urinary elimination Explanation: In addition to risk for injury and pain, another appropriate nursing diagnosis would be risk for impaired urinary elimination related to pressure from the hematoma on urinary structures. Ineffective tissue perfusion and impaired tissue integrity are nursing diagnoses associated with postpartum lacerations. Deficient fluid volume is a nursing diagnoses associated with postpartum hemorrhage.

A client's gestational age is 38 weeks and 6 days. If the baby is born today, which of the following terms accurately describes the gestational age of the newborn? a) Term. b) Premature. c) Postterm. d) Preterm.

Term. Correct Explanation: A term infant is born after the beginning of week 38 and before week 42 of pregnancy. Premature or preterm refers to the birth prior to 37 completed weeks. Postterm refers to birth beyond 42 weeks.

The nurses at a local free clinic are concerned there may be an increase in small-for-gestational age infants in the community. When collecting data to research the situation, the nurses will exclude infants above which category?

The 10th percentile for gestational age

With postterm birth, the fetus uses stored nutrients to stay alive, and wasting occurs. After 42 weeks' gestation, the placenta loses its ability to provide adequate oxygen and nutrients to the fetus, causing the fetus to use stored nutrients to stay alive. This leads to wasting. Meconium aspiration can occur with postterm newborns, but this is not the reason for the baby's wasted appearance. Hyperbilirubinemia occurs with the increased breakdown of red blood cells, but this too would not account for the wasted appearance. Exposure to an intrauterine infection is unrelated to the wasted appearance. p 858

When documenting the newborn's weight on a growth chart, the nurse recognizes the newborn is large-for-gestational-size based on which percentile on growth charts?

above 90th percentile A newborn whose weight is above the 90th percentile on growth charts is defined as large-for-gestational-age.

During the newborn's assessment, which finding would lead the nurse to suspect that a large-for-gestational-age newborn has experienced birth trauma?

asymmetrical movement A birth injury is typically characterized by asymmetrical movement. Temperature instability, seizures, and feeble sucking suggest hypoglycemia. p 837

Which of the following is the most frequent reason for postpartum hemorrhage? a) Endometritis. b) Uterine atony. c) Perineal lacerations. d) Disseminated intravascular coagulation.

b)Uterine atony. Explanation: When a uterus does not contract well, the denuded placental surface can bleed excessively. Therefore options A, C, and D are incorrect.

The nurse suspects a preterm newborn receiving enteral feedings of having necrotizing enterocolitis (NEC). What assessment finding best correlates with this diagnosis?

bloody stools

A newborn is designated as extremely low birth weight. The nurse understands that this newborn's weight is:

less than 1,000 g. An extremely low-birth-weight newborn weighs less than 1,000 g. A very-low-birthweight newborn weighs less than 1,500 g. A large-for-gestational-age newborn typically weighs more than 4,000 g. A small-for-gestational-age newborn or a low-birth-weight newborn typically weighs about 2,500 g. p. 834

less than 3 hours Precipitous labor is completed in less than 3 hours.

A newborn is found to have hemolytic disease. Which combination would be found related to the blood types of this newborn and the parents of the newborn?

newborn who is type A, mother who is type O Hemolytic disease today is principally the result of ABO incompatibility. The most common incompatibility in the newborn occurs between a woman with type O blood and an infant with type A or B blood.

Which finding would lead the nurse to suspect that a large-for-gestational-age newborn is developing hyperbilirubinemia?

tea-colored urine Hyperbilirubinemia is associated with jaundice and tea-colored urine. Temperature instability, seizures, and feeble sucking suggest hypoglycemia. pg 837

Which facial change is characteristic in a neonate with fetal alcohol syndrome (FAS)? A) well-developed philtrum B) microcephaly C) macrocephaly D) wide, palpebral fissures

B) microcephaly FAS infants are usually born with microcephaly. Their facial features include short, palpebral fissures and a thin upper lip.

A postpartal woman calls the nurse into her room because she is having a very heavy lochia flow containing large clots. The nurse's first action would be to: A) assess her blood pressure. B) palpate her fundus. C) have her turn to her left side. D) assess her perineum.

B) palpate her fundus Palpating the fundus will cause it to contract and reduce bleeding.

A nurse is caring for an infant. A serum blood sugar of 40 was noted at birth. What care should the nurse provide to this newborn? a) Focus on decreasing blood viscosity by introducing feedings b) Give dextrose intravenously before oral feedings c) Place infant on radiant warmer immediately d) Begin early feedings either by the breast or bottle

Begin early feedings either by the breast or bottle

A newborn at 33 weeks' gestation has an Apgar score of 5 at 10 minutes of life. Which nursing action is a priority?

Begin resuscitation measures.

Which finding might be seen in a neonate suspected of having an infection? A) Increased activity level B) Flushed cheeks C) Decreased temperature

C) Decreased temperature A decreased temperature in the neonate may be a sign of infection. The neonate's color commonly changes with an infectious process but generally becomes ashen or mottled. The neonate with an infection will usually show a decrease in activity level or lethargy.

An infant is suffering from neonatal abstinence syndrome. The nurse provides appropriate care and support for the infant during the infant's time on the unit. Besides nursing and medical care, what other step would the nurse take to support the infant? A) Make sure the infant was in a bright, loud room. B) Contact the chaplain. C) Link the family with community sources for aid. D) Make sure a volunteer feeds the baby.

C) Link the family with community sources for aid. Besides nursing care, the nurse would make sure that interdisciplinary members of team were involved such as the doctor, nutritionist, community worker or resources, and provide a supportive environment for the family and the client. The chaplain may not be support for infant or family may not be present. The bright room is overly stimulating to the withdrawing infant, and feeding is basic care.

Periventricular hemorrhage is suspected in a newborn of 30 weeks' gestation. The nurse would anticipate preparing the newborn for which of the following to confirm the diagnosis? a) Blood glucose level b) Arterial blood gases c) Cranial ultrasound d) Chest x-ray

Cranial ultrasound

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? A) "I need to avoid using any aspirin-containing products." B) "If I get a cut, I need to apply direct pressure for about 5 minutes or more." C) "If my lochia increases, I need to call my health care provider." D) "I should brush my teeth vigorously to stimulate the gums."

D) "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.

Hypoglycemia in a mature infant is defined as a blood glucose level below which amount? A) 30 mg/100 mL whole blood B) 80 mg/100 mL whole blood C) 100 mg/100 mL whole blood D) 40 mg/100 mL whole blood

D) 40 mg/100 mL whole blood Because newborns do not manifest symptoms of a reduced glucose level until it decreases well below adult levels, a finding below 40 mg/100 mL whole blood is considered hypoglycemia.

A 33-week-gestation infant has just been born. The child's heartbeat is not audible. Which of the following is the priority nursing intervention? a) Depression of the sternum with both thumbs 1 to 2 cm at a rate of 100 times per minute b) Transfer to a transitional or high-risk nursery for continuous cardiac surveillance c) Administration of IV epinephrine, as prescribed d) Palpation for a femoral pulse

Depression of the sternum with both thumbs 1 to 2 cm at a rate of 100 times per minute Explanation: If an infant has no audible heartbeat, or if the cardiac rate is below 60 beats per minute, closed-chest massage should be started. Hold the infant with fingers encircling the chest and wrapped around the back and depress the sternum with both your thumbs, on the lower third of the sternum approximately one third of its depth (1 or 2 cm) at a rate of 100 times per minute. If the pressure and the rate of massage are adequate, it should be possible, in addition, to palpate a femoral pulse. If heart sounds are not resumed above 60 beats per minute after 30 seconds of combined positive-pressure ventilation and cardiac compressions, intravenous epinephrine may be prescribed. Following cardio-resuscitation, newborns need to be transferred to a transitional or high-risk nursery for continuous cardiac surveillance to be certain cardiac function is maintained.

Which maternal factors should the nurse consider contributory to a newborn being large for gestational age? Select all that apply. a) Alcohol use b) Renal infection c) Diabetes mellitus d) Postdates gestation e) Prepregnancy obesity

Diabetes mellitus Postdates gestation Prepregnancy obesity

A woman's nurse-midwife tells her that the woman has developed dystocia. You would explain that this term means a) High blood pressure related to difficult labor. b) Potential for placental detachment. c) Difficult or abnormal labor. d) Muscle weakness related to prolonged labor.

Difficult or abnormal labor. Correct Explanation: Dystocia is a general term used to describe difficult or abnormal labor. Dystocia does not indicate high blood pressure related to difficult labor, a potential for placental detachment, nor muscle weakness related to prolonged labor.

The nurse in the NICU is caring for preterm newborns. Which guidelines are recommended for care of these newborns? Select all that apply.

Dress the newborn in ways to preserve warmth. Take the newborn's temperature often. Supply oxygen for the newborn, if necessary. Controlling the temperature of preterm newborns is often difficult; therefore, special care should be taken to keep these babies warm. Nurses should dress them in a stockinette cap, take their temperature often, and supply oxygen, if necessary. To conserve the energy of small newborns, the nurse should handle them as little as possible. Usually, they will not give them a bath immediately. Parents should be encouraged to bond with their infants. pg 850

A woman with hydramnios has just given birth. The nurse recognizes that the infant must be assessed for which of the following conditions? a) Torticollis b) Esophageal atresia c) Talipes d) Ankyloglossia

Esophageal atresia

Since the inclusion of calcium in prenatal vitamins and all cereal and grain products, the incidence of neural tube disorders has fallen dramatically in the United States. a) True b) False

False

The nurse in a newborn nursery is observing for developmentally appropriate care. Which of the following is an example of self-regulation? a) Infant has hand in mouth b) Infant is kicking feet c) Infant is crying d) Infant is quiet

Infant has hand in mouth Correct Explanation: Self-regulation is a form of self-soothing for an infant such as sucking on hands or putting hand to mouth type of movements.

A pre-term newborn is noted to have hypotonia, apnea, bradycardia, a bulging fontanelle, cyanosis, and increased head circumference. These signs indicate the newborn most likely has which of the following complications? a) Cold stress b) Intraventricular hemorrhage (IVH) c) Respiratory distress syndrome d) Retinopathy of prematurity (ROP)

Intraventricular hemorrhage (IVH)

A newborn is designated as very low birthweight. The nurse understands that this newborn's weight is: a) Approximately 2,500 g b) More than 4,000 g c) Less than 1,500 g d) Less than 1,000 g

Less than 1,500 g Correct Explanation: A very-low-birthweight newborn weighs less than 1,500 g. A large-for-gestational-age newborn typically weighs more than 4,000 g. A small-for-gestational-age newborn or a low-birthweight newborn typically weighs about 2,500 g. An extremely-low-birthweight newborn weighs less than 1,500 g.

A nursing student correctly identifies the causes of labor dysfunction to include which factors? Select all that apply.

problems with the uterus problems with the fetus Labor dysfunction can occur because of problems with the uterus or fetus. Although the others might affect the type of prenatal care a woman receives, they do not directly affect her process of labor

A nurse working in the newborn observational unit is assigned four newborns closely being monitored. Which newborn is at greatest risk of developing respiratory distress syndrome?

the male preterm infant born by cesarean birth with cold stress

A woman in labor is receiving oxytocin. Which effect would the nurse need to be alert for potentially occurring?

water intoxication Oxytocin can lead to water intoxication and can cause hypotension. Uterine hypertonicity is a possible adverse effect of oxytocin administration. Oxytocin does not cross the placental barrier, and no fetal problems have been observed.

Which safety precautions should a nurse take to prevent infection in a newborn? Select all that apply. a) Avoid using disposable equipment b) Use sterile gloves for an invasive procedure c) Avoid coming to work when ill d) Cover jewelry while washing hands e) Initiate universal precautions when caring for the infant

• Use sterile gloves for an invasive procedure • Avoid coming to work when ill • Initiate universal precautions when caring for the infant

A nurse is caring for a child with complex esophageal atresia who will be undergoing surgery for repair. What comment by the parents indicates further teaching is required? a) "Intravenous fluids are going to be needed so that the baby won't get dehydrated." b) "After this surgery is done tomorrow, my baby will be able to eat and drink." c) "They will be placing a tube in the stomach during surgery." d) "The baby will have tubes in the chest to drain chest fluids."

"After this surgery is done tomorrow, my baby will be able to eat and drink."

A nursing instructor is teaching about newborn congenital disorders and realizes that the student needs further instruction after making which statement?

"All congenital disorders can be diagnosed at birth." All congenital disorders are not diagnosed at birth. Hydrocephalus is one such disorder that may be diagnosed at birth but also may not be diagnosed until after a few weeks or months. It is also true that congenital defects may be caused by both genetics and environmental factors.

The nurse is doing teaching with the caregivers of an infant diagnosed with hypospadias. Which of the following statements made by the caregivers is accurate regarding hypospadias? a) "It is upsetting to me that he is in pain when he urinates." b) "We hadn't decided about circumcision, but he will have to be circumcised before they do the surgery." c) "At least he won't have to have surgery until he is almost ready to start school." d) "Being able to most likely correct this in one stage rather than several is reassuring."

"Being able to most likely correct this in one stage rather than several is reassuring."

The nursing student demonstrates an understanding of dystocia with which of the following statements? a) "Dystocia is not diagnosed until after the delivery." b) "Dystocia is diagnosed at the start of labor." c) "Dystocia is diagnosed after labor has progressed for a time." d) "Dystocia cannot be diagnosed until just before delivery."

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

"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.

The nurse is working with a group of parents of children who have congenital heart disorders. Which of the following statements made by the parents would most likely be an indication the child is showing signs of congestive heart failure. a) "They say he has a heart murmur but it may go away." b) "She gets so tired when she is eating." c) "His chest measurement is the same as his head." d) "When I move her legs up toward her chest I hear a click."

"She gets so tired when she is eating."

A nurse is explaining to the parents the preoperative care for their infant born with bladder exstrophy. The parents ask, "What will happen to the bladder while waiting for the surgery?" What is the nurse's best response?

"The bladder will covered in a sterile plastic bag to keep it moist."

The nurse is caring for a newborn client newly diagnosed with dysplasia of the hip. Which response by the nurse educates the parents on the correct plan of treatment for this diagnosis?

"Treatment will begin immediately."

A newborn boy is diagnosed with esophageal atresia and tracheoesophageal fistula. After the nurse provides preoperative teaching, which statement indicates that the parents need additional teaching?

"We can probably start feeding him with the bottle about a day after the surgery."

An infant was born with a severely deformed hand. He is now 6 months old. The nurse informs the parents that the orthopedic surgeon has recommended amputation of the hand and fitting of a prosthesis. The mother objects and tells the nurse that they would like to wait and see how the hand develops. Which of the following should the nurse say in response? a) "An alternative to amputation and prosthesis is administration of a new drug that can help regenerate the hand." b) "With a deformity such as this, the hand is highly unlikely to improve." c) "If we perform the amputation and you change your mind later, the hand can always be surgically reattached." d) "I agree. You should wait until your son is older and let him decide whether he would like to have it done."

"With a deformity such as this, the hand is highly unlikely to improve."

Which of the following instructions would the nurse include in the teaching plan for a mother of a substance-exposed newborn? a) "Let your newborn sleep in his stomach for naps but not at night." b) "Place your newborn on his side when you feed him." c) "Wrap him snugly in a blanket and gently rock him if he's fussy." d) "Avoid using a pacifier because it can damage his teeth in the future."

"Wrap him snugly in a blanket and gently rock him if he's fussy."

A nurse is administering prescribed enteral feedings to assist in preparing the gut of a preterm newborn. The nurse integrates understanding of this measure, administering the feedings at which rate?

0.5 to 1 mL/kg/h Minimal enteral feeding is used to prepare the preterm newborn's gut to overcome the many feeding difficulties associated with gastrointestinal immaturity. It involves the introduction of small amounts, usually 0.5 to 1 mL/kg/h, of enteral feeding to induce surges in gut hormones pg 842

A client has had a cesarean birth. Which of the following amounts of blood loss would the nurse document as a postpartum hemorrhage in this client? a) 500 ml. b) 250 ml. c) 750 ml. d) 1000 ml.

1000 ml. Explanation: 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 baby who is declared AGA (appropriate for gestational age) falls in what weight percentile? a) 95 b) 20 c) 5 d) 9

20 Explanation: AGA infants are infants that fall between the 10th and 90th percentile for weight.

The nurse is weighing a newborn and documents AGA (appropriate for gestational age) on the newborn record. Which weight percentile is anticipated?

20th Appropriate for gestation age infants fall between the 10th and 90th percentile for weight.

In which time period would the nurse expect a client who has given birth to twins to experience late postpartum hemorrhage?

24 hours to 12 weeks after birth 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.

Mrs. M. and her infant are being discharged home after an unplanned cesarean delivery. You explain to her that she is at a higher risk for postpartum infection than most patients. What is the major risk factor for a post-partum infection? a) Labor more than 12 hours long. b) A planned cesarean birth. c) Labor less than 12 hours long. d) A nonelective cesarean birth.

A nonelective cesarean birth.

A nurse is caring for a preterm infant. Which intervention will prepare the newborn's gastrointestinal tract to better tolerate feedings when initiated? a) Administer 0.5 ml/kg/hr of breast milk enterally b) Administer dextrose intravenously c) Administer iron supplements d) Administer vitamin D supplements

Administer 0.5 ml/kg/hr of breast milk enterally

Which postoperative intervention should a nurse perform when caring for a client who has undergone a cesarean birth?

Assess uterine tone to determine fundal firmness. When caring for a client who has undergone a cesarean birth, the nurse should assess the client's uterine tone to determine fundal firmness. The nurse should assist with breastfeeding initiation and offer continued support. The nurse can also suggest alternate positioning techniques to reduce incisional discomfort while breastfeeding. Delaying breastfeeding may not be required. The nurse should encourage the client to cough, perform deep-breathing exercises, and use the incentive spirometer every 2 hours. The nurse should assist the client with early ambulation to prevent respiratory and cardiovascular problems.

Which postoperative intervention should a nurse perform when caring for a client who has undergone a cesarean birth?

A woman with hydramnios has just given birth. The nurse recognizes that the infant must be assessed for which condition? A) talipes B) esophageal atresia C) ankyloglossia D) torticollis

B) esophageal atresia Esophageal atresia must be ruled out in any infant born to a woman with hydramnios (excessive amniotic fluid). Hydramnios occurs because, normally, a fetus swallows amniotic fluid during intrauterine life. A fetus with esophageal atresia cannot effectively swallow, so the amount of amniotic fluid can grow abnormally large. The other conditions listed are not associated with hydramnios.

When educating the postterm pregnant client, what should the nurse be sure to include to prevent fetal complications?

Be sure to monitor fetal movements daily. The nurse should be sure to teach the postterm client to monitor fetal movements daily.

A newborn at 33 weeks' gestation has an Apgar score of 5 at 10 minutes of life. Which nursing action is a priority?

Begin resuscitation measures. Determine the Apgar score at 1 and 5 minutes; if less than 7 at 5 minutes, repeat the assessment at 10 minutes of age. If the initial assessment is poor, begin resuscitation measures until the Apgar score is above 7. The Ballard score would not be performed at this time. Reviewing the L & D records or repeating the Apgar are not priorities.

Which measurement best describes delayed postpartum hemorrhage? a) Blood loss in excess of 300 ml, occurring 24 hours to 6 weeks after delivery b) Blood loss in excess of 800 ml, occurring 24 hours to 6 weeks after delivery c) Blood loss in excess of 1,000 ml, occurring 24 hours to 6 weeks after delivery d) Blood loss in excess of 500 ml, occurring 24 hours to 6 weeks after delivery

Blood loss in excess of 500 ml, occurring 24 hours to 6 weeks after delivery

You are caring for a postpartum woman who exhibits a large amount of bleeding. Which areas would you need to assess before the woman ambulates? a) Attachment, lochia color, complete blood cell count b) Blood pressure, pulse, complaints of dizziness c) Height, level of orientation, support systems d) Degree of responsiveness, respiratory rate, fundus location

Blood pressure, pulse, complaints of dizziness Correct Explanation: 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.

The nurse is caring for an infant born to a mother who abused cocaine during her pregnancy. The nurse would likely notice that this infant: A) weighed above average when born. B) has facial deformities. C) cries when touched. D) sleeps for long periods of time.

C) cries when touched. Developmental delays occur in young children of substance abusers. Infants of cocaine abusers do not like to be touched or held and avoid the caregiver's gaze, which contributes to bonding delays. Infants of cocaine abusers are often restless and below average weight when born.

A premature infant develops respiratory distress syndrome. With this condition, circulatory impairment is likely to occur because with increased lung tension, the: A) foramen ovale closes prematurely. B) pulmonary artery closes. C) ductus arteriosus remains open. D) aorta or aortic valve strictures.

C) ductus arteriosus remains open. Excess pressure in the alveoli stimulates the ductus arteriosus to remain open, compromising efficient cardiovascular function.

A nurse is assigned to care for a 38-year-old overweight client scheduled to undergo a cesarean birth. The client is at an increased risk of thromboembolic complications. During assessment, what factor will help the nurse in the diagnosis of deep vein thrombosis of the leg? a) Dyspnea b) Calf tenderness c) Tachypnea d) Sudden chest pain

Calf tenderness

The nurse notes that a client's uterus which was firm after the fundal massage has become "boggy." Which intervention would the nurse do next? a) Offer analgesics prescribed by primary care provider b) Use semi-Fowler's position to encourage uterine drainage c) Check for bladder distention, while encouraging the client to void d) Perform vigorous fundal massage for the client

Check for bladder distention, while encouraging the client to void

It is discovered that a new mother has developed a puerperal 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 or 38° C orally. As fever would accompany a puerperal 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 puerperal infection as does the reduced temperature.

Which clinical manifestation in a woman with DVT should you report immediately? a) Edema b) Homan's sign c) Pyrexia d) Dyspnea

Dyspnea Explanation: Dyspnea in any patient with a DVT may be an indicator the clot has moved from the original site to the lungs. This is an emergency. A patient who has a DVT would be expected to have a positive Homan's sign, pyrexia, and edema.

The nurse is admitting to the nursery a newborn of a mother who continued to drink alcohol during her pregnancy. Which finding does the nurse predict to encounter on the newborn's assessment?

Hyperactive and irritable

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? a) both types can result from the split ovum b) fraternal c) neither type results from a split ovum d) identical

Identical Correct 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).

A nurse is assessing vital signs for a postpartum patient 48 hours after delivery. The vital signs are: Temp 101.2F; HR 82; RR 18; BP 125/78. How will the nurse interpret the vital signs? a) Normal vital signs b) Dehydration c) Infection d) Shock

Infection Explanation: Temperatures elevated above 100.4F 24 hours after delivery are indicative of possible infection. All but the temperature for this patient are within normal limits, so they are not indicative of shock or dehydration

The nurse caring for a newborn notes a distended abdomen approximately 24 hours after birth. Which action should the nurse prioritize after review of the medical record reveals an apparent healthy newborn at birth but no documentation of a bowel movement

Inform the RN and/or primary care provider immediately

The nurse who is caring for newborn Andrew notices that although he has seemed healthy at 18 hours of age, Andrew's abdomen is now distended. By 24 hours he has passed no stool. The nurse will a) Inform the caregivers that Andrew might need surgery b) Schedule radiography to diagnose the problem c) Inform the physician of the findings d) Attempt to take a rectal temperature

Inform the physician of the findings

An infant that is diagnosed with meconium aspiration displays which symptom? a) Pink skin b) No heart murmur c) Respirations of 45 d) Intercostal and substernal retractions

Intercostal and substernal retractions

When teaching a postpartum woman about possible complications during this time, the nurse would include information about which of the following as a possible effect? a) Delayed development of the newborn b) Ineffectiveness of breast-feeding c) Interference with the maternal-newborn attachment process d) Alteration in normal maternal hormonal function

Interference with the maternal-newborn attachment process

The nurse is preparing to talk to a group of pregnant women about elective induction and why it is not highly recommended. Which statements should she include in her presentation? Select all that apply

It significantly increases the risk of cesarean birth. It significantly increases instrumented birth. It significantly increases the use of epidural analgesia. It significantly increases the admissions to the neonatal ICU. Evidence is compelling that elective induction of labor significantly increases the risk of cesarean birth, instrumented birth, use of epidural analgesia, and neonatal ICU admissions. Increased birth weight is not a factor. pg 776

While the nurse is weighing and measuring a toddler during his annual checkup, the toddler's mother mentions that she is thinking of having another child. The toddler is small in stature and seems mildly developmentally delayed. His eyelid folds are short and his nose is flat. What do the toddler's characteristics suggest is the best advice the nurse can give this mother about pregnancy? a) It's a good idea to stop drinking alcohol 3 months before trying to get pregnant b) It's important to keep insulin levels controlled during pregnancy c) It would be good to stop smoking before getting pregnant d) It's important to add iron and vitamin B supplements to your diet

It's a good idea to stop drinking alcohol 3 months before trying to get pregnant

When the nurse is assisting the parents in the grieving process after the death of their neonate, what is the nurse's most important action?

Keep the communication lines open. Failing to keep the lines of communication open with a bereaved client and her family closes off some of the channels to recovery and healing. Staff members that avoid dealing with the situation may imply that the problem will go away. As a result the family's needs go unrecognized, and they may feel isolated. The parents should be allowed to spend as much time as they need with the infant as it will help make the situation more real, help them in the grieving process, and allow them to say goodbye. pg 784

While assessing a postpartum woman, the nurse palpates a contracted uterus. Perineal inspection reveals a steady stream of bright-red blood trickling out of the vagina. The woman reports mild perineal pain. She just voided 200 mL of clear yellow urine. Which of the following would the nurse suspect? a) Uterine atony b) Uterine inversion c) Laceration d) Hematoma

Laceration

The nurse assesses the patient who is one hour postpartum and observes a heavy steady gush of bright red blood from the vagina in the presence of a firm fundus. Select the most likely cause of the signs and symptoms. a) Infection of the uterus. b) Uterine atony. c) Perineal hematoma. d) Lacerations.

Lacerations

The nurse is assessing the newborn male of a teen mother who was afraid to seek appropriate prenatal care. Which assessment finding should lead the nurse to question if this infant is preterm?

Lanugo on the back and shoulders

At the hospital, a client is attached to the fetal monitor for uterine rupture. The nurse would assess for which pattern indicating change in the uterus impacting the fetus? a) Early decelerations. b) Variable decelerations. c) Mild decelerations. d) Late decelerations.

Late decelerations. Explanation: When the fetus is being deprived of oxygen the fetus will demonstrated 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. (less)

An Rh-positive client vaginally delivers a 6-lb, 10-oz neonate after 17 hours of labor. Which condition puts this client at risk for infection? a) Size of the neonate b) Length of labor c) Method of delivery d) Maternal Rh status

Length of labor

An Rh-positive client vaginally delivers a 6-lb, 10-oz neonate after 17 hours of labor. Which condition puts this client at risk for infection? a) Length of labor b) Size of the neonate c) Method of delivery d) Maternal Rh status

Length of labor Correct Explanation: A prolonged length of labor places the mother at increased risk for developing an infection. The average size of the neonate, vaginal delivery, and Rh status of the client don't place the mother at increased risk

Which of the following would you expect to assess in an infant with hypoglycemia? a) Prolonged jaundice b) Limpness or jitteriness c) Pain along the sixth cranial nerve d) Excessive hunger

Limpness or jitteriness Correct Explanation: Hypoglycemia (reduced glucose serum level) usually presents with jitteriness.

The nurse cares for preterm infants and assesses them for potential complications to provide adequate countermeasures to prevent futher complications. Which complication should the nurse prioritize and initiate proper measures to protect the newborn?

Loss of body heat

Which of the following is a common finding in the child who has a ventricular septal defect? a) Delayed growth and development b) Loud, harsh murmur c) Bounding pulse d) Fatigue and dyspnea

Loud, harsh murmur

A physician orders oral tocolytic therapy for a woman with preterm labor. Which agent would the nurse be least likely to administer? a) Terbutaline b) Nifedipine c) Indomethacin d) Magnesium sulfate

Magnesium sulfate Correct Explanation: Magnesium sulfate is only given intravenously for preterm labor. Nifedipine and indomethacin are given orally for preterm labor. Terbutaline is given intravenously during the initial period and then switched to the oral route for maintenance.

Which nursing measure is most effective in reducing newborn infections?

Maintain medical asepsis while providing care.

In the infant born with a cleft lip and a cleft palate, the highest priority of the nurse is related to which intervention?

Maintaining the nutritional needs if the infant

In the infant born with a cleft lip and a cleft palate, the highest priority of the nurse is related to which of the following? a) Maintaining the nutritional needs if the infant b) Promoting coping skills in the family caregivers c) Reducing family anxiety related to the treatment d) Managing the pain level of the infant

Maintaining the nutritional needs if the infant

The hereditary defect known as Phenylketonuria (PKU) will cause which of the following if left untreated? a) Strangulated intestine b) Congenital heart defects c) Increased intracranial pressure d) Mental retardation

Mental retardation

When planning preoperative care for a newborn with a cleft lip and palate, a major need for which the nurse would plan interventions is:

Nutrition

The nurse is assessing for developmental dysplasia of the hip in the newborn. The dislocated hip elicits a characteristic clunk as the femoral head slides over the posterior rim of the acetabulum and the dislocation feels reduced. Which maneuver did the nurse perform? a) Pavlik b) Gower c) Barlow d) Ortolani

Ortolani

A postpartal woman calls you into her room because she is having a very heavy lochia flow containing large clots. Your first action would be to a) Assess her blood pressure. b) Palpate her fundus. c) Have her turn to her left side. d) Assess her perineum.

Palpate her fundus.

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 she 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 of the following conditions? a) Postpartum psychosis b) Postpartum panic disorder c) Postpartum blues d) Postpartum depression

Postpartum psychosis

A nursing student is caring for a newborn with a defect in the neural arch where the posterior laminae of the vertebrae have failed to close. The nurse knows that this infant is suffering from which disorder?

Spina bifida

The nurse is developing a plan of care for a neonate experiencing symptoms of drug withdrawal. What should be included in this plan?

Swaddle the infant between feedings.

A woman gives birth to a newborn at 38 weeks' gestation. The nurse classifies this newborn as which of the following? a) Late preterm b) Term c) Preterm d) Postterm

Term Correct Explanation: A term newborn is one born from the first day of the 38th week of gestation through 42 weeks. A postterm newborn is one born after completion of 42 weeks' gestation. A preterm newborn is one born before completion of 37 weeks' gestation. A late preterm newborn is one who is bone between 34 and 36-6/7 weeks' gestation

Which situation should concern the nurse treating a postpartum client within a few days of delivery? a) The client is nervous about taking the baby home b) The client feels empty since she delivered the neonate c) The client would like to watch the nurse give the baby her first bath d) The client would like the nurse to take her baby to the nursery so she can sleep

The client feels empty since she delivered the neonate

The nurse is caring for a newborn of a substance abusing mother who is withdrawing from alcohol. Which of the following would the nurse likely see in this newborn? a) The newborn has a large head circumference b) The newborn is lethargic and sleepy c) The newborn is hyperactive and irritable d) The newborn is above average birth weight

The newborn is hyperactive and irritable

Which complication is most likely responsible for a late postpartum hemorrhage? a) Cervical laceration b) Uterine subinvolution c) Clotting deficiency d) Perineal laceration

Uterine subinvolution

Following birth, the newborn's independent circulatory system is established. If there is an abnormal opening between the chambers in the heart, which cardiac defect may occur?

Ventricular septal defect

The neonatal intensive care nurse is assessing a new admission and suspects the newborn to have meconium aspiration syndrome. Which assessment finding would correlate with the nurse's suspicion?

a barrel-shaped chest with an increased anterior-posterior chest diameter Observe the newborn with MAS for a barrel-shaped chest with an increased anterior-posterior chest diameter, prolonged tachypnea, progression of respiratory distress, intercostal retractions, end-expiratory grunting, and cyanosis. Arterial blood gas analysis will indicate metabolic acidosis with a low blood pH, decreased PaO2, and increased PaCO2. The arterial blood gas values listed are normal as well as the vital signs. Acrocynosis is a normal expectation of a newborn immediately after birth.

The nurse is caring for a client experiencing a prolonged second stage of labor. The nurse would place priority on preparing the client for which intervention?

a forceps and vacuum-assisted birth A forceps-and-vacuum-assisted birth is required for the client having a prolonged second stage of labor. The client may require a cesarean birth if the fetus cannot be delivered with assistance. A precipitous birth occurs when the entire labor and birth process occurs very quickly. Artificial rupture of membranes is done during the first stage of labor.

Disseminated intravascular coagulation is a life-threatening condition that the nurse recognizes can occur as a complication secondary to which of the following primary conditions? (Select all that apply.) a)Septicemia b)Abruptio placenta c)Isoimmunization d)Ectopic pregnancy e)Severe preeclampsia

a)Septicemia b)Abruptio placenta e)Severe preeclampsia Explanation: DIC is always a secondary diagnosis that occurs as a complication of abruptio placenta, amniotic fluid embolism, intrauterine fetal death with prolonged retention of the fetus, severe preeclampsia, HELLP syndrome, septicemia, and hemorrhage.

A woman experiences an amniotic fluid embolism as the placenta is delivered. Your first action would be to a) administer oxygen by mask. b) increase her intravenous fluid infusion rate. c) put firm pressure on the fundus of her uterus. d) tell the woman to take short, catchy breaths.

administer oxygen by mask. Correct 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.

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

c)Ambulate the client as soon as her vital signs are stable Explanation: The best prevention for a thrombophlebitis is ambulation as soon as possible after recovery. Options A, B, and C are incorrect.

When providing care for a postpartum patient at a 6 week check-up, which behavior would alert the nurse the patient may have postpartum psychosis? a) Tearful during appointment b) Talkative and asking questions c) Restless and agitated, concerned with self d) States being tired and happy at same time

c)Restless and agitated, concerned with self Explanation: When a woman has postpartum psychosis the signs may vary but a woman presenting with restlessness, irritability and concerned only for self needs further evaluation. Therefore options A, B, and D are incorrect.

A premature infant develops respiratory distress syndrome. With this condition, circulatory impairment is likely to occur because with increased lung tension, the:

ductus arteriosus remains open. Excess pressure in the alveoli stimulates the ductus arteriosus to remain open, compromising efficient cardiovascular function. p 842

Which finding is common in the child who has a ventricular septal defect?

loud, harsh murmur Children with ventricular septal defects have a characteristic loud, harsh murmur. Fatigue and dyspnea, delayed growth and development, and a bounding pulse are seen in the child with patent ductus arteriosus

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?

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." pg 767

When caring for a preterm infant, what intervention will best address the sensorimotor needs of the infant? a) Using minimal amount of tape b) Rocking and massaging c) Using distraction through objects d) Swaddling and positioning

Rocking and massaging

When assessing a newborn, the nurse determines that the newborn is most likely experiencing respiratory distress syndrome (RDS) based on which of the following? a) Peripheral cyanosis b) Slightly diminished breath sounds c) See-saw respirations d) Respiratory distress occurring by 6 hours of age

See-saw respirations

A 35-year-old client has just given birth to a healthy newborn during her 43rd week of gestation. Which of the following should the nurse expect when assessing the condition of the newborn? a) Meconium aspiration in utero or at birth b) Yellow appearance of the newborn's skin c) Tremors, irritability, and high-pitched cry d) Seizures, respiratory distress, cyanosis, and shrill cry

Meconium aspiration in utero or at birth Correct Explanation: Infants born after 42 weeks of pregnancy are postterm. These infants are at a higher risk of swallowing or aspirating meconium in utero or after birth. As soon as the infant is born, the nurse usually suctions out the secretions and fluids in the newborn's mouth and throat before the first breath to avoid aspiration of meconium and amniotic fluid into the lungs. Seizures, respiratory distress, cyanosis, and shrill cry are signs and symptoms of infants with intracranial hemorrhage. Intracranial hemorrhage can be a dangerous birth injury that is primarily a problem for preterm newborns, not postterm neonates. Yellow appearance of the newborn's skin is usually seen in infants with jaundice. Tremors, irritability, high-pitched or weak cry, and eye rolling are seen in infants with hypoglycemia.

When assessing the patient for postpartum hemorrhage the nurse monitors which of the following every hour? a) Pad count b) Urine volume excreted c) Complete blood count d) Vital signs

Pad count Correct Explanation: The way to monitor for bleeding every hour is to assess pads and percent of pad saturated by blood in the previous hour. It would not be necessary to do a complete blood count every hour, nor hourly urines. Vital signs are not typically taken every hour.

An infant born is suspected of having persistent pulmonary hypertension of the newborn (PPHM). What intervention implemented by the nurse would be most beneficial in treating this client? a) Provide oxygen by oxygen hood or ventilator b) Encourage the parents to hold the infant for bonding c) Administer anticonvulsants as ordered d) Place the infant in a cool environment to prevent overheating

Provide oxygen by oxygen hood or ventilator

An infant is suspected of having persistent pulmonary hypertension of the newborn (PPHM). What intervention implemented by the nurse would be most beneficial in treating this client?

Provide oxygen by oxygen hood or ventilator.

A couple has just experienced intrauterine fetal demise. Which action by the nurse would be least effective in assisting them?

Refrain from discussing the situation with the couple. The nurse should encourage discussion of the loss and allow the couple to vent their feelings of grief and guilt. The nurse should allow the parents to spend unlimited time with their stillborn infant so that they can validate the death. Providing the parents and family with mementos of the infant helps validate the reality of the death. Assisting the family with arrangements is helpful to reduce the stress of coping with the situation and making decisions at this difficult time. pg 784

In the pre-term newborn, which of the following body systems are the most critical complications related to? a) Integumentary b) Immune c) Respiratory d) Digestive

Respiratory

A nurse is caring for a newborn with a repaired cleft lip. What intervention can the nurse provide to facilitate drainage of mucus and secretions to prevent aspiration?

Position the child on the side

Which recommendation should be given to a client with mastitis who is concerned about breastfeeding her neonate?

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.

A nurse is assigned to care for a newborn with esophageal atresia. What preoperative nursing care is the priority for this newborn?

Prevent aspiration by elevating the head of the bed, and insert an NG tube to low suction. The preoperative nursing care focuses on preventing aspiration by elevating the head of the bed and insertion of an NG tube to low suction to prevent aspiration. Documenting the amount and color of drainage is not needed with the NG tube in place. An infant with esophageal atresia is NPO and fed nothing until after repairing the defect. Administering antibiotics and total parenteral nutrition is a postoperative nursing intervention when caring for a newborn with esophageal atresia.

The nurse cares for a newborn with a congenital cardiac anomaly. What component of nursing care is the priority for the newborn? a) Accompany the newborn to all radiologic examinations b) Teach the parents to take pulse and blood pressure measurements c) Prevent pain as much as possible d) Maintain oxygen saturation at 95% or above

Prevent pain as much as possible

The nurse is preparing a nursing care plan for an infant who was born with spina bifida with myelomeningocele. Which nursing goal should the nurse prioritize for this child?

Preventing infection

The second-year nursing student taking an obstetrics course correctly attributes which descriptions to the term dystocia? Select all that apply.

Progress of labor deviates from normal. Labor is slow. Dystocia is said to exist when the progress of labor deviates from normal and is slow.

A preterm infant is transferred to a distant hospital for care. When her parents visit her, which of the following would be most important for you to urge them to do? a) Call the baby by her name. b) Touch and, if possible, hold her. c) Stand so the baby can see them. d) Bring a piece of clothing for her.

Touch and, if possible, hold her. Correct Explanation: Preterm infants may be hospitalized for an extended time, so parents need to be encouraged to touch and interact with the infant to begin bonding.

A meconium plug is an extremely hard portion of meconium that has completely blocked the intestinal lumen, causing bowel obstruction. a) True b) False

True

In vasa previa, the umbilical vessels of a velamentous cord insertion cross the cervical os and therefore deliver before the fetus.

True

A woman receiving an oxytocin infusion for labor induction develops contractions that occur every minute and last 75 seconds. Uterine resting tone remains at 20 mm Hg. Which action would be most appropriate? a) Slow the oxytocin infusion to the initial rate. b) Stop the infusion immediately. c) Continue to monitor contractions and fetal heart rate. d) Notify the birth attendant.

Stop the infusion immediately. Explanation: The woman is exhibiting signs of uterine hyperstimulation, which necessitate stopping the oxytocin infusion immediately to prevent further complications. Once the infusion is stopped, the nurse should notify the birth attendant and continue to monitor the woman's contractions and fetal heart rate.

The nurse is teaching a client about mastitis. Which statement should the nurse include in her teaching? a) Mastitis usually develops in both breasts of a breast-feeding client b) A breast abscess is a common complication of mastitis c) The most common pathogen is group A beta-hemolytic streptococci d) Symptoms include fever, chills, malaise, and localized breast tenderness

Symptoms include fever, chills, malaise, and localized breast tenderness

The nurse is teaching a client about mastitis. Which statement should the nurse include in her teaching? a) A breast abscess is a common complication of mastitis b) The most common pathogen is group A beta-hemolytic streptococci c) Symptoms include fever, chills, malaise, and localized breast tenderness d) Mastitis usually develops in both breasts of a breast-feeding client

Symptoms include fever, chills, malaise, and localized breast tenderness Correct Explanation: Mastitis is an infection of the breast characterized by flulike symptoms, along with redness and tenderness in the breast. The most common causative agent is Staphylococcus aureus. Breast abscess is rarely a complication of mastitis if the client continues to empty the affected breast. Mastitis usually occurs in one breast, not bilaterally.

A one-day-old neonate born at 32 weeks' gestation is in the neonatal intensive care unit under a radiant overhead warmer. The nurse assesses the morning axilla temperature as 95 degrees F (35 degrees C). What could explain the assessment finding?

The supply of brown adipose tissue is not developed. Typically newborns use nonshivering thermogenesis for heat production by metabolizing their own brown adipose tissue. However, this preterm newborn has an inadequate supply of brown fat because he or she left the uterus early before the supply was adequate. Conduction heat loss allows an increased transfer of heat from their bodies to the environment, but there is nothing to substantiate conduction heat loss. Axillary temperatures are accurate and the mode of taking temperatures for neonates.

When providing care to a newborn with necrotizing enterocolitis (NEC), the nurse would need to report which finding immediately?

abdomen appearing red and shiny

When providing care to a newborn with necrotizing enterocolitis (NEC), the nurse would need to report which finding immediately?

abdomen appearing red and shiny An abdomen that appears red and shiny in a newborn with NEC indicates peritonitis and must be reported immediately. A decrease in abdominal girth, stools negative for blood, and active bowel sounds suggest that the condition is resolving.

What would the nurse use to monitor the effectiveness of intravenous anticoagulant therapy for a postpartum woman with deep vein thrombosis?

activated partial thromboplastin time The activated partial thromboplastin time is used to monitor the effectiveness of intravenous anticoagulant therapy, most commonly heparin. Prothrombin time is used to monitor the effectiveness of the oral anticoagulant warfarin. Although platelets and fibrinogen are involved in blood clotting, they are not used to monitor the effectiveness of intravenous anticoagulant therapy.

A nurse is caring for a neonate of 25 weeks' gestation who is at risk for intraventricular hemorrhage (IVH). Which assessment finding should be reported immediately?

a sudden drop in hemoglobin

Over 75% of women who give birth experience postpartum depression. a) True b) False

b)False Explanation: Although almost every woman notices some immediate (1 to 10 days postpartum) feelings of sadness (postpartal "blues") after childbirth, these feelings develop into postpartum depression in about 20%.

b)Palpate her fundus. Explanation: Palpating the fundus will cause it to contract and reduce bleeding. This makes options A, C, and D incorrect.

Which measurement best describes delayed postpartum hemorrhage?

blood loss in excess of 500 ml, occurring 24 hours to 6 weeks after birth Postpartum hemorrhage involves blood loss in excess of 500 ml. Most delayed postpartum hemorrhages occur between the fourth and ninth days postpartum. The most common causes of a delayed postpartum hemorrhage include retained placental fragments, intrauterine infection, and fibroids.

The nurse suspects a preterm newborn receiving enteral feedings of having necrotizing enterocolitis (NEC). What assessment finding best correlates with this diagnosis?

bloody stools NEC assessment includes assessing the newborn's health history and physical examination as well as laboratory and diagnostic testing. The onset of NEC is demonstrated by the development of feeding intolerance, abdominal distention, and bloody stools in a preterm infant receiving enteral feedings. As the disease worsens, the infant develops signs and symptoms of septic shock with RDS, temperature instability, lethargy, hypotension, and oliguria.

A preterm newborn is being monitored for potential necrotizing enterocolitis. The nurse recognizes which factors as major pathologic mechanisms that could lead to this complication? Select all that apply.

bowel ischemia perinatal stressors formula feeding

A client is experiencing shoulder dystocia during birth. The nurse would place priority on performing which assessment postbirth?

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. Cleft palate and cardiac anomalies are not related to shoulder dystocia.

A nursing student correctly identifies the problem of fetal buttocks instead of the head presenting first as which type of presentation?

breech presentation Breech presentation is when the fetal buttocks present first rather than the head. Face and brow presentation has complete extension of the fetal head. Brow presentation is when the fetal head is between full extension and full flexion so that the largest fetal skull diameter presents to the pelvis. Persistent occiput posterior position is the engagement of fetal head in the left or right occiputo-transverse position with the occiput rotating posteriorly rather than into the more favorable occiput anterior position. Normal presentation is head first or occiput anterior.

A nursing student correctly identifies the problem of fetal buttocks instead of the head presenting first as which of the following? a) face and brow presentation b) breech presentation c) normal presentation d) persistent occiput posterior presentation

breech presentation Correct Explanation: Breech presentation is when the fetal buttocks present first rather than the head. Face and brow presentation has complete extension of the fetal head. Brow presentation is when the fetal head is between full extension and full flexion so that the largest fetal skull diameter presents to the pelvis. Persistent occiput posterior position is the engagement of fetal head in the left or right occiputo-transverse position with the occiput rotating posteriorly rather than into the more favorable occiput anterior position. Normal presentation is head first or occiput anterior.

A nurse is caring for a client with idiopathic thrombocytopenic purpura (ITP). Which intervention should the nurse perform first?

administration of platelet transfusions as prescribed When caring for a client with ITP, the nurse should administer platelet transfusions as ordered to control bleeding. Glucocorticoids, intravenous immunoglobulins, and intravenous anti-Rho D are also administered to the client. The nurse should not administer NSAIDs when caring for this client since nonsteroidal anti-inflammatory drugs cause platelet dysfunction.

A nurse is reading a journal article about birth defects and finds that some birth defects are preventable. Which risk factor would the nurse expect to find as being cited as the current leading preventable cause of birth defects?

alcohol

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?

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. pg 789

Uterine atony, or the inability of the uterus to effectively contract, has four major causes. What is one of them? a) Disruption in fetal clotting mechanisms b) Laceration of the placenta c) Laceration of the cervix d) Disruption of placental clotting mechanisms

c)Laceration of the cervix Explanation: There are four major causes of postpartum hemorrhage: uterine atony, inability of the uterus to contract effectively; lacerations to the uterus, cervix, vagina, or perineum; retained placenta; and disruption in maternal clotting mechanisms. It is important to monitor all postpartum women for excessive bleeding because two-thirds of the women who experience postpartum hemorrhage have no risk factors.

When working in a free clinic for children, the nurse observes a mother with her 2 week infant. Which of the following behaviors should the nurse bring to the attention of the health care provider? a) Talking to the infant and rocking the infant b) Breastfeeding the infant in public c) Non-responsive to the infant crying d) Discussing her birth with another new mom

c)Non-responsive to the infant crying Explanation: When a mother is not engaged with the infant and is demonstrating signs of not providing care or responding to the infant, there is a concern about malattachment. This needs to be reported to the health care provider for follow-up. Options A, C, and D are normal activities for a new mother who is two weeks post partum.

Your patient delivered six hours ago. She calls you to her room complaining of pain "deep inside." You medicate her per orders with no relief attained. You check her vital signs and find they are markedly different then when the CNA charted them 30 minutes ago. What would you suspect? a) Early postpartum hemorrhage b) Late postpartum hemorrhage c) Pelvic hematoma d) Uterine laceration

c)Pelvic hematoma Explanation: A hematoma also can form deep in the pelvis where it is much more difficult to identify. The primary symptom is deep pain unrelieved by comfort measures or medication and accompanied by vital sign instability.

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?

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 common symptom that would alert the nurse that a preterm infant is developing respiratory distress syndrome is:

expiratory grunting. Expiratory grunting is a physiologic measure to ensure alveoli do not fully close on expiration (so they require less energy expenditure to reopen). p 845

A premature infant is admitted to the neonatal intensive care unit with respiratory distress syndrome and requires assisted ventilation. The parents asks the nurse, "Why won't our baby breath on its own?" What is the nurse's best response?

"Your infant cannot sustain respirations yet due to the lack of assistance from surfactant." Preterm infants lacks surfactant to lower the surface tension in the alveoli and stabilize them to prevent their collapse. Even if preterm newborns can initiate respirations, they have a limited ability to retain air due to insufficient surfactant. Preterm newborns develop atelectasis quickly without alveoli stabilization. Fetal circulation patterns persist.

The experienced labor and delivery nurse knows to evaluate progress in active labor by using which simple rule? a) 1/2 cm/hour for cervical dilation b) 1 cm/hour for cervical dilation c) 2 cm/hour for cervical dilation d) 1/4 cm/hour for cervical dilation

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

What percentage of neonates require some type of assistance to transition to extrauterine life?

10% Most newborns transition to extrauterine life smoothly. About 10% of newborns need some type of assistance at birth.

With the administration of oxygen, a preterm infant's Pa02 level is monitored carefully. It is important to keep this level under which value to help prevent retinopathy of prematurity? a) 180 mm Hg b) 50 mm Hg c) 100 mm Hg d) 40 mm Hg

100 mm Hg Explanation: Retinal capillaries can be damaged by excessive oxygen levels. Keeping the Pa02 level under 100 mm Hg helps prevent this.

A client is admitted to the unit in preterm labor. In preparing the client for this therapy, the nurse anticipates that the client's pregnancy may be prolonged for how long when this therapy is used?

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.

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 or more. Macrosomia occurs when the fetus measures 4,000 g (8.13 lbs) or more at birth and complicates approximately 10% of all pregnancies. The excessive fetal size and abnormalities contribute to labor and birth dysfunctions.

Hypoglycemia in a mature infant is defined as a blood glucose level below which amount?

40 mg/100 mL whole blood Because newborns do not manifest symptoms of a reduced glucose level until it decreases well below adult levels, a finding below 40 mg/100 mL whole blood is considered hypoglycemia. p 837

Hypoglycemia in a mature infant is defined as a blood glucose level below which of the following? a) 30 mg/100 mL whole blood b) 100 mg/100 mL whole blood c) 40 mg/100 mL whole blood d) 80 mg/100 mL whole blood

40 mg/100 mL whole blood Explanation: Because newborns do not manifest symptoms of a reduced glucose level until it decreases well below adult levels, a finding below 40 mg/100 mL whole blood is considered hypoglycemia

The nurse is caring for a client after experiencing a placental abruption. Which finding is the priority to report to the health care provider?

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.

The nurse is teaching a client about mastitis. Which statement should the nurse include in her teaching? A) Symptoms include fever, chills, malaise, and localized breast tenderness. B) A breast abscess is a common complication of mastitis. C) The most common pathogen is group A beta-hemolytic streptococci. D) Mastitis usually develops in both breasts of a breastfeeding client.

A) Symptoms include fever, chills, malaise, and localized breast tenderness. Mastitis is an infection of the breast characterized by flulike symptoms, along with redness and tenderness in the breast. The most common causative agent is Staphylococcus aureus. Breast abscess is rarely a complication of mastitis if the client continues to empty the affected breast. Mastitis usually occurs in one breast, not bilaterally.

An infant that is diagnosed with meconium aspiration displays which symptom? A) intercostal and substernal retractions B) pink skin C) respirations of 45 D) no heart murmur

A) intercostal and substernal retractions Meconium aspiration is when the infant passes the first stool in utero and some of stool particles are ingested into the lungs at birth. This can cause the infant to be in distress displayed by mild cyanosis, tachypnea, retractions, hyperinflated chest, and hypercapnia.

The obstetrical nurse admits a premature, small-for-gestational age infant to the observational unit for assessment. The maternal record reveals an obese 27-year-old homeless woman with limited prenatal, medical, or dental care. Her blood pressure on admission was 170/90 mm Hg. Which factors in the maternal history would have suggested a high-risk pregnancy? Select all that apply. A) periodontal disease B) obesity C) maternal age D) maternal hypertension E) lack of prenatal care F) homelessness

A) periodontal disease B) obesity D) maternal hypertension E) lack of prenatal care F) homelessness The factors for a high-risk pregnancy include: maternal nutrition (obesity), substandard living conditions (homelessness), maternal age of less than 20 or more than 35 years, periodontal disease, lack of prenatal care, and maternal disease (hypertension).

When providing care to a newborn with necrotizing enterocolitis (NEC), which of the following would the nurse need to report immediately? a) Stools negative for blood b) Abdomen appearing red and shiny c) Decrease in abdominal girth d) Bowel sounds in all four quadrants

Abdomen appearing red and shiny

When examining a newborn for developmental hip dysplasia, which of the following motions would the newborn's hip be unable to accomplish? a) Extension b) Abduction c) Adduction d) Rotation

Abduction

Which of the following behaviors exhibited by a 4-hour postpartum woman requires further interventions by the nurse? a) Returns her son to the nursery because of fatigue. b) Absent verbalization about the birthing process. c) Cuddles her son close to her while feeding. d) Tells visitors about her son and the labor.

Absent verbalization about the birthing process. Correct Explanation: After delivery the woman would be excited and interested in the delivery and the infant. A woman may be tired and to ask for sleep is also expected, unexpected is the absent verbalization of the activities and birth. Therefore options A, C, and D are incorrect answers.

A nurse is caring for a preterm infant. Which intervention will prepare the newborn's gastrointestinal tract to better tolerate feedings when initiated?

Administer 0.5 ml/kg/hr of breast milk enterally. The nurse should administer 0.5 to 1 ml/kg/hr of breast milk enterally to induce surges in gut hormones that enhance maturation of the intestine. Administering vitamin D supplements, iron supplements, or intravenous dextrose will not significantly help the preterm newborn's gut overcome feeding difficulties.

A nurse is caring for a newborn with transient tachypnea. Which is the priority nursing intervention? a) Administer IV fluids; gavage feedings b) Perform gentle suctioning c) Monitor for signs of hypotonia d) Maintain adequate hydration

Administer IV fluids; gavage feedings

The nurse is caring for a patient who has gone into labor 6 weeks early and whose amniocentesis has shown a lack of lecithin. Of the following interventions, which would the nurse most likely do first?

Administer a glucocorticosteroid to the mother

A nurse is assessing a term newborn and finds the blood glucose level is 23 mg/dl. The newborn has a weak cry, is irritable, and exhibits bradycardia. Which intervention is most appropriate? a) Monitor the infant's hematocrit levels closely b) Place the infant on a radiant warmer c) Administer PO glucose water immediately d) Administer dextrose intravenously

Administer dextrose intravenously

A nurse is assessing a term newborn and finds the blood glucose level is 23 mg/dl. The newborn has a weak cry, is irritable, and exhibits bradycardia. Which intervention is most appropriate?

Administer dextrose intravenously. The infant is demonstrating signs and symptoms of significant hypoglycemia. IV dextrose should be administered to the term newborn intravenously when the blood glucose level is less than 40 mg per dL, and the newborn is symptomatic for hypoglycemia. Administration of IV glucose assists in stabilizing blood glucose levels. Providing oral glucose feedings or placing the infant on a radiant warmer will not help maintain the glucose level. Monitoring the infant's hematocrit level is not a priority and not related to the problem at hand. pg 840

A woman is going to have labor induced with oxytocin. Which statement below reflects the induction technique you anticipate her primary-care provider will order? a) Administer oxytocin diluted in the main intravenous fluid. b) Administer Pitocin in two divided intramuscular sites. c) Administer Pitocin in a 20 cc bolus of saline. d) Administer oxytocin diluted as a "piggyback" infusion.

Administer oxytocin diluted as a "piggyback" infusion. Correct Explanation: Pitocin is always infused in a secondary or "piggyback" infusion system so it can be halted quickly if overstimulation of the uterus occurs.

A nurse is caring for a client at 38 weeks gestation who is diagnosed with chorioamnionitis. On which intervention should the nurse place priority?

Administer oxytocin. Chorioamnionitis is an indication for labor induction. The WBC, temperature, and amniotic fluid are not priority to assess because the nurse already knows the client has chorioamnionitis.

Which of the following would the nurse expect to be included in the plan of care for an infant of a diabetic mother who has a serum calcium level of 6.2 mg/dL? a) Administration of calcium gluconate b) Infusions of intravenous glucose c) Initiation of phototherapy d) Initiation of oral feedings

Administration of calcium gluconate

A nurse is caring for a client with idiopathic thrombocytopenic purpura (ITP). The nurse is correct when performing which intervention? a) Avoiding administration of oxytocics b) Administration of prescribed nonsteroidal anti-inflammatory drugs (NSAIDs) c) Continual firm massage of the uterus d) Administration of platelet transfusions as ordered

Administration of platelet transfusions as ordered

Immediately after delivering a full-term infant, a patient 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 patient? a) Congestive heart failure b) Amniotic fluid embolism c) Placental separation d) Aspiration

Amniotic fluid embolism Correct 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 class about various methods for cervical ripening, the instructor determines that the teaching was successful when the class identifies which of the following as a surgical method? a) Laminaria b) Amniotomy c) Breast stimulation d) Prostaglandin

Amniotomy Correct 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.

The nurse is caring for a newborn diagnosed with congenital talipes equinovarus. Which of the following treatments would the nurse most likely expect for this newborn? a) Placing the child in special shoes b) Doing passive range of motion c) Application of a cast d) Putting the child in Bryant's traction

Application of a cast

Four weeks before the birth of her already large child, the physician has told the pregnant woman that if the baby gets bigger and his lungs are ready, the physician would like to perform a cesarean to deliver the baby. The woman asks the nurse what the downside is to having a cesarean rather than a vaginal delivery. What is an appropriate response by the nurse? a) "As the baby passes through the birth canal some of the excess fluid is expelled from the lungs, if that doesn't happen there's a higher risk of respiratory distress." b) "If the physician has recommended the procedure, it's likely that the benefits outweigh the risks." c) "The procedure isn't risky for the baby, but your healing takes longer and you'll have a scar." d) "Some women don't have any problem delivering large babies. You might want to get a second opinion."

"As the baby passes through the birth canal some of the excess fluid is expelled from the lungs, if that doesn't happen there's a higher risk of respiratory distress."

A client who has been in prolonged labor reports extreme back pain. She asks why her back hurts so much. What would be the best response by the nurse?

"Different fetal positions can cause prolonged labor and back pain." Fetal malposition can cause prolonged labor. A labor complicated by occiput posterior position is usually prolonged and characterized by maternal perception of increased intensity of back discomfort. The other answers do not address the client's question. pg 759

A patient who has been in prolonged labor reports extreme back pain. She asks why her back hurts so much. The best response by the nurse would be which of the following? a) "Let me help you out of bed to try walking it off." b) "Different fetal positions can cause prolonged labor and back pain." c) "This is just a normal part of labor." d) "Perhaps you have been in one position for too long."

"Different fetal positions can cause prolonged labor and back pain." Correct Explanation: Fetal malposition can cause prolonged labor. A labor complicated by occiput posterior position is usually prolonged and characterized by maternal perception of increased intensity of back discomfort. The other answers do not address the patient's question.

A client who gave birth 2 hours ago expresses concern about her baby developing jaundice. Which response from the nurse would be best?

"I understand your concern because as many as 50% of babies can develop jaundice." As many as 50% of term newborns will develop physiologic jaundice. Physiologic jaundice occurs after the first 24 hours of life and is not pathologic. Pathologic jaundice will develop within the first 24 hours of life.

In examining her newborn son, a mother becomes concerned that the frenulum, under his tongue, is too short. She points it out to the nurse. Which of the following should the nurse say in response to this mother's concern? a) "In most cases, a short frenulum does not cause problems and does not need to be corrected." b) "The child will most likely develop speech problems and will require speech therapy." c) "It is likely that the child will need to have surgery in the coming weeks to prevent developmental problems." d) "This condition can be corrected by passive stretching exercises of the tongue."

"In most cases, a short frenulum does not cause problems and does not need to be corrected."

A group of nursing students is discussing hydrocephalus. The students make the following statements related to the noncommunicating type of congenital hydrocephalus. Which statement is the most accurate? a) "There is an opening between the ventricles and the spinal cord that usually closes at birth." b) "There is an obstruction that keeps cerebrospinal fluid from passing between the ventricles and the spinal cord." c) "There is a decreased production of cerebrospinal fluid." d) "There is defective absorption of cerebrospinal fluid."

"There is an obstruction that keeps cerebrospinal fluid from passing between the ventricles and the spinal cord."

A nursing student is learning about fetal presentation. The nursing instructor realizes a need for further instruction when the student makes which of the following statements?

"Transverse lie is the same as when the fetal buttocks present to the birth canal." In most term pregnancies the fetus presents head down. In a breech presentation, the fetal buttocks, feet, or both present to the birth canal. Transverse lie is the same as shoulder presentation.

The nurse is caring for a newborn client newly diagnosed with dysplasia of the hip. Which response by the nurse educates the parents on the correct plan of treatment for this diagnosis?

"Treatment will begin immediately." Dysplasia of the hip is a congenital newborn condition that requires immediate intervention. The development of the acetabulum of the hip is defective, and it may or may not be dislocated. Treatment of the defect and dislocated hips involves positioning the hip into a flexed, abducted (externally rotated) position to attempt to press the femur into the acetabulum. This involves splints and halters as the first line of treatment. Treatment should not be delayed. Surgery and casts are typically not used as the first line of treatment.

A newborn boy is diagnosed with esophageal atresia and tracheoesophageal fistula. After the nurse provides preoperative teaching, which statement indicates that the parents need additional teaching?

"We can probably start feeding him with the bottle about a day after the surgery." Preoperatively, the newborn is at risk for pneumonitis due to aspiration of food and secretions. Antibiotics are typically given until the anastomosis is proven intact and patent. Oral feedings are usually started within a week after surgery once the esophageal anastomosis is proven to be intact and patent. Proper position with elevation of the head is important for the newborn with esophageal atresia and tracheoesophageal fistula because he is at risk for aspiration of food and secretions. Using a pacifier to provide nonnutritive sucking helps to meet the newborn's need to suck.

The nurse teaches the parents of a newborn with hyperbilirubinemia about home phototherapy using bilirubin lights. Which statement indicates that the teaching was successful? a) "We will turn him every ½ hour to make sure that his whole body is exposed." b) "We should see reddened areas on his skin, which mean the treatment is working." c) "We'll place the lights so that they are about 5 inches above our baby at all times." d) "We'll take off the patches on his eyes when we're feeding him so he can look at us."

"We'll take off the patches on his eyes when we're feeding him so he can look at us."

The nurse in the NICU is caring for preterm newborns. Which guidelines are recommended for care of these newborns? Select all that apply. A) Handle the newborn as much as possible. B) Take the newborn's temperature often. C) Dress the newborn in ways to preserve warmth. D) Discourage contact with parents to maintain asepsis. E) Supply oxygen for the newborn, if necessary. F) Give the newborn a warm bath immediately.

B) Take the newborn's temperature often. C) Dress the newborn in ways to preserve warmth. E) Supply oxygen for the newborn, if necessary. Controlling the temperature of preterm newborns is often difficult; therefore, special care should be taken to keep these babies warm. Nurses should dress them in a stockinette cap, take their temperature often, and supply oxygen, if necessary. To conserve the energy of small newborns, the nurse should handle them as little as possible. Usually, they will not give them a bath immediately. Parents should be encouraged to bond with their infants.

A newborn with high serum bilirubin is receiving phototherapy. Which of the following is the most appropriate nursing intervention for this client? a) Gentle shaking of the baby b) Placing light 6 inches above the newborn's bassinet c) Application of eye dressings to the infant d) Delay of feeding until bilirubin levels are normal

Application of eye dressings to the infant Correct Explanation: Continuous exposure to bright lights by phototherapy may be harmful to a newborn's retina, so the infant's eyes must always be covered while under bilirubin lights. Eye dressings or cotton balls can be firmly secured in place by an infant mask. The lights are placed 12 to 30 inches above the newborn's bassinet or incubator. Bilirubin is removed from the body by being incorporated into feces. Therefore, the sooner bowel elimination begins, the sooner bilirubin removal begins. Early feeding (either breast milk or formula), therefore, stimulates bowel peristalsis and helps to accomplish this. Gently shaking the infant is a method of stimulating breathing in an infant experiencing apnea.

Immediately after birth, the nurse is caring for a newborn with a myelomeningocele. What intervention should the nurse provide to prevent drying out of the sac to avoid damage?

Apply a sterile dressing moistened in a warm sterile saline solution.

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?

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.

What assessment by the nurse will best monitor the nutrition and fluid balance in the postterm newborn? a) Monitor for fall in temperature, indicative of dehydration b) Assess for decrease in urinary output c) Assess for increased muscle tone d) Measure weight once every 2-3 days

Assess for decrease in urinary output

A postpartal woman is developing a thrombophlebitis in her right leg. Which assessments would the nurse make to detect this?

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.

In caring for the child with esophageal atresia, the nurse recognizes the priority assessment is which?

Assessment for respiratory distress. Children with esophageal atresia have periods of respiratory distress with choking and cyanosis. This is a priority assessment as the implications include the highest risk. Excessive bleeding, cardiac status for anomolies, and feeding difficulties are not concerns in the child with esophageal atresia.

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

B) 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 (30.0° 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.

Which nursing measure is most effective in reducing newborn infections? A) Place newborns in an isolette. B) Maintain medical asepsis while providing care. C) Promote early discharge of all newborns. D) Limit the number of newborns in newborn nurseries.

B) Maintain medical asepsis while providing care. Nurses possess the education and assessment tools to decrease the incidence of and reduce the impact of newborn infections. Nurses should implement measures for prevention and early recognition, including maintaining medical and surgical asepsis for all providing care. Nurses should outline and carry out measures to prevent hospital-acquired infections, such as thorough hand-washing hygiene for all staff.

A ventilated 33 weeks' gestation newborn in the neonatal intensive care unit (NICU) receives surfactant therapy. Which would the nurse expect to assess as a positive response to this therapy? A) Glucose is 60 mg/dl (3.3 mmol/L). B) Oxygen saturation levels are at 98%. C) PaCO2 is 35 to 45 mm Hg. D) Heart rate is 60 bpm.

B) Oxygen saturation levels are at 98%. Rescue treatment is indicated for newborns with established RDS who require mechanical ventilation and supplemental oxygen. The earlier the surfactant is administered, the better the effect on gas exchange with an aim to have the O2 saturation level of 98%. Glucose level assessment does not correlate with this therapy. The HR of 60 bpm is an abnormal finding and not a positive result of the therapy. The PaCO2 indicates respiratory acidosis.

When planning preoperative care for a newborn with a cleft lip and palate, a major need for which the nurse would plan interventions is:

nutrition. An infant with a cleft lip is unable to suck effectively, so obtaining adequate nutrition is a major concern

A nursing student correctly identifies the most desirable position to promote an easy birth as which position?

occiput anterior Any presentation other than occiput anterior or a slight variation of the fetal position or size increases the probability of dystocia.

A nursing student correctly identifies the most desirable position to promote an easy delivery as which of the following? a) occiput anterior b) face and brow c) shoulder dystocia d) breech

occiput anterior Correct Explanation: Any presentation other than occiput anterior or a slight variation of the fetal position or size increases the probability of dystocia.

It would be best to place an infant with a myelomeningocele in which position prior to surgery?

on the stomach (prone) Placing the infant prone prevents direct trauma to the lesion and reduces the chance that feces will contaminate the lesion.

A woman who has a history of cocaine abuse gives birth to a newborn. Which findings would the nurse expect to assess in the newborn? Select all that apply.

piercing cry poor sucking inconsolable

A woman is in the hospital only 15 minutes when she begins to give birth precipitously. The fetal head begins to emerge as the nurse walks into the labor room. The nurse's best action would be to:

place a hand gently on the fetal head to guide birth. If a head is controlled as it emerges, trauma to internal vessels or to the maternal cervix is less apt to occur.

The nurse is assessing a small-for-gestational age (SGA) newborn, 12 hours of age, and notes the newborn is lethargic with cyanosis of the extremities, jittery with handling, and a jaundiced, ruddy skin color. The nurse expects which diagnosis as a result of the findings?

polycythemia Newborns born small for gestational age (SGA) are at risk for polycythemia. They should therefore undergo screening at 2, 12, and 24 hours of age. Observe for clinical signs of polycythemia (respiratory distress, cyanosis, jitteriness, jaundice, ruddy skin color, and lethargy).

The nurse preceptor explains that several factors are involved with the "powers" that can cause dystocia. She focuses on the dysfunction that occurs when the uterus contracts so frequently and with such intensity that a very rapid birth will take place. This is known as which term?

precipitous labor When the expulsive forces of the uterus become dysfunctional, the uterus may either never fully relax (hypertonic contractions) placing the fetus in jeopardy, or relax too much (hypotonic contractions), causing ineffective contractions. Another dysfunction can occur when the uterus contracts so frequently and with such intensity that a very rapid birth will take place (precipitous labor).

A nurse is working with a child who has spina bifida. Which nursing goal for this child would have the highest priority?

preventing infection The highest priority nursing goal is preventing infection because of the vulnerability of the myelomeningocele sac. Promoting comfort is important but not as high a priority because the child does not usually have severe pain with this diagnosis. Reducing anxiety and teaching are lower priorities; physical is a higher priority than psychosocial.

A thin newborn has a respiratory rate of 80 breaths/min, nasal flaring with sternal retractions, a heart rate of 120 beats/min, temperature of 36° C (96.8° F) and persisting oxygen saturation of <87%. The nurse interprets these findings as:

respiratory distress. Ineffective breathing pattern related to immature respiratory system and respiratory distress as evidenced by tachypnea, nasal flaring, sternal retractions, and/or oxygen saturation less than 87 %. These assessment findings do not indicate bronchial pneumonia respiratory alkalosis or cardiac distress at this time. p 846

When providing care for a postpartum client at a 6-week check up, which behavior would alert the nurse the client may have postpartum psychosis?

restless and agitated, concerned with self When a woman has postpartum psychosis the signs may vary, but a woman presenting with restlessness, irritability and concerned only for self needs further evaluation.

A postpartum woman is diagnosed as having endometritis. Which position would the nurse expect to place her in based on this diagnosis?

semi-Fowler's A semi-Fowler's 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 be contraindicated.

A client with a pendulous abdomen and uterine fibroid tumors had 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?

transverse lie A transverse lie, in which the fetus is more horizontal than vertical, occurs in women with pendulous abdomens, with uterine fibroid tumors that obstruct the lower uterine segment, with contraction of the pelvic brim, with congenital abnormalities of the uterus, or with hydramnios. Anterior fetal position and cephalic presentation are normal conditions. Occipitoposterior position tends to occur in women with android, anthropoid, or contracted pelves.

The nurse is admitting a newborn male for observation with the diagnosis of preterm. What assessment finding corresponds with this gestational age diagnosis?

undescended testes Some common physical characteristics of preterm infants include: undescended testes in the male; absent to a few creases in the soles and palms; breast and nipples not clearly delineated; and abundant vernix caseosa. pg 841

The nursing instructor is teaching a session on techniques which the nursing students can use to properly address concerns of parents with children who are born with a congenital disorder. The instructor determines the session is successful when the students correctly choose which nursing intervention as being the most effective in these situations?

use reflective listening and offer nonjudgmental support.

A primigravida at 28 weeks' gestation comes to the clinic for a check-up. She tells the nurse that her mother gave birth to both of her children prematurely, and she is afraid that the same will happen to her. Which risk factors associated with premature birth would the nurse discuss with the client? Select all that apply.

uterine or cervical abnormalities current multiple gestation pregnancy history of previous preterm birth The top three risk factors for premature birth are history of previous preterm birth, current multiple gestation pregnancy, and uterine or cervical abnormalities.

Which complication is most likely responsible for a late postpartum hemorrhage?

uterine subinvolution Late postpartum bleeding is usually the result of subinvolution of the uterus. Retained products of conception or infection commonly cause subinvolution. Cervical or perineal lacerations can cause an immediate postpartum hemorrhage. A client with a clotting deficiency may have an immediate postpartum hemorrhage if the deficiency is not corrected at the time of birth.

Following birth, the newborn's independent circulatory system is established. If there is an abnormal opening between the chambers in the heart, which cardiac defect may occur?

ventricular septal defect A ventricular septal defect is the most common intracardiac defect. It consists of an abnormal opening in the septum between the two ventricles.

What are the causes of retinopathy of the preterm newborn? Select all that apply. a) Assistive ventilation with high oxygen content b) Insufficient oxygenation in an Isolette c) Shock d) Alkalosis e) Fragility of blood vessels in the eyes in response to changes on oxygenation.

• Assistive ventilation with high oxygen content • Fragility of blood vessels in the eyes in response to changes on oxygenation. • Shock

The second-year nursing student taking an obstetrics course correctly attributes which of the following to the term dystocia? (Check all that apply.) a) Labor progresses normally. b) Progress of labor deviates from normal. c) Labor is fast. d) Labor is slow.

• Progress of labor deviates from normal. • Labor is slow. Explanation: Dystocia is said to exist when the progress of labor deviates from normal and is slow.

A client who is hypertensive and who received corticosteroids during pregnancy gave birth by cesarean and subsequently developed endometritis. Her incision is red, warm, and very sensitive to touch, and she remains febrile despite antibiotic therapy. What is the most important aspect of post hospital care the nurse should teach her? A) use of warm compresses and sitz baths B) proper perineal care C) wound care and hand washing D) strict adherence to antibiotic therapy

C) wound care and hand washing The use of systemic corticosteroids prior to birth has increased her risk for development of an infection. She has been treated for endometritis and is now at greater risk for infection. Hand washing is the best defense again transmission of any infection. While adherence to antibiotic therapy, proper perineal care, and use of warm compresses and sitz baths may be indicated, they would not be a higher priority than wound care and hand washing.

You are conducting discharge teaching with a postpartum woman. What would be an important instruction for this patient? a) Call her caregiver if amount of lochia decreases. b) Call her caregiver if lochia moves from serosa to rubra. c) Call her caregiver if lochia moves from rubra to serosa. d) Call her caregiver if lochia moves from serosa to alba.

Call her caregiver if lochia moves from serosa to rubra.

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 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).

A nurse is working with a client who has just begun labor and who has given birth vaginally five previous times. Which of the following interventions will the nurse most likely need to implement to meet the needs of this particular client?

Convert the birthing room to birth readiness before full dilatation is obtained Both grand multiparas (women who have given birth five or more times) and women with histories of precipitate labor should have the birthing room converted to birth readiness before full dilatation is obtained. Then, even if a sudden birth should occur, it can be accomplished in a controlled surrounding. As the client is likely to give birth relatively quickly, there is no need for oxytocin or to darken the room lights. There is also no indication that cesarean birth will be necessary, particularly because all of the client's previous births were vaginal.

The nurse is caring for a newborn who has transient tachypnea of the newborn. In discussing the contributing factors for this disorder, which statement is most accurate? A) This disorder may be seen with advanced gestational age. B) This disorder is often seen in newborns born by cesarean birth. C) This disorder is associated with fetal distress during labor. D) This disorder usually occurs when the mother has a history of hypertension.

B) This disorder is often seen in newborns born by cesarean birth. TTN commonly occurs in newborns born by cesarean birth. The newborn does not experience the compression of the thoracic cavity that occurs with passage through the birth canal, so he or she retains some fluid in the lungs that usually squeezes out as the thoracic area is compressed during a vaginal birth. Meconium aspiration syndrome is associated with fetal distress during labor, a maternal history of diabetes or hypertension, difficult birth, and advanced gestational age.

Which behavior exhibited by a 4-hour postpartum woman requires further interventions by the nurse? A) returns her son to the nursery because of fatigue B) absent verbalization about the birthing process C) cuddles her son close to her while feeding D) tells visitors about her son and the labor

B) absent verbalization about the birthing process After birth the woman would be excited and interested in the birth and the infant. A woman may be tired and to ask for sleep is also expected; unexpected is the absent verbalization of the activities and birth.

Which measure would the nurse expect to be included in the plan of care for an infant of a diabetic mother who has a serum calcium level of 6.2 mg/dL? A) infusions of intravenous glucose B) administration of calcium gluconate C) initiation of phototherapy D) initiation of oral feedings

B) administration of calcium gluconate Serum calcium levels less than 7 mg/dL indicate the need for supplementation with oral or IV calcium gluconate. Phototherapy would be used if the newborn develops hyperbilirubinemia. Intravenous glucose solutions would be used to stabilize the newborn's blood glucose levels and prevent hypoglycemia. Feedings help to control glucose levels, reduce hematocrit, and promote bilirubin excretion.

Periventricular hemorrhage is suspected in a newborn of 30 weeks' gestation. The nurse would anticipate preparing the newborn for which diagnostic tool to confirm the diagnosis? A) blood glucose level B) arterial blood gases C) cranial ultrasound D) chest X-ray

C) cranial ultrasound The diagnostic tool of choice to detect periventricular hemorrhage is a cranial ultrasound. Arterial blood gases would be helpful in evaluating for metabolic acidosis. Blood glucose levels provide information about the newborn's glucose stability. Chest X-ray would provide no information related to bleeding in the brain.

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

A nurse is assessing a newborn for jaundice. The nurse would first notice jaundice at which area?

face Neonatal jaundice first becomes visible in the face and forehead. Identification is aided by pressure on the skin, since blanching reveals the underlying color. Jaundice then gradually becomes visible on the trunk and extremities.

A nursing student has read that cleft lip is diagnosed at birth based on inspection of physical appearance, and that cleft palate is diagnosed in which of the following ways? a) ultrasound b) X-ray c) blood work d) feeling the palate with a gloved finger or using a tongue blade

feeling the palate with a gloved finger or using a tongue blade

The client is 35 weeks of gestation and is being admitted for vaginal bleeding. She is stable at the time of admission. The priority nursing assessment for the client is for:

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 newborn nursery nurse suspects a newborn of having neonatal abstinence syndrome. What assessment findings would most correlate with the diagnosis?

frequent yawning and sneezing

Prevention and early identification of newborns at risk are necessary nursing functions. A nurse anticipates the need for newborn resuscitation secondary to birth asphyxia based on which prenatal risk factors? Select all that apply.

gestational hypertension maternal infection congenital heart disease Prenatal risk factors that can help identify the newborn that may need resuscitation include history of substance abuse, gestational hypertension, fetal distress due to hypoxia before birth, chronic maternal diseases, maternal or perinatal infection, placental problems, umbilical cord problems, difficult or traumatic birth, multiple births, congenital heart disease, maternal anesthesia or recent analgesia, or preterm or postterm birth.

What is a consequence of hypothermia in a newborn?

holds breath 25 seconds Apnea is the cessation of breathing for a specific amount of time, and in newborns it usually occurs when the breath is held for 15 seconds. Apnea, cyanosis, respiratory distress, and increased oxygen demand are all consequences of hypothermia. p. 850

The nurse is assessing a newborn suspected of having meconium aspiration syndrome. What sign or symptom would be most suggestive of this condition? A) intermittent tachypnea B) bile-stained emesis C) expiratory grunting D) high-pitched, shrill cry

C) expiratory grunting Expiratory grunting, a barrel-shaped chest with an increased anterior-posterior chest diameter, prolonged tachypnea, progression from mild-to-severe respiratory distress, intercostal retractions, cyanosis, surfactant dysfunction, airway obstruction, hypoxia, and chemical pneumonitis with inflammation of pulmonary tissues are seen in a newborn with meconium aspiration syndrome. A high-pitched cry may be noted in periventricular hemorrhage/intraventricular hemorrhage. Bile-stained emesis occurs in necrotizing enterocolitis. Intermittent tachypnea can be indicative of transient tachypnea of the newborn or any mild respiratory distress problem.

What is a consequence of hypothermia in a newborn? A) skin pink and warm B) respirations of 46 C) holds breath 25 seconds D) heart rate of 126

C) holds breath 25 seconds Apnea is the cessation of breathing for a specific amount of time, and in newborns it usually occurs when the breath is held for 15 seconds. Apnea, cyanosis, respiratory distress, and increased oxygen demand are all consequences of hypothermia.

What would the nurse expect to prioritize in the assessment of a newborn who has a positive Coombs test? A) tremor activity B) phenylketonuria C) jaundice development D) hyperglycemia

C) jaundice development A direct Coombs test is done to identify hemolytic disease of the newborn; positive results indicate that the newborn's red blood cells have been coated with antibodies and thus are sensitized. The Coombs test is frequently used in the evaluation of a jaundiced infant. Phenylketonuria (PKU) is a genetic disorder in which the body cannot process part of a protein called phenylalanine.

When assessing a newborn, the nurse determines that the newborn is most likely experiencing respiratory distress syndrome (RDS) based on which finding? A) respiratory distress occurring by 6 hours of age B) slightly diminished breath sounds C) see-saw respirations D) peripheral cyanosis

C) see-saw respirations Typically the newborn with RDS demonstrates signs and symptoms of severe respiratory distress at birth or within a few hours of birth. Fine, inspiratory crackles are noted on auscultation of a newborn with RDS. See-saw respirations are characteristic of RDS. A newborn with RDS typically demonstrates generalized cyanosis.

A nurse is assigned to care for a high-risk newborn with a periventricular-intraventricular hemorrhage (PVH-IVH) in the home environment after discharge. For which condition should the nurse monitor the infant?

hydrocephalus

In addition to newborns of diabetic mothers being at risk for hypoglycemia, these newborns are also at risk for which condition?

hypocalcemia The newborn of the diabetic mother is at risk for hypocalcemia, hypomagnesemia, polycythemia with hyperviscosity, and hyperbilirubinemia. Potassium concerns are not a risk for these newborns.

When evaluating a newborn with congenital clubfoot, the nurse recognizes this condition usually involves:

internal rotation of leg.

A nurse assisting in a birth notices that the amniotic fluid is stained greenish black as the baby is being delivered. Which of the following interventions should the nurse implement as a result of this finding? a) Administration of oxygen via a bag and mask b) Intubation and suctioning of the trachea c) Gently shaking the infant d) Flicking the sole of the infant's foot

Intubation and suctioning of the trachea Correct Explanation: Although there is some dispute regarding whether all infants with meconium staining need intubation, those with severe staining are usually intubated and meconium is suctioned from their trachea and bronchi. Do not administer oxygen under pressure (bag and mask) until a meconium stained infant has been intubated and suctioned, so the pressure of the oxygen does not drive small plugs of meconium farther down into the lungs, worsening the irritation and obstruction. Gently shaking the infant and flicking the sole of his foot are methods of stimulating breathing in an infant experiencing apnea.

When caring for a neonate of a mother with diabetes, which physiologic finding is most indicative of a hypoglycemic episode? a) Serum glucose level of 60 mg/dl b) Jitteriness c) Hyperalert state d) Loud and forceful crying

Jitteriness Explanation: Hypoglycemia in a neonate is expressed as jitteriness, lethargy, diaphoresis, and a serum glucose level below 40 mg/dl. A hyperalert state in a neonate is more suggestive of neuralgic irritability and has no correlation to blood glucose levels. Weak crying is found in babies with hypoglycemia. A serum glucose level of 60 mg/dl is a normal level.

Periventricular hemorrhage is suspected in a newborn of 30 weeks' gestation. The nurse would anticipate preparing the newborn for which of the following to confirm the diagnosis? a) Cranial ultrasound b) Blood glucose level c) Chest x-ray d) Arterial blood gases

Cranial ultrasound

A nurse is caring for an infant born with polycythemia. Which intervention is most appropriate when caring for this infant? A) Repeat screening every 2 to 3 hours or before feeds. B) Focus on decreasing blood viscosity by increasing fluid volume. C) Check blood glucose within 2 hours of birth by reagent test strip. D) Focus on monitoring and maintaining blood glucose levels.

D) Focus on decreasing blood viscosity by increasing fluid volume. The nurse should focus on decreasing blood viscosity by increasing fluid volume in the newborn with polycythemia. Checking blood glucose within 2 hours of birth by a reagent test strip and screening every 2 to 3 hours or before feeds are not interventions that will alleviate the condition of an infant with polycythemia. The nurse should monitor and maintain blood glucose levels when caring for a newborn with hypoglycemia, not polycythemia.

A nurse finds that a client is bleeding excessively after a vaginal delivery. Which assessment finding would indicate retained placental fragments as a cause of bleeding? a) Firm uterus with a steady stream of brightred blood b) Large uterus with painless dark-red blood mixed with clots c) Firm uterus with trickle of bright-red blood in perineum d) Soft and boggy uterus that deviates from the midline

Large uterus with painless dark-red blood mixed with clots

When monitoring a postpartum client 2 hours after delivery, the nurse notices heavy bleeding with large clots. Which response is most appropriate initially? a) Performing bimanual compressions b) Massaging the fundus firmly c) Notifying the primary health care provider d) Administering ergonovine (Ergotrate)

Massaging the fundus firmly Correct Explanation: Initial management of excessive postpartum bleeding is firm massage of the fundus and administration of oxytocin (Pitocin). Bimanual compression is performed by a primary health care provider. Ergotrate should be used only if the bleeding doesn't respond to massage and oxytocin. The primary health care provider should be notified if the client doesn't respond to fundal massage, but other measures can be taken in the meantime.

The nurse is assessing the breast of a woman who is 1 month postpartum. The woman is complaining of a painful area on one breast with a red area. The nurse notes a local area on one breast, red and warm to touch. Which of the following should the nurse suspect is the potential diagnosis? a) Plugged milk duct b) Breast yeast c) Mastitis d) Engorgement

Mastitis Correct Explanation: Mastitis usually occurs 2-3 weeks after delivery and is noted to be unilateral. Mastitis needs to be assessed and treated with antibiotic therapy. The scenario described is not indicative of a plugged milk duct or engorgement. Breast yeast is a distracter for this question.

A laboring patient has been pushing without delivering the fetal shoulders. The physician determines the fetus is experiencing shoulder dystocia. What intervention can the nurse assist with to help with the delivery? a) Positioning the woman prone b) Fundal pressure c) Lamaze position d) McRobert's maneuver

McRobert's maneuver Correct Explanation: The McRobert's maneuver is frequently successful and often tried first. It requires assistance from two people. Two nurses place the patient in the lithotomy position, while each holds a leg and sharply flexes the leg toward the woman's shoulders. This opens the pelvis to its widest diameters and allows the anterior shoulder to deliver in almost half of the cases.

A neonatal intensive care nurse is caring for a preterm newborn diagnosed with transient tachypnea who is NPO and receiving intravenous fluid therapy. When would the nurse expect the newborn to begin oral feedings? A) When intake and output correlate. B) When serum glucose is 30 mg/dL (1.7 mmol). C) When the oxygen saturation level is at 92%. D) When the respiratory rate is 44 BPM.

D) When the respiratory rate is 44 BPM. Nursing management of transient tachypnea of the newborn (TTN) is supportive with the administration of intravenous (IV) fluids and/or gavage feedings until the respiratory rate decreases enough to allow safe oral feeding. RR of 44 bpm is normal. The O2 sat level is too low to start oral feedings. The glucose levels indicates hypoglycemia. Intake and output measurements do not indicate the newborn will manage oral feedings.

Two weeks after a vaginal delivery, a client presents with low-grade fever. The client also complains of a loss of appetite and low energy levels. The physician suspects an infection of the episiotomy. What sign or symptom is most indicative of an episiotomy infection? a) Apprehension and diaphoresis b) Foul-smelling vaginal discharge c) Sudden onset of shortness of breath d) Pain in the lower leg

Foul-smelling vaginal discharge

A nurse is caring for a pregnant client whose fetus has been diagnosed with macrosomia. When reviewing the client's history, which of the following would the nurse expect to find? a) Pre-term pregnancy b) Gestational diabetes c) Maternal rickets d) Small body size of mother

Gestational diabetes Correct Explanation: Macrosomia usually results from uncontrolled gestational diabetes, genetic problems, multiparity, or post-term pregnancy. Pre-term pregnancy, small body size of mother, and maternal rickets are not associated with macrosomia. Small body size and maternal rickets are associated with pelvic contraction at the inlet.

A client has delivered a small for gestation age (SGA) newborn. Which of the following would the nurse expect to assess? a) Head larger than body b) Brown lanugo body hair c) Round flushed face d) Protuberant abdomen

Head larger than body Explanation: Head being larger than the rest of the body is the characteristic feature of small for gestational age infants. Small for gestational age infants weigh below the 10th percentile on the intrauterine growth chart for gestational age. The heads of SGA infants appear larger in proportion to their body. They have an angular and pinched face and not a rounded and flushed face. Round flushed face and protuberant abdomen are the characteristic features of large for gestational age (LGA) infants. Preterm infants, and not SGA infants, are covered with brown lanugo hair all over the body.

You administer methylergonovine (Methergine) 0.2 mg to a postpartal woman with uterine subinvolution. Which of the following assessments should you make prior to administering the medication? a) Her blood pressure is below 140/90. b) Her hematocrit level is over 45%. c) She can walk without experiencing dizziness. d) Her urine output is over 50 mL/h.

Her blood pressure is below 140/90.

You administer methylergonovine (Methergine) 0.2 mg to a postpartal woman with uterine subinvolution. Which of the following assessments should you make prior to administering the medication? a) She can walk without experiencing dizziness. b) Her blood pressure is below 140/90. c) Her hematocrit level is over 45%. d) Her urine output is over 50 mL/h.

Her blood pressure is below 140/90. Explanation: Methylergonovine elevates blood pressure. It is important to assess that it is not already elevated before administration.

Which assessment on the third postpartal day would make you evaluate a woman as having uterine subinvolution? a) Her uterus is at the level of the umbilicus. b) Her uterus is 2 cm above the symphysis pubis. c) Her uterus is three finger widths under the umbilicus. d) She experiences "pulling" pain while breastfeeding.

Her uterus is at the level of the umbilicus.

Which assessment on the third postpartal day would make the nurse evaluate a woman as having uterine subinvolution?

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

Which assessment on the third postpartal day would make you evaluate a woman as having uterine subinvolution? a) Her uterus is three finger widths under the umbilicus. b) She experiences "pulling" pain while breastfeeding. c) Her uterus is at the level of the umbilicus. d) Her uterus is 2 cm above the symphysis pubis.

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

For which of the following would you commonly assess in an infant following surgery for a myelomeningocele? a) Dehydration b) Cerebrovascular accident c) Hydrocephalus d) Urinary tract infection

Hydrocephalus

A full-term pregnant client is being assessed for induction of labor. Her Bishop score is less than 6. Which prescription would the nurse anticipate?

Insert a Foley catheter into the endocervical canal. A Bishop score of less than 6 indicates that a cervical ripening method should be used before inducing labor. A low Bishop score is not an indication for cesarean birth; there are several other factors that need to be considered for a cesarean birth. A Bishop score of less than 6 indicates that vaginal birth will be unsuccessful and prolonged because the duration of labor is inversely correlated with the Bishop score.

Four weeks before the birth of a client's already large child, the primary care provider has told the client that if the baby gets bigger and the baby's lungs are ready, the care provider would like to perform a cesarean birth. The woman asks the nurse what the downside is to having a cesarean rather than a vaginal birth. What is an appropriate response by the nurse?

"As the baby passes through the birth canal some of the excess fluid is expelled from the lungs, if that doesn't happen there's a higher risk of respiratory distress."

The mother of a preterm infant tells her nurse that she would like to visit her newborn, who is in the neonatal intensive care unit (NICU). Which of the following would be the most appropriate response by the nurse? a) "I'm sorry. You may not visit your son until he has been released from the NICU." b) "Certainly. You may only observe the child from a distance, however, as his immune system is still not developed adequately." c) "Certainly. You will need to wash your hands and gown before you can hold him, however." d) "I'm sorry. You may not visit the NICU, but we can arrange to have your son brought to your room so that you can hold him."

"Certainly. You will need to wash your hands and gown before you can hold him, however." Correct Explanation: Be certain the parents of a high-risk newborn are kept informed of what is happening with their child. They should be able to visit the special nursing unit to which the newborn is admitted as soon and as often as they choose, and, after washing and gowning, hold and touch their newborn, both actions which help make the child's birth more real to them.

Shoulder dystocia is a true medical emergency that can cause fetal demise because the baby cannot be delivered. Stuck in the birth canal, the infant cannot take its first breath. What is the first maneuver tried to deliver an infant with shoulder dystocia? a) McRonald Maneuver b) McRoberts maneuver c) McGeorge maneuver d) McDonald maneuver

McRoberts maneuver Correct Explanation: McRoberts maneuver is an intervention that is frequently successful in cases of shoulder dystocia, and is often tried first. McRoberts requires the assistance of two individuals. Two nurses are ideal; however, a support person or a technician can serve as the second assistant. With the woman in lithotomy position, each nurse holds one leg and sharply flexes the leg toward the woman's shoulders. This opens the pelvis to its widest diameters and allows the anterior shoulder to deliver in almost half of the cases.

A woman recovering from cesarean birth in the hospital and who was catheterized complains of a feeling of burning on urination and a feeling of frequency. Which of the following should be the next nursing action? a) Suggest that she take an oral analgesic b) Encourage her to drink large amounts of fluid c) Administer amoxicillin, as prescribed d) Obtain a clean-catch urine specimen

Obtain a clean-catch urine specimen

You are assisting with delivery of the second child of a healthy young woman. Her pregnancy has been uneventful, and labor has been progressing well. The fetal head begins to deliver but instead of continuing to emerge, it retracts into the vagina. What should you try first? a) Attempt to push one of the fetus' shoulders in a clockwise or counterclockwise motion. b) McRobert's maneuver c) Apply pressure to the fundus. d) Zavanelli's maneuver

McRobert's maneuver Correct Explanation: This intervention is used with a large baby who may have shoulder dystocia and require 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 delivery. Fundal pressure is contraindicated with shoulder dystocia. It is out of the province of the LVN to attempt delivery of the fetus by pushing one of the fetus' shoulders in a clockwise or counterclockwise motion.

Shoulder dystocia is a true medical emergency that can cause fetal demise because the baby cannot be born. Stuck in the birth canal, the infant cannot take its first breath. What is the first maneuver tried to deliver an infant with shoulder dystocia?

McRoberts maneuver McRoberts maneuver is an intervention that is frequently successful in cases of shoulder dystocia, and it is often tried first. McRoberts requires the assistance of two individuals. Two nurses are ideal; however, a support person or a technician can serve as the second assistant. With the woman in lithotomy position, each nurse holds one leg and sharply flexes the leg toward the woman's shoulders. This opens the pelvis to its widest diameters and allows the anterior shoulder to deliver in almost half of the cases.

Palpate her fundus. Correct Explanation: Palpating the fundus will cause it to contract and reduce bleeding. This makes options A, C, and D incorrect.

A client has just given birth at 42 weeks' gestation. What would the nurse expect to find during her assessment of the neonate? a) Lanugo covering the neonate's body b) A sleepy, lethargic neonate c) Vernix caseosa covering the neonate's body d) Peeling and wrinkling of the neonate's epidermis

Peeling and wrinkling of the neonate's epidermis Correct Explanation: Postdate neonates lose the vernix caseosa, and the epidermis may become peeled and wrinkled. A neonate at 42 weeks' gestation is usually very alert and missing lanugo.

Which of the following instructions should the nurse offer a client as primary preventive measures to prevent mastitis? a) Apply cold compresses to the breast b) Perform handwashing before breastfeeding c) Avoid frequent breastfeeding d) Avoid massaging the breast area

Perform handwashing before breastfeeding

Which of the following instructions should the nurse offer a client as primary preventive measures to prevent mastitis? a) Perform handwashing before breastfeeding b) Avoid massaging the breast area c) Avoid frequent breastfeeding d) Apply cold compresses to the breast

Perform handwashing before breastfeeding Correct Explanation: As a primary preventive measure to prevent mastitis, the nurse should instruct the client to perform good handwashing before breastfeeding. The nurse should instruct the client to frequently breastfeed to prevent engorgement and milk stasis. If the breast is distended before feeding, the nurse should instruct the client to apply cold, not warm, moist heat to the breast. Gently massaging the affected area of the breast also helps.

The nurse is changing the diaper on a newborn and notices that there is a musty smell to the infant's urine. This finding is a characteristic sign of which of the following disorders? a) Turner syndrome b) Phenylketonuria c) Congenital hypothyroidism d) Galactosemia

Phenylketonuria

When preparing to resuscitate a preterm newborn, the nurse would perform which action first?

Place the newborn's head in a neutral position. When preparing to resuscitate a preterm newborn, the nurse should position the head in a neutral position to open the airway. Hyperextending the newborn's neck would most likely close off the airway and is inappropriate. Positive-pressure ventilation is used if the newborn is apneic or gasping or the pulse rate is less than 100 beats per minute. Epinephrine is given if the heart rate is less than 60 beats per minute after 30 seconds of compression and ventilation. p 848

When preparing to resuscitate a preterm newborn, which of the following would the nurse do first? a) Use positive-pressure ventilation. b) Administer epinephrine. c) Hyperextend the newborn's neck. d) Place the newborn's head in a neutral position.

Place the newborn's head in a neutral position. Correct Explanation: When preparing to resuscitate a preterm newborn, the nurse should position the head in a neutral position to open the airway. Hyperextending the newborn's neck would most likely close off the airway and is inappropriate. Positive-pressure ventilation is used if the newborn is apneic or gasping or the pulse rate is less than 100 beats per minute. Epinephrine is given if the heart rate is less than 60 beats per minute after 30 seconds of compression and ventilation.

A patient is 23 weeks gestation and was admitted for induction and delivery after noting the infant was an intrauterine fetal death. The patient had fallen 3 days prior to the diagnosis and landed on her side. What is the most likely attributable cause to the fetal death? a) Placental abruption b) Preeclampsia c) Premature rupture of membranes d) Genetic abnormality

Placental abruption Correct Explanation: The most common cause of fetal death after a trauma is placental abruption, where the placenta separates from the uterus and the fetus is not able to survive. Genetic abnormalities typically cause spontaneous abortion in the first trimester. The scenario does not indicate that there has been a premature rupture of membranes, nor the possibility of preeclamsia.

A nurse is caring for a newborn with a repaired cleft lip. What intervention can the nurse provide to facilitate drainage of mucus and secretions to prevent aspiration? a) Place a wedge under the child's crib. b) Place the child on the abdomen. c) Place the child on the back. d) Position the child on the side.

Position the child on the side.

A nurse is caring for a newborn with a repaired cleft lip. What intervention can the nurse provide to facilitate drainage of mucus and secretions to prevent aspiration?

Position the child on the side. To facilitate drainage of mucus and secretions, the nurse should position the infant on the side, never on the abdomen, after a cleft lip repair.

A preterm infant is placed on ventilatory assistance for respiratory distress syndrome. In light of her lung pathology, which additional ventilatory measure would you anticipate planning? a) Administration of chilled oxygen to reduce lung spasm b) Positive end-expiratory pressure to increase oxygenation c) Increased inspiratory pressure; decreased expiratory pressure d) Administration of dry oxygen to avoid over-humidification

Positive end-expiratory pressure to increase oxygenation Correct Explanation: Positive end-expiratory pressure, like expiratory grunting, prevents alveoli from fully closing on expiration and reduces the respiratory effort needed for inspiration.

Two weeks after their baby is born, Tom calls to report that his wife Sylvia is behaving strangely. She is extremely talkative and energetic and he has not observed her sleeping for more than an hour or two at a time. She is also forgetting to eat and neglecting her appearance, but worse, she seems to barely be aware of the baby's needs and appears surprised when Tom asks her about the child, "As if," Tom says, "she's forgotten that we even have a baby!" You tell him to bring her in right away, because you suspect Sylvia is suffering from what condition? a) Postpartum depression b) Postpartum blues c) Maladjustment d) Postpartum psychosis

Postpartum psychosis

Two weeks after their baby is born, Tom calls to report that his wife Sylvia is behaving strangely. She is extremely talkative and energetic and he has not observed her sleeping for more than an hour or two at a time. She is also forgetting to eat and neglecting her appearance, but worse, she seems to barely be aware of the baby's needs and appears surprised when Tom asks her about the child, "As if," Tom says, "she's forgotten that we even have a baby!" You tell him to bring her in right away, because you suspect Sylvia is suffering from what condition? a) Maladjustment b) Postpartum psychosis c) Postpartum blues d) Postpartum depression

Postpartum psychosis Explanation: Postpartum psychosis can present with a patient in extreme mood changes and odd behavior. Her sudden change in behavior from normal and lack of self care and care for the infant are a sign 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. Maladjustment is a distracter for this question

A client is admitted to the health care facility. The fetus has a gestational age of 42 weeks and is suspected to have cephalopelvic disproportion. Which should the nurse do next?

Prepare the client for a cesarean birth. Cephalopelvic disproportion is associated with postterm pregnancy. This client will not be able to vaginally give birth and should be prepared for a cesarean birth. Lithotomy position, artificial rupture of membranes, and oxytocin are interventions for a vaginal birth. pg 775

The nurse is admitting a client in labor. The care provider determines that the fetus is in a transverse lie and not responsive to Leopold's maneuvers. What intervention should the nurse provide for the client?

Prepare the client for a cesarean birth. If a transverse lie persists, the fetus cannot be born vaginally. The most common method the practitioner uses to diagnose fetal malpresentation is Leopold's maneuvers followed by ultrasound. Sometimes the practitioner notes transverse lie by looking at the contour of the abdomen, which tends to be in the shape of a football, wider side to side than top to bottom. pg 759

The nurse is monitoring a client in labor who has had a previous cesarean section 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 her abdomen and shoulder. What should the nurse prepare to do?

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. Others are reports of pain in the abdomen, shoulder, or back in a laboring woman who had previous good 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.

A client is admitted to the health care facility. The fetus has a gestational age of 42 weeks and is suspected to have cephalopelvic disproportion. Which should the nurse do next?

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

Prepare the patient for a cesarean section. Correct Explanation: 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. Others are reports of pain in the abdomen, shoulder, or back in a laboring woman who had previous good 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 delivery.

A multipara presents to the hospital after 2 hours of labor. The fetus is presenting in transverse lie. You notify the physician and take what action? a) Apply pressure to the woman's lower back with a fisted hand. b) Include a set of piper forceps when you prep the table. c) Assist with Nitrazine and fern tests. d) Prepare to assist with external version or prep for a cesarean section delivery.

Prepare to assist with external version or prep for a cesarean section delivery. Correct 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 or be delivered via a cesarean delivery. Piper forceps are used in the delivery 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. Counter pressure applied to the lower back with a fisted hand sometimes helps the woman to cope with the "back labor" that is characteristic of occiput posterior positioning

A nurse is assigned to care for a newborn with esophageal atresia. What priority preoperative nursing care is the priority for this newborn? a) Prevent aspiration by elevating the head of the bed and insert an NG tube to low suction b) Administer antibiotics and total parenteral nutrition as ordered c) Provide NG feedings only d) Document the amount and color of esophageal drainage

Prevent aspiration by elevating the head of the bed and insert an NG tube to low suction

A nurse is working with a child who has spina bifida. The highest priority nursing goal for this child would be which of the following? a) Providing caregiver teaching b) Reducing family anxiety c) Promoting comfort measures d) Preventing infection

Preventing infection

The second-year nursing student taking an obstetrics course correctly attributes which descriptions to the term dystocia? Select all that apply.

Progress of labor deviates from normal. Labor is slow. Dystocia is said to exist when the progress of labor deviates from normal and is slow.

A newborn is being monitored for retinopathy of prematurity. Which of the following conditions predisposes an infant to this condition? a) Esophageal atresia b) Down syndrome c) Respiratory distress syndrome d) Hydrocephalus

Respiratory distress syndrome Correct Explanation: Retinopathy of prematurity (ROP) is a complication that can occur when high concentrations of oxygen are given during the course of treatment for respiratory distress syndrome (RDS). ROP is caused by separation and fibrosis of the retinal blood vessels and can often result in blindness.

A preterm newborn receives oxygen therapy to treat respiratory distress syndrome (RDS). Which complication should the nurse consider a result of oxygen administration at a high concentration?

Retinopathy of prematurity Retinopathy of prematurity can occur as a complication associated with the use of high concentrations of oxygen. High concentrations of oxygen can damage the fragile retinal blood vessels of the preterm infants and cause retinopathy. Bronchopulmonary dysplasia, diminished erythropoiesis, and necrotizing enterocolitis are not complications associated with a high concentration of oxygen. Bronchopulmonary dysplasia is a chronic lung disease that results from the effect of long-term mechanical ventilation. Diminished erythropoiesis in the preterm newborn is due to immaturity of the hemopoietic system. Necrotizing enterocolitis is associated with ischemia of the bowel, leading to necrosis and perforation.

A preterm newborn receives oxygen therapy to treat respiratory distress syndrome (RDS). Which of the following should the nurse consider as a complication of oxygen administration at a high concentration? a) Retinopathy of prematurity b) Diminished erythropoiesis c) Bronchopulmonary dysplasia d) Necrotizing enterocolitis

Retinopathy of prematurity Correct Explanation: Retinopathy of prematurity can occur as a complication associated with the use of high concentrations of oxygen. High concentrations of oxygen can damage the fragile retinal blood vessels of the preterm infants and cause retinopathy. Bronchopulmonary dysplasia, diminished erythropoiesis, and necrotizing enterocolitis are not complications associated with a high concentration of oxygen. Bronchopulmonary dysplasia is a chronic lung disease that results from the effect of long-term mechanical ventilation. Diminished erythropoiesis in the preterm newborn is due to immaturity of the hemopoietic system. Necrotizing enterocolitis is associated with ischemia of the bowel, leading to necrosis and perforation.

The nurse is giving an educational presentation to the local Le Leche league chapter. One woman asks about mastitis. What would be the nurse's best response?

Risk factors include nipple piercing. Certain risk factors contribute to the development of mastitis. These include: inadequate or incomplete breast emptying during feeding or lack of frequent feeding leading to milk stasis; engorgement; clogged milk ducts; cracked or bleeding nipples; nipple piercing; and use of plastic-backed breast pads.

You are the nurse giving an educational presentation to the local Le Leche league chapter. One woman asks you about mastitis. What would be your best response? a) Risk factors include nipple piercing. b) Risk factors include complete emptying of the breast c) Risk factors include breast pumps. d) Risk factors include frequent feeding.

Risk factors include nipple piercing. Correct Explanation: Certain risk factors contribute to the development of mastitis. These include: inadequate or incomplete breast emptying during feeding or lack of frequent feeding leading to milk stasis; engorgement; clogged milk ducts; cracked or bleeding nipples; nipple piercing; use of plastic-backed breast pads.

A woman arrives at the office for her 4-week postpartal visit. Her uterus is still enlarged and soft, and lochial discharge is still present. Which of the following is the most likely nursing diagnosis for this patient? a) Risk for infection related to microorganism invasion of episiotomy b) Risk for fatigue related to chronic bleeding due to subinvolution c) Ineffective peripheral tissue perfusion related to interference with circulation secondary to development of thrombophlebitis d) Risk for impaired breastfeeding related to development of mastitis

Risk for fatigue related to chronic bleeding due to subinvolution

Jerry, who is hypertensive and who received corticosteroids during pregnancy, delivered by cesarean and subsequently developed endometritis. Her incision is red, warm, and very sensitive to touch, and she remains febrile despite antibiotic therapy. What is the most important aspect of post hospital care to teach her? a) Wound care and hand washing b) Use of warm compresses and sitz baths c) Proper perineal care d) Strict adherence to antibiotic therapy

Wound care and hand washing Correct Explanation: The use of systemic corticosteroids prior to delivery has increased her risk for development of an infection. She has been treated for endometritis and is now at greater risk for infection. Hand washing is the best defense again transmission of any infection. While adherence to antibiotic therapy, proper perineal care, and use of warm compresses and sitz baths may be indicated, they would not be a higher priority than wound care and hand-washing.

An infant has just been born with a cleft lip and palate. The birthing room suddenly becomes very quiet, and the birth team seem somber. The health care provider is busy examining the newborn, but the mother is obviously aware that something is not right. What should the nurse do?

Say to the parents, "Your son has been born with a cleft lip and palate. This condition is highly treatable by surgery, however, and he is otherwise in excellent health." Nurses need to be familiar with the most frequently encountered physical or developmental anomalies which are present at birth so, as the person who at that moment in the birth process is most available for client education, they can explain the problem to parents. It is a good rule to explain to parents what the disorder consists of and what the usual prognosis is before showing the baby to them as parents may find it hard to look at an infant with a cleft lip or palate or exposed abdominal contents, for example, and listen at the same time.

The parents of an infant with congenital club foot question the nurse about what the treatment will be to address this problem. What initial treatment plan would the nurse explain to the parents? a) Initiation of physical therapy b) Immediate surgery to straighten the ankle c) Application of bilateral braces d) Serial casting

Serial casting

The parents of an infant with congenital club foot question the nurse about what the treatment will be to address this problem. What initial treatment plan would the nurse explain to the parents? a) Serial casting b) Application of bilateral braces c) Initiation of physical therapy d) Immediate surgery to straighten the ankle

Serial casting

The nurse would prepare a client for amnioinfusion when which of the following occurs? a) Fetal presenting part fails to rotate fully and descend in the pelvis b) Maternal pushing is compromised due to anesthesia c) The fetus shows non-reassuring fetal heart rate patterns d) Severe variable decelerations are due to cord compression

Severe variable decelerations are due to cord compression Correct Explanation: Indications for amnioinfusion include severe variable decelerations resulting from cord compression, oligohydramnios (decreased amniotic fluid), postmaturity, preterm labor with rupture of the membranes, and thick meconium fluid. Failure of the fetal presenting part to rotate fully, descend in the pelvis, non-reassuring fetal heart rate patterns or acute pulmonary edema, and compromised maternal pushing sensations from anesthesia are indications for forceps-assisted birth, and not for amniofusion.

Which recommendation should be given to a client with mastitis who's concerned about breast-feeding her neonate? a) She should stop breast-feeding until completing the antibiotic b) She shouldn't use analgesics because they aren't compatible with breastfeeding c) She should supplement feeding with formula until the infection resolves d) She should continue to breast-feed; mastitis won't infect the neonate

She should continue to breast-feed; mastitis won't infect the neonate

Which recommendation should be given to a client with mastitis who's concerned about breast-feeding her neonate? a) She should stop breast-feeding until completing the antibiotic b) She should continue to breast-feed; mastitis won't infect the neonate c) She should supplement feeding with formula until the infection resolves d) She shouldn't use analgesics because they aren't compatible with breastfeeding

She should continue to breast-feed; mastitis won't infect the neonate Explanation: The client with mastitis should be encouraged to continue breast-feeding while taking antibiotics for the infection. No supplemental feedings are necessary because breastfeeding doesn't need to be altered and actually encourages resolution of the infection. Analgesics are safe and should be administered as needed

A nurse is caring for a newborn with jaundice undergoing phototherapy. What intervention is appropriate when caring for the newborn?

Shield the newborn's eyes The nurse should shield the newborn's eyes and cover the genitals to protect these areas from becoming irritated or burned when using direct lights and to ensure exposure of the greatest surface area. The nurse should place the newborn under the lights or on the fiberoptic blanket, exposing as much skin as possible. Breast or bottle feedings should be encouraged every 2 to 3 hours. Loose, green, and frequent stools indicate the presence of unconjugated bilirubin in the feces. This is normal; therefore, there is no need for therapy to be discontinued. Lack of frequent green stools is a cause for concern.

A nurse is caring for a postpartum client who has been treated for deep vein thrombosis (DVT). Which prescription would the nurse question?

Take an oral contraceptive daily. When caring for a client with DVT, the nurse should instruct the client to avoid using oral contraceptives. Cigarette smoking, use of oral contraceptives, sedentary lifestyle, and obesity increase the risk for developing DVT. The nurse should encourage the client with DVT to wear compression stockings. The nurse should instruct the client to avoid using products containing aspirin when caring for clients with bleeding, but not for clients with DVT. Prolonged rest periods should be avoided. Prolonged rest involves staying motionless; this could lead to venous stasis, which needs to be avoided in cases of DVT.

Tell her that the hospital will keep the photos for her in case she changes her mind. Emotional care of the woman is complex. The woman may 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 delivery. 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.

A newborn is suspected of having gastroschisis at birth. How would the nurse differentiate this problem from other congenital defects? a) The umbilical cord comes out of middle of the defect b) The intestines appear reddened and swollen and have no sac around them c) The abdominal contents are contained within a thin, transparent sac d) The skin over the abdomen is wrinkled and looks like a prune

The intestines appear reddened and swollen and have no sac around them

The nurse is caring for a newborn who was small for gestational age and has been determined to have the condition intrauterine growth restriction (IUGR). Which of the following factors would most likely have contributed to this condition? a) The mother of this newborn has a history of abnormal blood glucose levels b) The mother of this newborn was on a food stamp program during pregnancy c) The mother of this newborn has been pregnant 3 previous times d) The mother of this newborn smoked until 4 years ago

The mother of this newborn has a history of abnormal blood glucose levels

The nurse is caring for a newborn who was small for gestational age and has been determined to have the condition intrauterine growth restriction (IUGR). Which of the following factors would most likely have contributed to this condition? a) The mother of this newborn smoked until 4 years ago b) The mother of this newborn has been pregnant 3 previous times c) The mother of this newborn has a history of abnormal blood glucose levels d) The mother of this newborn was on a food stamp program during pregnancy

The mother of this newborn has a history of abnormal blood glucose levels

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

The myometrium becomes sensitive from the lack of relaxation and anoxia of uterine cells. Correct Explanation: Hypertonic contractions cause uterine cell anoxia, which is painful. Therefore options A, C, and D are incorrect.

A neonate born at 40 weeks' gestation, weighing 2300 grams (5 lb, 1 oz) is admitted to the newborn nursery for observation only. What is the nurse's first observation about the infant?

The neonate is small for its gestational age. Small for gestational age (SGA) describes newborns that typically weigh less than 2,500 g (5 lb, 8 oz) at term due to less growth than expected in utero. A newborn is also classified as SGA if his or her birthweight is at or below the 10th percentile as correlated with the number of weeks of gestation. In some SGA newborns, the rate of growth does not meet the expected growth pattern. These infants are considered to have fetal growth restriction resulting in pathology. pg 834

A nurse is assessing a newly admitted newborn who is 2 hours old. Which assessment findings would concern the nurse? Select all that apply.

The newborn has visible bilateral nasal flaring. The newborn has visible chest retractions The signs and symptoms of respiratory distress include tachypnea, periodic breathing, apnea, retractions, nasal flaring, grunting, pallor, and cyanosis. These findings require interventions. The blue hands and feet, apical pulse rate, and minimal response to voices are all appropriate for a newborn who is two hours old.

A 20-year-old client gave birth to a baby boy during the 43rd week of gestation. Which of the following might the nurse observe in the newborn during routine assessment? a) The testes in the child may be undescended. b) The newborn may have short nails and hair. c) The infant may have excess of lanugo and vernix caseosa. d) The newborn may look wrinkled and old at birth.

The newborn may look wrinkled and old at birth.

A 20-year-old client gave birth to a baby boy during the 43rd week of gestation. Which of the following might the nurse observe in the newborn during routine assessment? a) The newborn may have short nails and hair. b) The newborn may look wrinkled and old at birth. c) The testes in the child may be undescended. d) The infant may have excess of lanugo and vernix caseosa.

The newborn may look wrinkled and old at birth. Correct Explanation: Postterm babies are those born past 42 weeks of gestation. These babies often appear wrinkled and old at birth. They often have long fingernails and hair, dry parched skin, and no vernix caseosa. Both the quantity of lanugo and the amount of vernix decrease with gestational age. Undescended testes are usually not seen in postterm newborns; however, they are highly prevalent in preterm infants

A 20-year-old client gave birth to a baby boy during the 43rd week of gestation. Which of the following might the nurse observe in the newborn during routine assessment? a) The newborn may have short nails and hair. b) The infant may have excess of lanugo and vernix caseosa. c) The testes in the child may be undescended. d) The newborn may look wrinkled and old at birth.

The nurse is reinforcing discharge teaching with the mother of an infant who is being discharged prior to having a required blood test done. The nurse explains to this mother that she needs to bring the newborn back to check the infant's phenylalanine level. Which of the following is most accurate related to this blood test? a) It is common to perform this test after the newborn is five days old. b) The test is done after the newborn has ingested protein. c) If the test is not done the newborn could be mentally retarded. d) The test is done by drawing blood from the infant's umbilical cord.

The test is done after the newborn has ingested protein.

The test is done after the newborn has ingested protein. As soon as the newborn with phenylketonuria begins to take milk, phenylalanine builds up in the blood serum to as much as 20 times the normal level. This build-up occurs so quickly that increased levels of phenylalanine appear in the blood after only one or two days of ingestion of milk.

A client and her infant are being discharged home after an unplanned cesarean birth. The nurse explains to her that she is at a higher risk for postpartum infection than most clients. What is the major risk factor for a postpartum infection?

a nonelective cesarean birth The major risk factor for postpartum infection is a nonelective cesarean birth. Antepartum risk factors include history of infection; history of chronic conditions, such as diabetes, anemia, or poor nutrition; infections of the genital tract; smoking; and obesity.

In the infant diagnosed with spina bifida with myelomeningocele, the infant will likely have:

a partial to complete paralysis in the lower extremities. In spina bifida with myelomeningocele, there is a protrusion of the spinal cord and the meninges, with nerve roots embedded in the wall of the cyst. The effects of this defect vary in severity from sensory loss or partial paralysis below the lesion to complete flaccid paralysis of all muscles below the lesion.

As the nurse examines the birth records, which newborn would the nurse expect to monitor closely for respiratory distress syndrome (RDS)?

a term male newborn, born by a repeat cesarean birth, whose mother has diabetes mellitus It is necessary to review the maternal history for risk factors associated with RDS. Risk factors in the term infant placing the infant at most risk include a cesarean birth in the absence of preceding labor, male gender, and maternal diabetes, which produces high levels of insulin which inhibit surfactant production. The other infant situations would not be the priority.

Which woman should you suspect of having endometritis? a) A woman with diabetes who has delivered vaginally and develops tachycardia and a fever of 101.7 degrees on the third postpartum day. The next day, she appears ill; fever is 102.9 degrees; WBC is 31,500 cells/mm3; blood cultures are negative. b) A woman with a history of infection and smoking who develops a temperature of 101 degrees on the fourth postpartum day. She reports severe perineal pain. The edges of the episiotomy have separated. c) An obese woman who has a temperature of 100.4 degrees at 12 hours after delivery. Her lochia is moderate; vaginal cultures are negative. d) A woman with PROM before delivery complains of severe burning with urination, malaise and severe temperature spikes on the seventh postpartum day. WBC is 21,850cells/mm3; temperature is 101 degrees; and her skin is pale and clammy.

a)A woman with diabetes who has delivered vaginally and develops tachycardia and a fever of 101.7 degrees on the third postpartum day. The next day, she appears ill; fever is 102.9 degrees; WBC is 31,500 cells/mm3; blood cultures are negative. Explanation: Endometritis is an infection of the endometrium of the uterus. The woman has an very elevated temp greater than 24 hours after delivery and high WBC. She would be treated for infection and monitored. Therefore options B, C, and D are incorrect.

Which of the following would the nurse use to monitor the effectiveness of intravenous anticoagulant therapy for a postpartum woman with deep vein thrombosis? a) Activated partial thromboplastin time b) Prothrombin time c) Platelet level d) Fibrinogen level

a)Activated partial thromboplastin time Explanation: The activated partial thromboplastin time is used to monitor the effectiveness of intravenous anticoagulant therapy, most commonly heparin. Prothrombin time is used to monitor the effectiveness of the oral anticoagulant warfarin. Although platelets and fibrinogen are involved in blood clotting, they are not used to monitor the effectiveness of intravenous anticoagulant therapy.

On examining a woman who gave birth 5 hours ago, the nurse finds that the woman has completely saturated a perineal pad within 15 minutes. Which action by the nurse should be implemented first? a) Assess the woman's fundus. b) Begin an IV infusion of Ringer's lactate solution. c) Call the woman's health care provider. d) Assess the woman's vital signs.

a)Assess the woman's fundus. Explanation: In order to have a suggested idea of the location of the bleeding the nurse would need to assess the funds of the patient first. Although all actions may be appropriate, they would not have the priority of fundal assessment.

You are conducting discharge teaching with a postpartum woman. What would be an important instruction for this patient? a) Call her caregiver if lochia moves from serosa to rubra. b) Call her caregiver if lochia moves from rubra to serosa. c) Call her caregiver if lochia moves from serosa to alba. d) Call her caregiver if amount of lochia decreases.

a)Call her caregiver if lochia moves from serosa to rubra. Explanation: Most cases of late postpartum hemorrhage occur after the woman leaves the health care or birthing facility. Therefore, patient 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).

It is discovered that a new mother has developed a puerperal infection. Which of the following is the most likely expected outcome that the nurse will identify for this patient related to this condition? a) Client's temperature remains below 100.4° F or 38° C orally b) Fundus remains firm and midline with progressive descent c) Lochia discharge amount is 6 inches or less on a perineal pad in 1 hour d) Client maintains a urinary output greater than 30 mL per hour

a)Client's temperature remains below 100.4° F or 38° C orally Explanation: As fever would accompany a puerperal 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 puerperal infection as does the reduced temperature.

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

a)Endometritis Explanation: The woman with endometritis typically looks ill and commonly develops a fever of 100.4°F (38°C) or higher (more commonly 101°F [38.4°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.

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

a)Escherichia coli Explanation: 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 metritis, but some species of Klebsiella may cause urinary tract infections.

A 35-year-old G2, P2 client presents to her postpartum appointment with vague complaints. The nurse suspects postpartum depression after the client expresses all except which of the following? a)Feels like eating all the time b)Change in sleep c)Appears detached from infant d)Lack of energy and motivation

a)Feels like eating all the time Explanation: Some signs and symptoms of postpartum depression include feeling restless, worthless, guilty, hopeless, moody, sad, overwhelmed, cry a lot, exhibit a lack of energy and motivation, experience a lack of pleasure, changes in appetite, sleep, or weight, withdraw from friends and family, feel negatively toward her baby, or shows lack of interest in her baby.

Various medications are available to help control hemorrhage in the postpartum client. When reviewing the client's history, the nurse notes she has a history of asthma. Which of the following medications would be contraindicated in her case? a)Hemabate b)Cytotec c)Methergine d)Pitocin

a)Hemabate Explanation: Hemabate is contraindicated with asthma due to the risk of bronchial spasms. Pitocin should be given undiluted as a bolus injection, Cytotec should not be given to women with active CVD, pulmonary or hepatic disease, and Methergine should not be given to a woman who is hypertensive.

The nurse is assessing the breast of a woman who is 1 month postpartum. The woman is complaining of a painful area on one breast with a red area. The nurse notes a local area on one breast, red and warm to touch. Which of the following should the nurse suspect is the potential diagnosis? a) Mastitis b) Engorgement c) Plugged milk duct d) Breast yeast

a)Mastitis Explanation: Mastitis usually occurs 2-3 weeks after delivery and is noted to be unilateral. Mastitis needs to be assessed and treated with antibiotic therapy. The scenario described is not indicative of a plugged milk duct or engorgement. Breast yeast is a distracter for this question.

Which recommendation should be given to a client with mastitis who's concerned about breast-feeding her neonate? a) She should continue to breast-feed; mastitis won't infect the neonate b) She should supplement feeding with formula until the infection resolves c) She should stop breast-feeding until completing the antibiotic d) She shouldn't use analgesics because they aren't compatible with breastfeeding

a)She should continue to breast-feed; mastitis won't infect the neonate Explanation: The client with mastitis should be encouraged to continue breast-feeding while taking antibiotics for the infection. No supplemental feedings are necessary because breastfeeding doesn't need to be altered and actually encourages resolution of the infection. Analgesics are safe and should be administered as needed.

The nurse is teaching a client about mastitis. Which statement should the nurse include in her teaching? a) Symptoms include fever, chills, malaise, and localized breast tenderness b) The most common pathogen is group A beta-hemolytic streptococci c) Mastitis usually develops in both breasts of a breast-feeding client d) A breast abscess is a common complication of mastitis

a)Symptoms include fever, chills, malaise, and localized breast tenderness Explanation: Mastitis is an infection of the breast characterized by flulike symptoms, along with redness and tenderness in the breast. The most common causative agent is Staphylococcus aureus. Breast abscess is rarely a complication of mastitis if the client continues to empty the affected breast. Mastitis usually occurs in one breast, not bilaterally.

A fundal massage is sometimes performed on a postpartum woman. Which of the following is a reason for performing a fundal massage? a) Uterine atony b) Uterine contraction c) Uterine prolapse d) Uterine subinvolution

a)Uterine atony Explanation: 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.

A nurse is assigned to care for a client with a uterine prolapse. Which of the following would be most important for the nurse to assess when determining the severity of the prolapse? a) Uterine bleeding present b) Foul smelling lochia c) Pain in the lower abdomen d) Uterine protrusion into the vagina

a)Uterine protrusion into the vagina Explanation: To determine if the uterine prolapse in the client is mild or severe, the nurse should assess for uterine protrusion of the cervix and uterus into the vagina. As more of the uterus descends, the vagina becomes inverted. Uterine bleeding, foul-smelling lochia, and pain or tenderness in the lower abdomen are all characteristic manifestations of late postpartum hemorrhage.

When examining a newborn for developmental hip dysplasia, which motion would the newborn's hip be unable to accomplish?

abduction

What is a typical feature of a small for gestational age (SGA) newborn that differentiates it from a preterm baby with a low birth weight?

ability to tolerate early oral feeding Unlike preterm babies with low birth weights, a small for gestational age baby can safely tolerate early oral feeding. It usually has a coordinated sucking and swallowing reflex. Decreased muscle mass, decreased body temperature, and an angular and pinched face are features common to both an SGA and a preterm baby.

Disseminated intravascular coagulation is a life-threatening condition that the nurse recognizes can occur as a complication secondary to which primary conditions? Select all that apply.

abruptio placenta severe preeclampsia septicemia DIC is always a secondary diagnosis that occurs as a complication of abruptio placenta, amniotic fluid embolism, intrauterine fetal death with prolonged retention of the fetus, severe preeclampsia, HELLP syndrome, septicemia, and hemorrhage.

A woman experiences an amniotic fluid embolism as the placenta is delivered. The nurse's first action would be to:

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 nurse assesses a client in labor and suspects hypotonic uterine dysfunction. Which intervention would the nurse expect to include in the plan of care for this client?

administering oxytocin Oxytocin would be appropriate for the woman experiencing hypotonic uterine dysfunction (problem with the powers). 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 with hypertonic uterine dysfunction to augment labor. A hands-and-knees position helps to promote fetal head rotation with a persistent occiput posterior position.

After an hour of oxytocin therapy, a woman in labor states she feels dizzy and nauseated. The nurse's best action would be to:

assess the rate of flow of the oxytocin infusion. A toxic effect of oxytocin therapy is water intoxication. Symptoms include dizziness and nausea. Assessing and slowing the infusion rate will relieve symptoms.

After an hour of oxytocin therapy, a woman in labor states she feels dizzy and nauseated. Your best action would be to a) administer oral orange juice for added potassium. b) assess her vaginally for full dilation. c) assess the rate of flow of the oxytocin infusion. d) instruct her to breathe in and out rapidly.

assess the rate of flow of the oxytocin infusion. Correct Explanation: A toxic effect of oxytocin therapy is water intoxication. Symptoms include dizziness and nausea. Assessing and slowing the infusion rate will relieve symptoms.

What are the causes of retinopathy of the preterm newborn? Select all that apply.

assistive ventilation with high oxygen content fragility of blood vessels in the eyes in response to changes on oxygenation. shock Retinopathy of the preterm newborn typically develops in both the eyes secondary to an injury such as hyperoxemia resulting from prolonged assistive ventilation and high oxygen exposure, fragility of retinal blood vessels in response to changes in oxygentaion, and shock. Alkalosis does not contribute to this problem- acidosis does.

What objective data gathered by the nurse could indicate a diagnosis of developmental dysplasia of the hip? Select all that apply.

asymmetry of the gluteal skin folds limited abduction of the affected hip apparent shortening of the femur Signs that are useful after age 1 month are asymmetry of the gluteal skin folds, limited abduction of the affected hip, and apparent shortening of the femur.

Which of the following assessments would lead you to believe a postpartal woman is developing a urinary complication? a) Her perineum is obviously edematous on inspection. b) At 8 hours postdelivery she has voided a total of 100 mL in four small voidings. c) She has voided a total of 1000 mL in two voidings, each spaced 1 hour apart. d) She tells you she is extremely thirsty.

b) At 8 hours postdelivery she has voided a total of 100 mL in four small voidings. Explanation: Postpartal women who void in small amounts may be experiencing bladder overflow from retention

Retention of placental fragments commonly leads to hypertension. a) False b) True

b) True

When teaching a postpartum woman about possible complications during this time, the nurse would include information about which of the following as a possible effect? a) Ineffectiveness of breast-feeding b) Interference with the maternal-newborn attachment process c) Delayed development of the newborn d) Alteration in normal maternal hormonal function

b)Interference with the maternal-newborn attachment process Explanation: The nurse would include information that maternal postpartum complications affect not only the health status of the woman, but also that of the newborn by potentially interfering with the maternal-newborn attachment process. Furthermore, they can disrupt the dynamics of the entire family, with health-related, fiscal, and emotional effects and costs. Maternal postpartum complications are not known to result in ineffective breast-feeding, delayed development of the newborn, or altered maternal hormonal function.

An Rh-positive client vaginally delivers a 6-lb, 10-oz neonate after 17 hours of labor. Which condition puts this client at risk for infection? a) Method of delivery b) Length of labor c) Size of the neonate d) Maternal Rh status

b)Length of labor Explanation: A prolonged length of labor places the mother at increased risk for developing an infection. The average size of the neonate, vaginal delivery, and Rh status of the client don't place the mother at increased risk

When monitoring a postpartum client 2 hours after delivery, the nurse notices heavy bleeding with large clots. Which response is most appropriate initially? a) Administering ergonovine (Ergotrate) b) Massaging the fundus firmly c) Notifying the primary health care provider d) Performing bimanual compressions

b)Massaging the fundus firmly Explanation: Initial management of excessive postpartum bleeding is firm massage of the fundus and administration of oxytocin (Pitocin). Bimanual compression is performed by a primary health care provider. Ergotrate should be used only if the bleeding doesn't respond to massage and oxytocin. The primary health care provider should be notified if the client doesn't respond to fundal massage, but other measures can be taken in the meantime.

After teaching a class on ways to decrease the postpartum complication of thrombotic conditions, the nurse recognizes more teaching is needed when one of the participants states: a)"Using passive range-of-motion exercises in bed sounds easy enough." b)"At least, I don't have to give up smoking for this one." c)"He has to do the deep breathing exercises with me." d)"I can drink more, so I don't get dehydrated."

b)"At least, I don't have to give up smoking for this one." Explanation: Preventing thrombotic conditions is an important aspect of postpartum care and proper nursing management. There are many simple measures that can be utilized, to include encouraging leg exercises and walking; using intermittent sequential compression devices; stopping smoking to reduce or prevent vascular vasoconstriction; using compression stockings; performing passive range-of-motion exercises while in bed; using postoperative deep breathing exercises to improve venous return; and increasing fluid intake to prevent dehydration.

After teaching a local woman's group about postpartum affective disorders, which statement by the group indicates that the teaching was successful? a) "Postpartum blues usually resolves by the 4th or 5th postpartum day." b) "Postpartum depression develops gradually, appearing within the first 6 weeks." c) "Postpartum psychosis usually appears soon after the woman comes home." d) "Postpartum psychosis usually involves psychotropic drugs but not hospitalization."

b)"Postpartum depression develops gradually, appearing within the first 6 weeks." Explanation: Postpartum depression usually has a more gradual onset, becoming evident within the first 6 weeks postpartum. Postpartum blues usually peaks on the 4th to 5th postpartum day and resolves by the 10th day. Postpartum psychosis generally surfaces within 3 weeks of giving birth. Treatment typically involves hospitalization for up to several months. Psychotropic drugs are almost always a part of treatment, along with individual psychotherapy and support group therapy

When treating a postpartum woman for hemorrhage, the nurse will prepare the client for a blood transfusion once the estimates of blood loss reach which level? a)1,000mL b)1,500mL c)1,750mL d)1,250mL

b)1,500mL Explanation: Once estimates of blood loss reach 1,500 mL, transfusion of blood products should be instituted immediately.

On the third day postpartum, which temperature is internationally defined as a postpartal infection? a) 99.6°F (37.5°C) b) 100.4°F (38°C) c) 102.4°F (39.1°C) d) 104.2°F (40.1°C)

b)100.4°F (38°C) Explanation: A temperature over 100.4°F (38°C) past the first day postpartum is suggestive of infection.

b)Absent verbalization about the birthing process. Explanation: After delivery the woman would be excited and interested in the delivery and the infant. A woman may be tired and to ask for sleep is also expected, unexpected is the absent verbalization of the activities and birth. Therefore options A, C, and D are incorrect answers.

When diagnosed with a deep vein thrombosis, the nurse knows the patient will be treated with which medication? a) Non-steroidal inflammatory b) Anticoagulants c) Narcotic analgesics d) Beta blockers

b)Anticoagulants Explanation: Anticoagulant therapy is used as the primary treatment option for DVT. This makes options A, C, and D incorrect.

A postpartal woman is developing a thrombophlebitis in her right leg. Which of the following assessments would you make to detect this? a) Ask her to raise her foot and draw a circle. b) Dorsiflex her right foot and ask if she has pain in her calf. c) Bend her knee and palpate her calf for pain. d) Blanch a toe and count the seconds it takes to color again.

b)Dorsiflex her right foot and ask if she has pain in her calf. Explanation: A Homans' sign (pain in the calf on dorsiflexion of the foot) is a common assessment for thrombophlebitis in conjunction with assessing for edema and calf redness. Having her raise her foot and draw a circle would not be an assessment for thrombophlebitis in her leg, nor would assessing capillary refill in a toe.

The majority of women who experience postpartal psychosis had no symptoms of mental illness before pregnancy. a) True b) False

b)False Explanation: The majority of women who experience postpartal psychosis had symptoms of mental illness before pregnancy.

The nurse is assisting a client in completing the Postpartum Depression Screening Scale tool to assess for postpartum depression. Which of the following is least likely to be screened with this tool? a)Emotional liability b)Family and social support system c)Guilt d)Cognitive impairment

b)Family and social support system Explanation: The Postpartum Depression Screening Scale is divided into seven conceptual domains: anxiety/insecurity; sleep/eating disturbance/ emotional liability; loss of self-esteem; guilt/shame/ cognitive impairment; and suicidal thoughts.

About 10 days following birth, a new mother visits her physician with localized symptoms of redness, swelling, warmth, and a hard inflamed vessel in one leg. The nurse should suspect which of the following conditions? a) Subinvolution b) Femoral thrombophlebitis c) Mastitis d) Uterine atony

b)Femoral thrombophlebitis Explanation: A woman experiencing a femoral thrombophlebitis will usually have unilateral localized symptoms such as redness, swelling, warmth, and a hard inflamed vessel in the affected leg. Symptoms for thrombophlebitis usually present about 10 days after birth. Symptoms of uterine atony are a soft fundus and hemorrhage from the vagina. Symptoms of mastitis, infection of the breast, include a painful, swollen, reddened breast; fever; and scant breast milk. Symptoms of subinvolution include an enlarged, soft uterus and lochial discharge.

In preparing for a class in teaching women and their partners, which of the following would be the most important to emphasize as helping to prevent postpartum complications? a)Adequate follow-up with their health care provider b)Handwashing c)Ensure proper hydration d)Limiting contact with outsiders for the first week

b)Handwashing Explanation: Stressing proper handwashing, especially after perineal care and before and after breast-feeding will help to decrease the chances of infection and complications accompanying it.

You administer methylergonovine (Methergine) 0.2 mg to a postpartal woman with uterine subinvolution. Which of the following assessments should you make prior to administering the medication? a) She can walk without experiencing dizziness. b) Her blood pressure is below 140/90. c) Her urine output is over 50 mL/h. d) Her hematocrit level is over 45%.

b)Her blood pressure is below 140/90. Explanation: Methylergonovine elevates blood pressure. It is important to assess that it is not already elevated before administration.

Which assessment on the third postpartal day would make you evaluate a woman as having uterine subinvolution? a) Her uterus is three finger widths under the umbilicus. b) Her uterus is at the level of the umbilicus. c) Her uterus is 2 cm above the symphysis pubis. d) She experiences "pulling" pain while breastfeeding.

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

The nurse is teaching a group of students about factors that place a pregnant woman at risk for infection in the postpartum period. Which of the following would the nurse be least likely to include? a) Loss of protection with premature rupture of membranes b) Increased vaginal acidity leading to growth of bacteria c) Prolonged labor with multiple vaginal examinations to evaluate progress d) Retained placental fragments

b)Increased vaginal acidity leading to growth of bacteria Explanation: Vaginal acidity is decreased due to the presence of amniotic fluid, blood, and lochia, all of which are alkaline. An alkaline environment encourages the growth of bacteria. With rupture of membranes, the barrier is removed, allowing bacteria to ascend through the internal genital structures. A prolonged labor with multiple vaginal examinations provides opportunities for exposure to organisms, with time for the bacteria to multiply. Retained placental fragments provide an excellent medium for bacterial growth.

Samantha delivered her fourth child after protracted and difficult labor during which oxytocin was used to augment her contractions. The next day, her vaginal bleeding continues to be moderately heavy with numerous large clots. Palpating her fundus, you find that it is in the midline but boggy and above the level of the umbilicus. Fundal massage is indicated; what should you do first? a) Ensure that her bladder is empty. b) Place one hand over the symphysis pubis. c) Insert uterine packing to control the hemorrhage. d) Seek an order to obtain and administer an oxytocic.

b)Place one hand over the symphysis pubis. Explanation: A boggy fundus with active bleedings and clots the day after delivery is indicative of uterus atony. The nurse should prepare to initiate fundal massage.The first step in this procedure is to place one had over the symphysis pubis. The first step in fundal massage is not to ensure that the patient's bladder is empty, seek an order for an oxytocic, nor insert uterine packing.

Methylergonovine is ordered for a woman experiencing postpartum hemorrhage. The nurse monitors the woman closely for which of the following adverse effects? a) Headache b) Seizures c) Uterine hyperstimulation d) Flushing

b)Seizures Explanation: Seizures, hypertension, uterine cramping, nausea, vomiting, and palpitations are adverse effects of methylergonovine. Uterine hyperstimulation is an adverse effect of oxytocin. Flushing and headache are adverse effects of carboprost.

Which factor puts a multiparous client on her first postpartum day at risk for developing hemorrhage? a) Moderate amount of lochia rubra b) Uterine atony c) Thrombophlebitis d) Hemoglobin level of 12 g/dl

b)Uterine atony Explanation: Multiparous women typically experience a loss of uterine tone due to frequent distentions of the uterus from previous pregnancies. As a result, this client is also at higher risk for hemorrhage. Thrombophlebitis doesn't increase the risk of hemorrhage during the postpartum period. The hemoglobin level and lochia flow are within acceptable limits.

A woman is two 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?

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 [38.4° 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

The nursing student correctly identifies which risk factors for developing dystocia? Select all that apply.

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, ineffetive 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.

A nurse in the newborn nursery has noticed that an infant is frothing and appears to have excessive drooling. Further assessment reveals that the baby has episodes of respiratory distress with choking and cyanosis. What disorder should the nurse suspect based on these findings?

esophageal atresia

The nurse is feeding a 2-day-old in the nursery when the infant begins choking and becomes cyanotic. Frothy sputum is observed coming from the mouth. What congenital malformation does the nurse understand these symptoms indicate?

esophageal atresia Any mucus or fluid that a newborn with esophageal atresial swallows enters the blind pouch of the esophagus. The pouch fills and overflows, usually resulting in aspiration into the trachea. The newborn with this disorder has frothing, excessive drooling, and periods of respiratory distress with choking and cyanosis.

The nurse assesses that the fetus of a woman is in an occiput posterior position. Which description identifies the way the nurse would expect the client's labor to differ from others?

experience of additional back pain 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 dilatational stage of labor, it does not indicate the need to have the baby manually rotated, and it does not indicate a necessity for a vacuum extraction birth.

The nurse is assessing a newborn suspected of having meconium aspiration syndrome. What sign or symptom would be most suggestive of this condition?

expiratory grunting

The nurse is assessing a newborn suspected of having meconium aspiration syndrome. What sign or symptom would be most suggestive of this condition?

expiratory grunting Expiratory grunting, a barrel-shaped chest with an increased anterior-posterior chest diameter, prolonged tachypnea, progression from mild-to-severe respiratory distress, intercostal retractions, cyanosis, surfactant dysfunction, airway obstruction, hypoxia, and chemical pneumonitis with inflammation of pulmonary tissues are seen in a newborn with meconium aspiration syndrome. A high-pitched cry may be noted in periventricular hemorrhage/intraventricular hemorrhage. Bile-stained emesis occurs in necrotizing enterocolitis. Intermittent tachypnea can be indicative of transient tachypnea of the newborn or any mild respiratory distress problem.

A common symptom that would alert you that a preterm infant is developing respiratory distress syndrome is a) inspiratory "crowing." b) expiratory grunting. c) inspiratory stridor. d) expiratory wheezing.

expiratory grunting. Correct Explanation: Expiratory grunting is a physiologic measure to ensure alveoli do not fully close on expiration (so they require less energy expenditure to reopen).

A client in week 38 of her pregnancy 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?

external cephalic version 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 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.

Over the course of an eight-hour shift of postoperative care for a child who has had ventriculoatrial shunt placement, the nurse notes that the child's cry has become increasingly shrill and the child has projectile vomiting. The nurse would notify the primary care provider immediately because of the possibility that the child might be experiencing:

increased intracranial pressure. Symptoms of increased intracranial pressure (IICP) may include irritability, restlessness, personality change, high-pitched cry, ataxia, projectile vomiting, failure to thrive, seizures, severe headache, changes in level of consciousness, and papilledema. At least every 2-4 hours, the nurse should monitor the newborn's level of consciousness, check the pupils for equality and reaction, monitor the neurologic status, and observe for a shrill cry, lethargy, or irritability.

A premature, 38-week-gestation neonate is admitted to the observational nursery and placed under bili-lights with evidence of hyperbilirubinemia. Which assessment findings would the neonate demonstrate? Select all that apply.

increased serum bilirubin levels clay-colored stools tea-colored urine Hyperbilirubinemia is indicated when the newborn presents with elevated serum bilirubin levels, tea-colored urine, and clay-colored stools. Cyanosis would not be seen in infants in this scenario. Mongolian spots are not associated with newborn jaundice.

The nurse is conducting a review class for a group of perinatal nurses about factors that place a pregnant woman at risk for infection in the postpartum period. The nurse determines that additional teaching is needed when the group identifies which factor?

increased vaginal acidity leading to growth of bacteria Vaginal acidity is decreased due to the presence of amniotic fluid, blood, and lochia, all of which are alkaline. An alkaline environment encourages the growth of bacteria. With rupture of membranes, the barrier is removed, allowing bacteria to ascend through the internal genital structures. A prolonged labor with multiple vaginal examinations provides opportunities for exposure to organisms, with time for the bacteria to multiply. Retained placental fragments provide an excellent medium for bacterial growth.

A nursing instructor is teaching students about fetal presentations during delivery. The most common cause for increased incidence of shoulder dystocia is: a) increased number of overall pregnancies b) poor quality of prenatal care c) increasing birth weight d) longer lengths of labor

increasing birth weight Correct Explanation: Shoulder dystocia is the obstruction of fetal descent and birth by the axis of the fetal shoulders after the fetal head has been delivered. The incidence of shoulder dystocia is increasing because of increasing birth weights, with reports of it in up to 2% of vaginal births

A nursing instructor is teaching students about fetal presentations during birth. The most common cause for increased incidence of shoulder dystocia is:

increasing birth weight. Shoulder dystocia is the obstruction of fetal descent and birth by the axis of the fetal shoulders after the fetal head has emerged. The incidence of shoulder dystocia is increasing because of increasing birth weights, with reports of it in up to 2% of vaginal births. pg 758

When teaching a postpartum woman about possible complications during this time, the nurse would include information about which possible effect?

interference with the maternal-newborn attachment process The nurse would include information that maternal postpartum complications affect not only the health status of the woman, but also that of the newborn by potentially interfering with the maternal-newborn attachment process. Furthermore, they can disrupt the dynamics of the entire family, with health-related, fiscal, and emotional effects and costs. Maternal postpartum complications are not known to result in ineffective breastfeeding, delayed development of the newborn, or altered maternal hormonal function.

The nurse assesses a large for gestational age infant admitted to the newborn observational unit with the diagnosis of hypoglycemia. What would best correlate with this diagnosis?

jitteriness Jitteriness is evident with a newborn with hypoglycemia as well as poor feeding with feeble sucking. The newborn would have tachypnea. Jaundice is not part of the newborn hypoglycemic syndrome. Positive Moro reflex and palmar creases are normal. pg 840

A nurse is reading a journal article about cesarean births and the indications for them. Place the indications for cesarean birth below in the proper sequence from most frequent to least frequent. All options must be used.

labor dystocia abnormal fetal heart rate tracing fetal malpresentation multiple gestation suspected macrosomia The most common indications for primary cesarean births include, in order of frequency, labor dystocia, abnormal fetal heart rate tracing, fetal malpresentation, multiple gestation, and suspected macrosomia.

While assessing a postpartum woman, the nurse palpates a contracted uterus. Perineal inspection reveals a steady stream of bright red blood trickling out of the vagina. The woman reports mild perineal pain. She just voided 200 mL of clear yellow urine. Which condition would the nurse suspect?

laceration Lacerations typically present with a firm contracted uterus and a steady stream of unclotted bright red blood. Hematoma would present as a localized bluish bulging area just under the skin surface in the perineal area, accompanied by perineal or pelvic pain and difficulty voiding. Uterine inversion would present with the uterine fundus at or through the cervix. Uterine atony would be manifested by a noncontracted uterus.

Uterine atony, or the inability of the uterus to effectively contract, has four major causes. What is one of them?

laceration of the cervix There are four major causes of postpartum hemorrhage: uterine atony, inability of the uterus to contract effectively; lacerations to the uterus, cervix, vagina, or perineum; retained placenta; and disruption in maternal clotting mechanisms. It is important to monitor all postpartum women for excessive bleeding because two-thirds of the women who experience postpartum hemorrhage have no risk factors.

The nurse assesses the client who is one hour postpartum and observes a heavy steady gush of bright red blood from the vagina in the presence of a firm fundus. What is the most likely cause of this finding?

lacerations A gush of blood with a firm uterus is more likely to occur from a laceration rather than from the uterine atony. This type of bleeding is usually bright red in color rather than the dark red color of lochia. A perineal hematoma presents as a bulging, swollen mass on the perineum. Uterine infection typically presents with a foul smelling discharge.

A nurse is assessing a preterm newborn. The nurse determines that the newborn is comfortable and without pain based on which finding?

lack of body posturing The newborn may be in pain if the following are exhibited: sudden high-pitched cry; facial grimace with furrowing of brown and quivering chin; increased muscle tone; oxygen desaturation; body posturing, such as squirming, kicking, and arching; limb withdrawal and thrashing movements; increase in heart rate, blood pressure, pulse, and respirations; fussiness and irritability

In the infant with developmental dysplasia of the hip (DDH), which sign would likely be noted?

limited abduction of the affected hip The infant with DDH usually has limited abduction of the affected hip. They have asymmetry of the gluteal skin folds and shortening of the femur. Adduction is not a concern.

A nursing instructor teaching about risk factors associated with preterm labor should discuss which demographic and lifestyle issues? Select all that apply.

low socioeconomic status smoking high level of stress alcohol use Demographic and lifestyle risk factors associated with preterm labor are extremes of maternal age (younger than 17 years or older than 35 years), low socioeconoomic status, smoking, alcohol or drug use, high levels of stress, and long working hours. Infection and hypertension are medical risk factors and not demographic or lifestyle factors.

A client is entering her 42nd week of gestation and is being prepared for induction of labor. The nurse recognizes that the fetus is at risk for which condition?

macrosomia Fetal risks associated with a prolonged pregnancy include macrosomia, shoulder dystocia, brachial plexus injuries, low Apgar scores, postmaturity syndrome, cephalopelvic disproportion, uteroplacental insufficiency, meconium aspiration, and intrauterine infection. Amniotic fluid volume begins to decline by 40 weeks of gestation, possibly leading to oligohydramnios. Hemorrhage, infection, and dystocia are risk to the mother not the fetus.

What terminology would the nurse use to document a newborn who weighs 4,000 (8.13 lbs) or more at birth? a) meconia b) hydrocephalus c) macrosomia d) microsomia

macrosomia Correct Explanation: Macrosomia, in which a newborn weighs 8.13 to 9.15 lb or more at birth, complicates approximately 10% of all pregnancies. Meconium is the first stool passed by a newborn. Hydrocephalus is a buildup of fluid inside the skull.

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

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. pg 769

After teaching a local woman's group about postpartum affective disorders, which statement by the group indicates that the teaching was successful? a)"Postpartum psychosis usually appears soon after the woman comes home." b)"Postpartum psychosis usually involves psychotropic drugs but not hospitalization." c)"Postpartum depression develops gradually, appearing within the first 6 weeks." d)"Postpartum blues usually resolves by the fourth or fifth postpartum day."

c)"Postpartum depression develops gradually, appearing within the first 6 weeks." Explanation: Postpartum depression usually has a more gradual onset, becoming evident within the first 6 weeks postpartum. Postpartum blues usually peaks on the fourth to fifth postpartum day and resolves by the 10th day. Postpartum psychosis generally surfaces within 3 weeks of giving birth. Treatment typically involves hospitalization for up to several months. Psychotropic drugs are almost always a part of treatment, along with individual psychotherapy and support group therapy.

Which of the following instructions would the nurse include in the teaching plan for a postpartum woman with mastitis? a)"Limit the amount of fluid you drink so your breasts don't get much fuller." b)"Stop breast-feeding until the pain and swelling subside." c)"Try applying warm compresses to your breasts to encourage the milk to be released." d)"You'll need to take this medication to stop the milk from being produced."

c)"Try applying warm compresses to your breasts to encourage the milk to be released." Explanation: Warm compresses promote the let-down reflex, encouraging the milk to be released. They also provide comfort. With mastitis, breast-feeding is encouraged to empty the breasts and reverse milk stasis and to maintain the milk supply. Lactation is not suppressed. Fluid intake is important to ensure adequate milk supply. In addition, fluid intake is important when infection is present.

In which time period would the nurse most likely expect a client who has delivered twins to experience late postpartum hemorrhage? a) 24 to 48 hours after delivery b) 6 weeks to 3 months after delivery c) 24 hours to 6 weeks after delivery d) 6 weeks to 6 months after delivery

c)24 hours to 6 weeks after delivery Explanation: Late or secondary postpartum hemorrhages occur more than 24 hours but less than 6 weeks postpartum. Early or primary postpartum hemorrhages occur within 24 hours of delivery.

Mrs. M. and her infant are being discharged home after an unplanned cesarean delivery. You explain to her that she is at a higher risk for postpartum infection than most patients. What is the major risk factor for a post-partum infection? a) Labor more than 12 hours long. b) Labor less than 12 hours long. c) A nonelective cesarean birth. d) A planned cesarean birth.

c)A nonelective cesarean birth. Explanation: The major risk factor for postpartum infection is a nonelective cesarean birth. Antepartum risk factors include history of infection; history of chronic conditions, such as diabetes, anemia, or poor nutrition; infections of the genital tract; smoking; and obesity.

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

c)Avoid over-the-counter (OTC) salicylates Explanation: Discharge teaching should include informing the client to avoid OTC salicylates, which may potentiate the effects of anticoagulant therapy. Iron won't 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.

You are the nurse giving an educational presentation to the local Le Leche league chapter. One woman asks you about mastitis. What would be your best response? a) Risk factors include frequent feeding. b) Risk factors include complete emptying of the breast c) Risk factors include nipple piercing. d) Risk factors include breast pumps.

c)Risk factors include nipple piercing. Explanation: Certain risk factors contribute to the development of mastitis. These include: inadequate or incomplete breast emptying during feeding or lack of frequent feeding leading to milk stasis; engorgement; clogged milk ducts; cracked or bleeding nipples; nipple piercing; use of plastic-backed breast pads.

Every postpartum client has the potential of hemorrhage. While assessing a client's status, the nurse recognizes which of the following would not be used as an indicator of possible hemorrhage? a)Estimated amount of blood loss b)Uterine tone c)Signs of shock d)Vital signs

c)Signs of shock Explanation: Signs of shock do not appear until the hemorrhage is far advanced due to the increased fluid and blood volume of pregnancy. Vital signs would show an increased pulse rate and decreased level of consciousness. The amount of lochia would be much greater than usual and urinary output would be diminished, with signs of acute renal failure. The uterus may also appear soft and spongy, instead of firm.

The nurse is teaching a client with newly diagnosed mastitis about her condition. The nurse would inform the client that she most likely contracted the disorder from which organism? a) Group beta-hemolytic streptococci (GBS) b) Streptococcus pyogenes c) Staphylococcus aureus d) Escherichia coli

c)Staphylococcus aureus Explanation: The most common cause of mastitis is S. aureus, transmitted from the neonate's mouth. Mastitis isn't harmful to the neonate. E. coli, GBS, and S. pyogenes aren't associated with mastitis. GBS infection is associated with neonatal sepsis and death.

Quickly determining the cause of postpartum hemorrhaging enables effective treatment. A nurse using the 5T's tool will recognize which of the following as being a potential cause of postpartum hemorrhage? (Select all that apply.) a)Technique of delivery b)Time c)Thrombin d)Tone e)Tissue

c)Thrombin d)Tone e)Tissue Explanation: A helpful way to remember the causes of postpartum hemorrhage is by using the 5 T's: tone; tissue; trauma; thrombin; and traction.

The nurse recognizes that any client may develop postpartum hemorrhage and frequent assessments are conducted to ensure this is not happening. Which of the following is the most common cause of postpartum hemorrhage? a)Distended bladder b)Uterine lacerations c)Uterine Atony d)Placenta Previa

c)Uterine atony Explanation: The most common cause of postpartum hemorrhage is uterine atony, or failure of the uterus to contract and retract after birth. Any factor that causes the uterus to relax after birth will cause bleeding, even a full bladder that displaces the uterus. Placenta previa and uterine lacerations are potential contributors to hemorrhaging but not the main cause.

In reviewing the postpartum G3, P3 woman's history the nurse notes it is positive for obesity and smoking. The nurse recognizes this client is at risk for which of the following complications? a)Postpartum Hemorrhage b)Uterine Atony c)Deep venous thrombosis d)Metritis

c)deep venous thrombosis Explanation: Factors that can increase a woman's risk for DVT include prolonged bed rest, diabetes, obesity, cesarean birth, progesterone-induced distensibility of the veins of the lower legs during pregnancy, severe anemia, varicose veins, advanced maternal age (older than 35), and multiparity.

The nurse is assessing a woman who had a forceps-assisted birth for complications. Which condition would the nurse assess in the fetus?

caput succedaneum Caput succedaneum is a complication that may occur in the newborn of a woman who had a forceps- assisted birth. Maternal complications include tissue trauma, such as lacerations of the cervix, vagina, and perineum, hematoma, extension of episiotomy into the anus, hemorrhage, and infection.

Various medications are available to help control hemorrhage in the postpartum client. When reviewing the client's history, the nurse notes she has a history of asthma. Which medication would be contraindicated in her case?

carboprost Carboprost is contraindicated with asthma due to the risk of bronchial spasms. Oxytocin should be given undiluted as a bolus injection, misoprostol should not be given to women with active CVD, pulmonary or hepatic disease, and methylergonovine should not be given to a woman who is hypertensive.

A 16-year-old client has been in the active phase of labor for 14 hours. An ultrasound reveals that the likely cause of delay in dilatation is cephalopelvic disproportion. Which intervention should the nurse most expect in this case?

cesarean birth If the cause of the delay in dilatation is fetal malposition or cephalopelvic disproportion (CPD), cesarean birth may be necessary. Oxytocin would be administered to augment labor only if CPD were ruled out. Administration of morphine sulfate (an analgesic) and darkening room lights and decreasing noise and stimulation are used in the management of a prolonged latent phase caused by hypertonic contractions. These measures would not help in the case of CPD. pg 775

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

The nurse is teaching the parents of a newborn who was born with a high type of imperforate anus the care the newborn will need at home after surgery. The parents need to be aware that the newborn will require which measure temporarily?

colostomy

A pregnant woman comes to the birthing center, stating she is in labor and does not know far along her pregnancy is because she has not had prenatal care. A primary care provider performs an ultrasound that indicates oligohydramnios. When the client's membranes rupture, meconium is in the amniotic fluid. What does the nurse suspect may be occurring with this client?

complications of a postterm pregnancy A postterm pregnancy carries risks for increased perinatal mortality, particularly during labor. Oligohydramnios and meconium staining of the amniotic fluid are common complications. Oligohydramnios increases the incidence of cord compression, which can lead to fetal distress during labor. Thick, meconium-stained fluid increases the risk for meconium aspiration syndrome.

When discussing heat loss in newborns, placing a newborn on a cold scale would be an example of what type of heat loss?

conduction A conduction heat loss results from direct contact with an object that is cooler. p 850

One of the primary assessments a nurse makes every day is for postpartum hemorrhage. What does the nurse assess the fundus for?

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 intervention would be most important when caring for the client with breech presentation confirmed by ultrasound?

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. pg 767

Which intervention would be most important when caring for the client with breech presentation confirmed by ultrasound?

Which finding would lead the nurse to suspect that the fetus of a woman in labor is in hypertonic uterine dysfuction?

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 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 woman is admitted to the labor suite with contractions every five minutes lasting one minute. She is postterm and has oligohydramnios. What does this increase the risk of during birth?

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.

Periventricular hemorrhage is suspected in a newborn of 30 weeks' gestation. The nurse would anticipate preparing the newborn for which diagnostic tool to confirm the diagnosis?

cranial ultrasound The diagnostic tool of choice to detect periventricular hemorrhage is a cranial ultrasound. Arterial blood gases would be helpful in evaluating for metabolic acidosis. Blood glucose levels provide information about the newborn's glucose stability. Chest X-ray would provide no information related to bleeding in the brain.

The nurse is caring for an infant born to a mother who abused cocaine during her pregnancy. The nurse would likely notice that this infant:

cries when touched.

The nurse is caring for an infant born to a mother who abused cocaine during her pregnancy. The nurse would likely notice that this infant:

cries when touched. Developmental delays occur in young children of substance abusers. Infants of cocaine abusers do not like to be touched or held and avoid the caregiver's gaze, which contributes to bonding delays. Infants of cocaine abusers are often restless and below average weight when born.

A client has had a cesarean birth. Which of the following amounts of blood loss would the nurse document as a postpartum hemorrhage in this client? a) 250 ml. b) 750 ml. c) 500 ml. d) 1000 ml.

d)1000 ml Explanation: 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.

The nurse determines that a woman is experiencing postpartum hemorrhage after a vaginal birth when the blood loss is greater than which amount? a)250mL b)300mL c)100mL d)500mL

d)500mL Explanation: Postpartum hemorrhage is defined as a blood loss of greater than 500 mL after a vaginal birth or more than 1,000 mL after a cesarean birth.

Which intervention would be helpful to a bottle-feeding client who's experiencing hard or engorged breasts? a) Applying warm compresses b) Administering bromocriptine (Parlodel) c) Restricting fluids d) Applying ice

d)Applying ice Explanation: Ice promotes comfort by decreasing blood flow (vasoconstriction), numbing the area, and discouraging further letdown of milk. Restricting fluids doesn't reduce engorgement and shouldn't 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.

Which measurement best describes delayed postpartum hemorrhage? a) Blood loss in excess of 1,000 ml, occurring 24 hours to 6 weeks after delivery b) Blood loss in excess of 300 ml, occurring 24 hours to 6 weeks after delivery c) Blood loss in excess of 800 ml, occurring 24 hours to 6 weeks after delivery d) Blood loss in excess of 500 ml, occurring 24 hours to 6 weeks after delivery

d)Blood loss in excess of 500 ml, occurring 24 hours to 6 weeks after delivery Explanation: Postpartum hemorrhage involves blood loss in excess of 500 ml. Most delayed postpartum hemorrhages occur between the fourth and ninth days postpartum. The most common causes of a delayed postpartum hemorrhage include retained placental fragments, intrauterine infection, and fibroids.

A nurse is assigned to care for a client experiencing early postpartum hemorrhage. The nurse is required to administer the prescribed methylergonovine maleate intramuscularly to the client. Which of the following conditions would the nurse identify as necessitating the cautious administration of this drug? a) Respiratory problems b) Low blood pressure c) Mild fever d) Cardiovascular disease

d)Cardiovascular disease Explanation: The nurse should know that the client with cardiovascular disease must understand that the drug has to be administered cautiously. Nurses must administer methylergonovine maleate with caution in women who have elevated blood pressure or cardiovascular disease because it causes a sudden increase in blood pressure and could initiate a cerebrovascular accident in women at risk with pre-existing conditions. Low blood pressure, respiratory problems, or mild fever is not known to enforce cautious use of methylergonovine maleate in clients with early postpartum hemorrhage.

A 17-year-old nulliparous client presents in active labor. It is discovered that she received no prenatal care. Which of the following would be important to collect first? a)Urinalysis b)HIV status c)STI status d)Coagulation studies

d)Coagulation studies Explanation: Coagulation studies should be ordered immediately to determine her coagulation status to help eliminate potential bleeding problems. Her STI and HIV status, although important, are not necessary emergently.

One of the primary assessments you, as a postpartum nurse, make every day is for postpartum hemorrhage. What do you assess the fundus for? a) Consistency, location, and place b) Content, lochia, place c) Location, shape, and content d) Consistency, shape, and location

d)Consistency, shape, and location Explanation: 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.

The nurse recognizes that maternal factors can increase the chance of a large-for-gestational-age newborn. When reviewing maternal history, the nurse would interpret which factors as placing a newborn at risk for being LGA? Select all that apply.

diabetes mellitus multiparity history of postdates gestation Maternal factors that increase the chance of bearing an LGA newborn include maternal diabetes mellitus or glucose intolerance, multiparity, prior history of a macrosomic infant, postdate gestation, maternal obesity, male fetus, and genetics. pg 840

A woman's nurse-midwife tells her that the woman has developed dystocia. The nurse explains that this term means:

difficult or abnormal labor. Dystocia is a general term used to describe difficult or abnormal labor. Dystocia does not indicate high blood pressure related to difficult labor, a potential for placental detachment, nor muscle weakness related to prolonged labor.

After an hour of administering oxytocin intravenously, the nurse assesses a woman's contractions to be 80 seconds in length. The nurse's first action would be to:

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 allows fetal nourishment

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?

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.

A premature infant develops respiratory distress syndrome. With this condition, circulatory impairment is likely to occur because with increased lung tension, the a) foramen ovale closes prematurely. b) ductus arteriosus remains open. c) pulmonary artery closes. d) aorta or aortic valve strictures.

ductus arteriosus remains open. Explanation: Excess pressure in the alveoli stimulates the ductus arteriosus to remain open, compromising efficient cardiovascular function.

The nursing student doing a clinical rotation in labor and delivery has noticed numerous women expressing various emotions during labor. The student's preceptor informs the student that these emotions can lead to psychological stress, which in turn can cause which of the following complications? a) pulmonary emboli b) dystocia c) deep vein thrombosis d) premature labor

dystocia Correct 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.

A nurse is providing care to a preterm neonate. Which interventions would be most effective in minimizing the newborn's pain? Select all that apply.

encouraging kangaroo care during procedures removing tape gently from the skin using a colorful mobile for distraction Interventions to reduce pain in the preterm newborn include swaddling the newborn closely to establish physical boundaries, using gentle handling, rocking, caressing, and cuddling, encouraging kangaroo care during procedures, and offering a pacifier for nonnutritive sucking prior to a procedure. Tape should be used minimally and should be removed gently to prevent skin tearing. Environmental stimuli need to be reduced, such as by turning down the volumes on alarms. Warm rather than cool blankets facilitate relaxation. Distraction using colorful mobiles or objects also can be effective. p 855

A 35-year-old client has just given birth to a healthy newborn during her 43rd week of gestation. What should the nurse expect when assessing the condition of the newborn?

meconium aspiration in utero or at birth Infants born after 42 weeks of pregnancy are postterm. These infants are at a higher risk of swallowing or aspirating meconium in utero or after birth. As soon as the infant is born, the nurse usually suctions out the secretions and fluids in the newborn's mouth and throat before the first breath to avoid aspiration of meconium and amniotic fluid into the lungs. Seizures, respiratory distress, cyanosis, and shrill cry are signs and symptoms of infants with intracranial hemorrhage. Intracranial hemorrhage can be a dangerous birth injury that is primarily a problem for preterm newborns, not postterm neonates. Yellow appearance of the newborn's skin is usually seen in infants with jaundice. Tremors, irritability, high-pitched or weak cry, and eye rolling are seen in infants with hypoglycemia. pg 858

A nurse is caring for a newborn whose chest X-ray reveals marked hyperaeration mixed with areas of atelectasis. The infant's arterial blood gas analysis indicates metabolic acidosis. For which dangerous condition should the nurse prepare when providing care to this newborn?

meconium aspiration syndrome The nurse should assess for meconium aspiration syndrome in the newborn. Meconium aspiration involves patchy, fluffy infiltrates unevenly distributed throughout the lungs and marked hyperaeration mixed with areas of atelectasis that can be seen through chest X-rays. Direct visualization of the vocal cords for meconium staining using a laryngoscope can confirm aspiration. Lung auscultation typically reveals coarse crackles and rhonchi. Arterial blood gas analysis will indicate metabolic acidosis with a low blood pH, decreased PaO2, and increased PaCO2. Newborns with choanal atresia, diaphragmatic hernia, and pneumonia do not exhibit to exhibit these manifestations.

Which symptom would most accurately indicate that a newborn has experienced meconium aspiration during the birth process?

meconium stained fluids followed by tachypnea Meconium stained cord and skin indicates a potential of meconium aspiration, and the nurse should inform the primary care provider. But if the infant actually experiences respiratory distress following a birth with meconium stained fluids, the likelihood of meconium aspiration is greatly increased. Listlessness or lethargy by themselves does not indicate meconium aspiration. Bluish skin discoloration is normal in infants shortly after birth until the infant's respiratory system clears out all the amniotic fluid. pg 837

A premature infant in the neonatal intensive care unit exhibits worsening respiratory distress and is noted to have abdominal distention, absent bowel sounds, and frequent diarrhea stools that are positive for hemoccult. What diagnosis would be most likely to correlate with the symptoms?

necrotizing enterocolitis Observations for the developemnt of NEC in the preamture newborn may include feeding intolerance with abdominal distention tenderness and bloody or hemoccult-positive stools. Diarrhea is present with NEC and worsening of respiratory distress. Decreased or absent bowel sounds are noted. Rotavirus causes inflammation of a child's stomach and digestive tract, usually triggering vomiting, diarrhea, and fever and not seen in a preterm infant. Garamycin-resistant bacteria is usually seen in older adults.

A newborn is found to have hemolytic disease. Which combination would be found related to the blood types of this newborn and the parents of the newborn?

newborn who is type A, mother who is type O

A nurse is working in the newborn observational unit and is assigned four newborns. In which newborn will the nurse suspect difficulties with thermal regulation?

newly born preterm infant Newborns use nonshivering thermogenesis for heat production by metabolizing their own brown adipose tissue. The preterm newborn has an inadequate supply of brown fat. The preterm newborn also has decreased muscle tone and thus cannot assume the flexed fetal position, which reduces the amount of skin exposed to a cooler environment. Preterm newborns have large body surface areas compared to their weight. A term infant with RH factor will not be at any greater risk for heat lost and stabilized with age. A 2-day-old infant postmaturity would not be stabilized and would initially be at risk for heat loss. The diabetic infant is stabilized and heat loss is not a great concern. pg 850

When planning preoperative care for a newborn with a cleft lip and palate, a major need for which you would plan interventions is a) visual stimulation. b) prevention of pneumonia. c) nutrition. d) prevention of oral infection.

nutrition

When assessing a client for postpartum hemorrhage, the nurse monitors what every hour?

pad count The way to monitor for bleeding every hour is to assess pads and percent of pad saturated by blood in the previous hour. It would not be necessary to do a complete blood count every hour, nor hourly urines. Vital signs are not typically taken every hour.

A client has just given birth at 42 weeks' gestation. What would the nurse expect to find during her assessment of the neonate?

peeling and wrinkling of the neonate's epidermis Postdate neonates lose the vernix caseosa, and the epidermis may become peeled and wrinkled. A neonate at 42 weeks' gestation is usually very alert and missing lanugo. p. 858

The nurse is changing the diaper on a newborn and notices that there is a musty smell to the infant's urine. This finding is a characteristic sign of which disorder?

phenylketonuria There is a characteristic musty smell to the urine in the child with phenylketonuria. None of the other disorders affect the urine or the smell of the urine.

A gravida 7, para 6 woman is in the hospital only 15 minutes when she begins to deliver precipitously. The fetal head begins to deliver as you walk into the labor room. Your best action would be to a) attach a fetal monitor to determine fetal status. b) ask her to push with the next contraction so delivery is rapid. c) place a hand gently on the fetal head to guide delivery. d) assess blood pressure and pulse to detect placental bleeding.

place a hand gently on the fetal head to guide delivery. Correct Explanation: If a head is controlled as it delivers, trauma to internal vessels or to the maternal cervix is less apt to occur.

A client is at 23 weeks' gestation and was admitted for induction and birth after noting the infant was an intrauterine fetal death. The client had fallen 3 days prior to the diagnosis and landed on her side. What is the most likely attributable cause to the fetal death?

placental abruption The most common cause of fetal death after a trauma is placental abruption, where the placenta separates from the uterus, and the fetus is not able to survive. Genetic abnormalities typically cause spontaneous abortion in the first trimester. The scenario does not indicate that there has been a premature rupture of membranes or the possibility of preeclamsia. pg 784

The newborn nursery nurse is admitting a small-for-gestational-age (SGA) infant and is reviewing the maternal history. What factor in the maternal history would the nurse correlate as a risk factor for a SGA infant?

placental factors Assessment of the SGA infant begins by reviewing the maternal history to identify risk factors such as placental factors with abnormal umbilical cord insertion, chronic placental abruption, malformed and smaller placentas, with placental previa or placental insufficiency being the main placental causes. Blood group incompatibility, having many pregnancies, and being over the age of 30 will not cause an SGA infant.

The small-for-gestational-age neonate is at increased risk for which complication during the transitional period?

polycythemia, probably due to chronic fetal hypoxia The small-for-gestational-age neonate is at risk for developing polycythemia during the transitional period in an attempt to decrease hypoxia. This neonate is also at increased risk for developing hypoglycemia and hypothermia due to decreased glycogen stores.

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

post-term pregnancy Correct Explanation: 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.

Two weeks after their baby is born, a father calls to report that his wife is behaving strangely. She is extremely talkative and energetic, and he has not observed her sleeping for more than an hour or two at a time. She is also forgetting to eat and neglecting her appearance, but worse, she seems to barely be aware of the baby's needs and appears surprised when the father asks her about the child, "As if," the father says, "she's forgotten that we even have a baby!" The nurse tells him to bring the mother in right away because the nurse suspects the mother is suffering from what condition?

postpartum psychosis Postpartum psychosis can present with a client in extreme mood changes and odd behavior. Her sudden change in behavior from normal and lack of self care and care for the infant are a sign 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 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 she 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 psychosis The client's signs and symptoms suggest that the 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 infant, 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 her life is rapidly tumbling out of control. The client thinks of herself 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 characteristics of postpartum blues.

When caring for a client requiring a forceps-assisted birth, the nurse would be alert for:

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 maternal tissues happens if the cup slips off the fetal head and the suction is not released.

precipitous labor Correct Explanation: When the expulsive forces of the uterus become dysfunctional, the uterus may either never fully relax (hypertonic contractions) placing the fetus in jeopardy, or relax too much (hypotonic contractions), causing ineffective contractions. Another dysfunction can occur when the uterus contracts so frequently and with such intensity that a very rapid birth will take place(precipitous labor).

A 30 weeks' gestation neonate born with low Apgar scores is in the neonatal intensive care unit with respiratory distress syndrome and underwent an exchange transfusion for anemia. Which factors place the neonate at risk for necrotizing enterocolitis? Select all that apply

preterm birth respiratory distress syndrome low Apgar scores exchange transfusion

preterm birth respiratory distress syndrome low Apgar scores exchange transfusion The predisposing factors for the development of necrotizing enterocolitis include preterm labor, respiratory distress syndrome, exchange transfusion, and low birth weight. Low Apgar scores, hypothermia, and hypoglycemia are also risk factors.

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?

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. 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 start of contraction to 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? a) preterm labor b) normal labor c) macrosomia d) dystocia

preterm labor Correct Explanation: 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 nurse needs to conduct a procedure on a preterm newborn. Which measures would be most effective in reducing pain? Select all that apply.

swaddling the newborn closely offering a pacifier prior to a procedure encouraging kangaroo care during procedures Interventions to reduce pain in the preterm newborn include swaddling the newborn closely to establish physical boundaries; using gentle handling, rocking, caressing, and cuddling; encouraging kangaroo care during procedures; and offering a pacifier for nonnutritive sucking prior to a procedure. Tape should be used minimally and should be removed gently to prevent skin tearing. Environmental stimuli need to be reduced, such as by turning down the volumes on alarms. Warm rather than cool blankets facilitate relaxation. pg 855

Which newborn would the nurse suspect to be most at risk for cognitive challenge due to the mother's actions during pregnancy?

the child of a client who admits to drinking a liter of alcohol daily during the pregnancy Fetal alcohol syndrome is one of the most common known causes of cognitive challenge. The newborn is also at risk for fetal alcohol spectrum disorder and other alcohol-related birth defects. The other illicit drugs are not linked to mental retardation but have many other teratogenic effects on the fetus/newborn. Marijuana has not shown to have teratogenic effects on the fetus.

A nurse working in the newborn observational unit is assigned four newborns closely being monitored. Which newborn is at greatest risk of developing respiratory distress syndrome?

the male preterm infant born by cesarean birth with cold stress The most common factor is a premature birth with additional factors of cesarean births and cold stress. Vaginal births and a parental history of asthma do not correlate with RDS. A positive Babinski reflex is normal in newborns and children up to 2 years old. Maternal hypertension with a term birth as well do not correlate.

A client gives birth to a newborn baby at term. The nurse records the weight of the baby as 1.2 kg, interpreting this to indicate that the newborn is of:

very low birth weight. A birth weight of 1.2 kg would be classified as very low birth weight. A normal birth weight at term ranges between 2,500 g and 4,000 g. Typically it is between 3,000 g and 4,000 g. A birth weight below 2,500 g is termed a low birth weight. A birth weight between 1,000 g and 1,500 g is termed a very low birth weight. A birth weight less than 1,000 g is termed an extremely low birth weight.

The nurse determines a newborn is small-for-gestational age based on which characteristics?

wasted appearance of extremities, thin umbilical cord, and reduced subcutaneous fat stores The nurse should perform a thorough physical examination of the newborn and closely observe the newborn for typical SGA characteristics, which include the following: a newborn head that is disproportionately large compared with rest of body; a wasted appearance of extremities with reduced subcutaneous fat stores; a reduced amount of breast tissue; poor muscle tone over buttocks and cheeks; and a thin umbilical cord pg 834

When assessing a postpartum client who was diagnosed with a cervical laceration that has been repaired, what sign should the nurse report as a possible development of hypovolemic shock?

weak and rapid pulse The sign of weak and rapid pulse in the body is a compensatory mechanism attempting to increase the blood circulation. This finding needs to be reported to the health care provider and RN as soon as possible.

An infant develops hydrocephalus at 2 weeks of age. Which finding would the nurse expect to assess?

white sclera showing above the pupils As accumulating cerebrospinal fluid puts pressure on the posterior surface of the eye globes, they tip downward; white sclera shows above the pupils.

wound care and hand washing The use of systemic corticosteroids prior to birth has increased her risk for development of an infection. She has been treated for endometritis and is now at greater risk for infection. Hand washing is the best defense again transmission of any infection. While adherence to antibiotic therapy, proper perineal care, and use of warm compresses and sitz baths may be indicated, they would not be a higher priority than wound care and hand washing.

The nurse caring for newborns on an obstetrical ward assesses a SGA newborn. What characteristics are typical for this classification of newborn? Select all that apply. a) Diminished muscle tissue b) Tight and moist skin c) Sparse or absent hair d) Narrow skull sutures e) Poor skin turgor f) Increased fatty tissue

• Poor skin turgor • Sparse or absent hair • Diminished muscle tissue Explanation: Characteristics of the SGA newborn include poor skin turgor, loose and dry skin, sparse or absent hair, wide skull sutures caused by inadequate bone growth, and diminished muscle and fatty tissue. Weight, length, and head circumference are below normal expectations as defined on growth charts.

A client in labor has been diagnosed with shoulder dystocia. Which of the following risk factors would the nurse expect to assess in the client? Select all that apply. a) Post-term pregnancy b) Incompetent cervix c) Fetal macrosomia d) Maternal diabetes e) Intrauterine growth restriction

• Post-term pregnancy • Fetal macrosomia • Maternal diabetes Correct Explanation: Risk factors of shoulder dystocia include maternal diabetes, maternal obesity, post-term pregnancy, fetal macrosomia, previous history of shoulder dystocia, and multiparity. Intrauterine growth restriction and incompetent cervix are not the risks associated with shoulder dystocia. Intrauterine growth restriction is one of the factors that increase the risk of a breech presentation. Incompetent cervix is a risk factor related to preterm labor.

Which of the following would lead the nurse to suspect that a pregnant woman is experiencing an amniotic fluid embolism? Select all that apply. a) Tachycardia b) Sudden onset of respiratory distress c) Acute, continuous abdominal pain d) Hypotension e) Sudden onset of fetal distress

• Sudden onset of respiratory distress • Hypotension • Tachycardia Explanation: The woman with an amniotic fluid embolism commonly reports difficulty breathing. Other signs include hypotension, tachycardia, cyanosis, seizures, coagulation difficulties, and uterine atony with subsequent hemorrhage. A sudden onset of fetal distress and acute continuous abdominal pain is associated with uterine rupture.

Which of the following would the nurse expect to find in a newborn who is considered small for gestational age? Select all that apply. a) Dry or thin umbilical cord b) Sunken abdomen c) Narrow skull sutures d) Poor muscle tone over buttocks e) Increased subcutaneous fat stores

• Sunken abdomen • Poor muscle tone over buttocks • Dry or thin umbilical cord Explanation: A small-for-gestational-age newborn typically has a sunken abdomen, wide skull sutures, decreased subcutaneous fat stores, poor muscle tone over buttocks and cheeks, and a thin umbilical cord.

Which of the following would be most effective in reducing pain in the preterm newborn? Select all that apply. a) Removing tape quickly from the skin b) Swaddling the newborn closely c) Offering a pacifier prior to a procedure d) Encouraging kangaroo care during procedures e) Increasing the volume on device alarms f) Using cool blankets to soothe the newborn

• Swaddling the newborn closely • Encouraging kangaroo care during procedures • Offering a pacifier prior to a procedure Explanation: Interventions to reduce pain in the preterm newborn include swaddling the newborn closely to establish physical boundaries, using gentle handling, rocking, caressing, and cuddling, encouraging kangaroo care during procedures, and offering a pacifier for nonnutritive sucking prior to a procedure. Tape should be used minimally and should be removed gently to prevent skin tearing. Environmental stimuli need to be reduced, such as by turning down the volumes on alarms. Warm rather than cool blankets facilitate relaxation.

A client is 2 weeks past her due date, and her physician is considering whether to induce labor. Which of the following conditions must be present before induction can take place? (Select all that apply.) a) The fetus is in a longitudinal lie b) Cephalopelvic disproportion is present c) Absence of eclampsia d) The cervix is ripe e) A presenting part is engaged f) Normal maternal blood pressure

• The fetus is in a longitudinal lie • The cervix is ripe • A presenting part is engaged Correct Explanation: Before induction of labor is begun in term and postterm pregnancies, the following conditions should be present: the fetus is in a longitudinal lie; the cervix is ripe, or ready for birth; a presenting part is engaged; there is no cephalopelvic disproportion; and the fetus is estimated to be mature by date (over 39 weeks) or demonstrated by a lecithin-sphingomyelin ratio or ultrasound biparietal diameter to rule out preterm birth. Normal maternal blood pressure and absence of eclampsia are not conditions required for induction; in fact, severe hypertension and eclampsia are conditions that may necessitate induction.

A nurse preceptor asks a student to list commonly used diagnostic tests for preterm labor risk assessment. Which of the following tests should the student include? (Select all that apply.) a) U/A b) arterial blood gases c) amniotic fluid analysis d) CBC e) thyroid level

• U/A • amniotic fluid analysis • CBC Correct Explanation: Commonly used diagnostic testing for preterm labor risk assessment includes a complete blood count, urinalysis, and an amniotic fluid analysis.

The nurse who works at the local health department is preparing to give a talk on post-term pregnancies. She wants to include the fetal risks. Which of the following should she include? (Check all that apply.) a) cephalopelvic disproportion b) brachial plexus injuries c) shoulder dystocia d) macrosomia e) failure to thrive

• cephalopelvic disproportion • brachial plexus injuries • shoulder dystocia • macrosomia Correct Explanation: Fetal risks associated with a post-term pregnancy include macrosomia, shoulder dystocia, brachial plexus injuries, and cephalopelvic disproportion. Failure to thrive is more frequently associated with newborns who are of a low birth weight.

A nurse is caring for a child with complex esophageal atresia who will be undergoing surgery for repair. What comment by the parents indicates further teaching is required?

"After this surgery is done tomorrow, my baby will be able to eat and drink"

The prenatal health nurse is conducting an educational session focusing on alcohol use during pregnancy. The nurse feels the session was a success when a participant makes which statement?

"Alcohol use could cause my baby to be cognitively challenged." Disorders included in the grouping fetal alcohol spectrum disorders are alcohol-related neurodevelopmental disorders (ARND). Children with ARND primarily display intellectual disabilities related to behavior and learning. Fetal alcohol syndrome is one of the most common known causes of cognitive challenge. Counsel girls and women to avoid any alcohol use during pregnancy. Participating in programs for at-risk groups, including adolescents, especially about the serious effects of substance abuse, especially alcohol, during pregnancy.

The nurse is teaching the caregivers of an infant diagnosed with hypospadias how to properly care for the infant. The nurse determines the session is successful when the caregivers make which statement?

"Being able to most likely correct this in one stage rather than several is reassuring."

The nurse is doing teaching with the caregivers of an infant diagnosed with hypospadias. Which statement made by the caregivers is accurate regarding hypospadias?

"Being able to most likely correct this in one stage rather than several is reassuring." Surgical repair is often accomplished in one stage and is often done as outpatient surgery. Surgical repair is desirable between the ages of 6-18 months, before body image and castration anxiety become problems. Urination is not affected, but the boy cannot void while standing in the normal male fashion. These newborns should not be circumcised because the foreskin is used in the repair.

The mother of a preterm infant tells her nurse that she would like to visit her newborn who is in the neonatal intensive care unit (NICU). Which response by the nurse would be the most appropriate?

"Certainly. You will need to wash your hands and gown before you can hold him, however." The nurse should be certain the parents of a high-risk newborn are kept informed of what is happening with their child. They should be able to visit the special nursing unit to which the newborn is admitted as soon and as often as they choose, and, after washing and gowning, hold and touch their newborn, both actions which help make the child's birth more real to them. p 852

The nursing student demonstrates an understanding of dystocia with which statement?

"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.

At a prenatal class the nurse describes the various birth weight terms that may be used to describe a newborn at birth. The nurse feels confident learning has has occurred when a participant makes which statement?

"Newborns who are appropriate for gestational age at birth have lower chance of complications than others." Birth weight variations include appropriate for gestational age (AGA), which describes a newborn with a weight that falls within the 10th to 90th percentile for that particular gestational age. This describes approximately 80% of all newborns. Infants who are appropriate for gestational age have lower morbidity and mortality than other groups. pg 834

The client is anxious about her prolonged pregnancy. She informs the nurse she has been doing research on the Internet and has read about certain herbs that can help to induce labor. Which response from the nurse would be appropriate?

"Please talk to your primary care provider first to ensure it is safe." It is important that the primary care provider knows if and when the client is using herbal supplements to ensure there will be no danger to the woman or fetus. The risks and benefits of these agents are unknown. None have been evaluated scientifically, and thus none can be recommended regarding their efficacy or safety. The statement about personal use is inappropriate because the nurse should not reveal personal information. Telling the client that the herbs will complicate the situation is inappropriate because the statement is judgmental and there is no information, whether positive or negative that the herbs can be harmful. The statement about doing something stupid is demeaning to the client. pg 778

After teaching a local woman's group about postpartum affective disorders, which statement by the group indicates that the teaching was successful? a) "Postpartum psychosis usually appears soon after the woman comes home." b) "Postpartum depression develops gradually, appearing within the first 6 weeks." c) "Postpartum psychosis usually involves psychotropic drugs but not hospitalization." d) "Postpartum blues usually resolves by the 4th or 5th postpartum day."

"Postpartum depression develops gradually, appearing within the first 6 weeks." Correct Explanation: Postpartum depression usually has a more gradual onset, becoming evident within the first 6 weeks postpartum. Postpartum blues usually peaks on the 4th to 5th postpartum day and resolves by the 10th day. Postpartum psychosis generally surfaces within 3 weeks of giving birth. Treatment typically involves hospitalization for up to several months. Psychotropic drugs are almost always a part of treatment, along with individual psychotherapy and support group therapy.

A client is 32 weeks pregnant and sent home on modified bedrest for preterm labor. She is on tocolytics and wants to know when she can have intercourse again with her husband. What is the most appropriate response by the nurse?

"That is a question to ask your health care provider; at this point you are on pelvic rest to try and stop any further labor." The client needs to be on pelvic rest until the health care provider says otherwise. The intercourse can cause excitability in the uterus and encourage cervical softening and should be avoided unless the provider says it is safe.

The nurse realizes the educational session conducted on due dates was successful when a participant is overheard making which statement?

"The ability of my placenta to provide adequate oxygen and nutrients to my baby after 42 weeks' gestation is thought to be compromised." The ability of the placenta to provide adequate oxygen and nutrients to the fetus after 42 weeks' gestation is thought to be compromised, leading to perinatal mortality and morbidity. After 42 weeks the placenta begins aging. Deposits of fibrin and calcium, along with hemorrhagic infarcts, occur and the placental blood vessels begin to degenerate. All of these changes affect diffusion of oxygen to the fetus. As the placenta loses its ability to nourish the fetus, the fetus uses stored nutrients to stay alive, and wasting occurs. pg 840

"The bladder will covered in a sterile plastic bag to keep it moist." In the preoperative period, the infant care is focused on protecting the exstrophied bladder and preventing infection. The infant is kept in a supine position, and the bladder is kept moist and covered with a sterile plastic bag. Change soiled diapers immediately to prevent contamination of the bladder with feces. Sponge-bathe the infant only rather than immersing him or her in water to prevent pathogens in the bath water from entering the bladder. Consult the ostomy nurse if necessary.

A group of nursing students is discussing hydrocephalus. The students make the following statements related to the noncommunicating type of congenital hydrocephalus. Which statement is the most accurate? a) "There is defective absorption of cerebrospinal fluid." b) "There is an obstruction that keeps cerebrospinal fluid from passing between the ventricles and the spinal cord." c) "There is an opening between the ventricles and the spinal cord that usually closes at birth." d) "There is a decreased production of cerebrospinal fluid."

"There is an obstruction that keeps cerebrospinal fluid from passing between the ventricles and the spinal cord."

A group of nursing students is discussing hydrocephalus. Which statement made by the students related to the noncommunicating type of congenital hydrocephalus is the most accurate?

"There is an obstruction that keeps cerebrospinal fluid from passing between the ventricles and the spinal cord." In the noncommunicating type of congenital hydrocephalus, an obstruction occurs, and CSF is not able to pass between the ventricles and the spinal cord. The blockage causes increased pressure on the brain or spinal cord. In the communicating type of hydrocephalus, no obstruction of the free flow of CSF exists between the ventricles and the spinal theca; rather, the condition is caused by defective absorption of CSF. There is no concern of decreased production of CSF and no opening between the ventricles and spinal cord in hydrocephalus

During labor, a woman at 41 weeks' gestation notes her amniotic fluid is leaking and is green in color. She is asking the nurse why the fluid is green. What is an appropriate response by the nurse?

"This is meconium-stained fluid from the baby." Green tinted amniotic fluid is most often a sign of the infant having a bowel movement in the uterus, called mecnomium-stained fluid. This is more typical in a postdates pregnancy. Green-stained amniotic fluid is not a normal color for amniotic fluid. However, it does not mean the mother has an infection and needs antibiotics, nor does it does mean there might be a yeast infection present or indicate the need for a culture of the fluid.

During labor, a woman at 41 weeks gestation notes her amniotic fluid is leaking and is green in color. She is asking the nurse why the fluid is green. What is an appropriate response by the nurse? a) "This is meconium-stained fluid from the baby." b) "You have an infection and need antibiotics." c) "Green might be a yeast infection and we need to culture the discharge." d) "Amniotic fluid is normally green."

"This is meconium-stained fluid from the baby." Correct Explanation: Green tinted amniotic fluid is most often a sign of the infant having a bowel movement in the uterus, called mecnomium-stained fluid. This is more typical in a post-dates pregnancy. Green-stained amniotic fluid is not a normal color for amniotic fluid. However, it does not mean the mother has an infection and needs antibiotics, nor does it does mean there might be a yeast infection present or indicate the need for a culture of the fluid.

A newborn is diagnosed with esophageal atresia and tracheoesophageal fistula. After providing preoperative teaching, which statement indicates that the parents need additional teaching? a) "We can give him a pacifier to help satisfy his need to suck." b) "The head of his bed will be elevated to prevent him from aspirating." c) "We can probably start feeding him with the bottle about a day after the surgery." d) "He'll need antibiotics for a bit after the surgery to prevent infection."

"We can probably start feeding him with the bottle about a day after the surgery."

An older infant is scheduled to have a cleft palate repair. The mother asks if she will still be able to breastfeed the baby during the postoperative phase. What is the best response by the nurse? a) "You will not be able to breastfeed but immediately after, but you can pump and feed the child with a cup." b) "Yes, the surgery will not interfere with breastfeeding your child." c) "No, you will have to put the baby on regular formula." d) "Yes, you will be able to breastfeed but will have to interrupt the feedings frequently."

"You will not be able to breastfeed but immediately after, but you can pump and feed the child with a cup."

On the third day postpartum, which temperature is internationally defined as a postpartal infection?

100.4° F (38° C) A temperature over 100.4° F (38° C) past the first day postpartum is suggestive of infection.

On the third day postpartum, which temperature is internationally defined as a postpartal infection? a) 102.4°F (39.1°C) b) 99.6°F (37.5°C) c) 104.2°F (40.1°C) d) 100.4°F (38°C)

100.4°F (38°C)

On the third day postpartum, which temperature is internationally defined as a postpartal infection? a) 104.2°F (40.1°C) b) 99.6°F (37.5°C) c) 102.4°F (39.1°C) d) 100.4°F (38°C)

100.4°F (38°C) Explanation: A temperature over 100.4°F (38°C) past the first day postpartum is suggestive of infection

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 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 client has had a cesarean birth. Which of the following amounts of blood loss would the nurse document as a postpartum hemorrhage in this client? a) 250 ml. b) 1000 ml. c) 500 ml. d) 750 ml.

1000 ml.

Assessment of a newborn at 40 weeks' gestation reveals that he is a low birth weight newborn. Which of the following weights would the nurse identify as being low birth weight? a) 4400 g b) 1400 g c) 2400 g d) 3400 g

2400 g Correct Explanation: A birth weight of less than 2500 g is categorized as a low birth weight in infants. The normal birth weight of term infants ranges from 3000-4000 g. Hence infants with a birth weight of 3500 g or 4500 g will not be categorized as low birth weight infants. Infants having birth weights lower than 1500g are termed as very low birth weight infants, and not merely low birth weight.

Baby Eliza is 7 minutes old. Her heart rate is 92, her cry is weak, her muscles are limp and flaccid, she makes a face when she is stimulated, and her body and extremities are pink. What would the nurse assign as her Apgar score? a) 6 b) 3 c) 4 d) 5

A woman is to undergo labor induction. The nurse determines that the woman most likely requires cervical ripening if her Bishop score is: a) 6 b) 9 c) 5 d) 7

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

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

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

The nurse determines that a woman is experiencing postpartum hemorrhage after a vaginal birth when the blood loss is greater than which amount? a) 500 mL b) 100 mL c) 300 mL d) 250 mL

500 mL

The nurse determines that a woman is experiencing postpartum hemorrhage after a vaginal birth when the blood loss is greater than which amount?

500 mL Postpartum hemorrhage is defined as a blood loss of greater than 500 mL after a vaginal birth or more than 1,000 mL after a cesarean birth.

The nurse determines that a woman is experiencing postpartum hemorrhage after a vaginal birth when the blood loss is greater than which amount? a) 300 mL b) 250 mL c) 500 mL d) 100 mL

500 mL Explanation: Postpartum hemorrhage is defined as a blood loss of greater than 500 mL after a vaginal birth or more than 1,000 mL after a cesarean birth.

Why is it important for the nurse to thoroughly assess maternal bladder and bowel status during labor?

A full bladder or rectum can impede fetal descent. Throughout labor the nurse needs to assess the woman's fluid balance status as well as check skin turgor and mucous membranes. In addition she needs to monitor the bladder and bowel status. A full bladder or rectum can impede fetal descent. pg 759

Why is it important for the nurse to thoroughly assess maternal bladder and bowel status during labor? a) A full bladder or rectum can impede fetal descent. b) If the woman has a full bladder, labor may be uncomfortable for her. c) A full rectum can cause diarrhea. d) If the woman's bladder is distended, it may rupture.

A full bladder or rectum can impede fetal descent. Explanation: Throughout labor the nurse needs to assess the woman's fluid balance status as well as check skin turgor and mucous membranes. In addition she needs to monitor the bladder and bowel status. A full bladder or rectum can impede fetal descent.

Mrs. M. and her infant are being discharged home after an unplanned cesarean delivery. You explain to her that she is at a higher risk for postpartum infection than most patients. What is the major risk factor for a post-partum infection? a) Labor less than 12 hours long. b) A nonelective cesarean birth. c) A planned cesarean birth. d) Labor more than 12 hours long.

A nonelective cesarean birth. Explanation: The major risk factor for postpartum infection is a nonelective cesarean birth. Antepartum risk factors include history of infection; history of chronic conditions, such as diabetes, anemia, or poor nutrition; infections of the genital tract; smoking; and obesity

In the infant diagnosed with spina bifida with myelomeningocele, the infant will likely have which of the following? a) A protruding sac that contains abdominal contents b) A membrane between the rectum and the anus c) An extremely large and rapidly growing head d) A partial to complete paralysis in the lower extremities

A partial to complete paralysis in the lower extremities

The nurse is reviewing the medical record of the antepartum client with an abnormal alpha-fetoprotein test. The mother is distraught and states, "How bad can it be?" The nurse is correct to describe which?

A type of spina bifida

While assessing a full-term neonate, which symptom would cause the nurse to suspect a neurologic impairment? a) A positive Babinski's reflex b) A positive rooting reflex c) A weak sucking reflex d) Startle reflex in response to a loud noise

A weak sucking reflex Correct Explanation: Normal neonates have a strong, vigorous sucking reflex. The rooting reflex is present at birth and disappears when the infant is between ages 3 and 4 months. A positive Babinski's reflex is present at birth and disappears by the time the infant is age 2. The startle reflex is present at birth and disappears when the infant is approximately age 4 months.

A 3-day-old neonate needs phototherapy for hyperbilirubinemia. Nursery care of a neonate receiving phototherapy includes which treatment? A) Eye patches to prevent retinal damage B) Temperature monitored every 6 hours during phototherapy C) Mask over mouth D) Tube feedings

A) Eye patches to prevent retinal damage The neonate's eyes must be covered with eye patches to prevent damage. The neonate can be removed from the lights and held for feeding. The mouth of the neonate doesn't need to be covered during phototherapy. The neonate's temperature should be monitored at least every 2 to 4 hours because of the risk of hyperthermia with phototherapy.

Which of the following is a typical feature of a small for gestational age (SGA) newborn that differentiates it from a preterm baby with a low birth weight? a) Decreased muscle mass b) Face is angular and pinched c) Decreased body temperature d) Ability to tolerate early oral feeding

Ability to tolerate early oral feeding Explanation: Unlike preterm babies with low birth weights, a small for gestational age baby can safely tolerate early oral feeding. It usually has a coordinated sucking and swallowing reflex. Decreased muscle mass, decreased body temperature and an angular and pinched face are features common to both an SGA and a preterm baby.

Absent verbalization about the birthing process.

Which of the following would the nurse use to monitor the effectiveness of intravenous anticoagulant therapy for a postpartum woman with deep vein thrombosis? a) Platelet level b) Fibrinogen level c) Prothrombin time d) Activated partial thromboplastin time

Activated partial thromboplastin time

A nursing instructor is teaching about newborn congenital disorders and realizes that the student needs further instruction after making which statement?

All congenital disorders can be diagnosed at birth.

A nursing instructor is teaching about newborn congenital disorders and realizes that the student needs further instruction upon making which of the following statements? a) All congenital disorders can be diagnosed at birth. b) Congenital defects may be caused by genetic or environmental factors. c) Hydrocephalus may not be diagnosed until after a few weeks or months of life. d) Hydrocephalus may be recognized at birth.

All congenital disorders can be diagnosed at birth.

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

Ambulate the client as soon as her vital signs are stable

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

Ambulate the client as soon as her vital signs are stable Explanation: The best prevention for a thrombophlebitis is ambulation as soon as possible after recovery. Options A, B, and C are incorrect.

The nurse is caring for a client within the first four hours of her cesarean birth. Which nursing intervention would be appropriate to prevent thrombophlebitis?

Ambulate the client as soon as her vital signs are stable. The best prevention for a thrombophlebitis is ambulation as soon as possible after recovery.

Which clinical manifestation is seen in the child with hydrocephalus?

An extremely large and rapidly growing head

All infants need to be observed for hypoglycemia during the newborn period. Based on the facts obtained from pregnancy histories, which infant would be most likely to develop hypoglycemia? a) An infant whose mother craved chocolate during pregnancy b) An infant whose labor began with ruptured membranes c) An infant who has marked acrocyanosis of his hands and feet d) An infant who had difficulty establishing respirations at birth

An infant who had difficulty establishing respirations at birth Explanation: Newborns use a great many calories in their effort to achieve effective respirations. Infants who had difficulty establishing respirations need to be assessed for hypoglycemia.

After delivery, an infant experiences meconium aspiration. What does the nurse anticipate the physician ordering prophylactically to prevent pneumonia? a) Intubation b) Antibiotics c) Inhaled surfactant d) Suction of the oropharynx

Antibiotics

When diagnosed with a deep vein thrombosis, the nurse knows the patient will be treated with which medication? a) Non-steroidal inflammatory b) Anticoagulants c) Narcotic analgesics d) Beta blockers

Anticoagulants

When diagnosed with a deep vein thrombosis, the nurse knows the patient will be treated with which medication? a) Non-steroidal inflammatory b) Anticoagulants c) Narcotic analgesics d) Beta blockers

Anticoagulants Correct Explanation: Anticoagulant therapy is used as the primary treatment option for DVT. This makes options A, C, and D incorrect.

The nurse examines a 26-week-old premature infant. The skin temperature is lowered. What could be a consequence of the infant being cold? a) Sleepiness b) Tachycardia c) Apnea d) Crying

Apnea Explanation: A premature infant has thin skin, an immature central nervous system (CNS), lack of brown fat stores, and an increased weight-to-surface area ratio. These are predisposing thermoregulation problems that can lead to hypothermia. As a result, the infant may become apneic, have respiratory distress, increase his or her oxygen need, or be cyanotic. The other choices are not specific to increased oxygen demand or respiratory distress.

Immediately after delivery, the nurse is caring for a newborn with a myeolomeningocele. What intervention should the nurse provide to prevent drying out of the sac to avoid damage? a) Cover the sac with petroleum jelly and a dry sterile dressing. b) Apply a sterile dressing moistened in a warm sterile saline solution. c) Cover the sac with a water-soluble lubricant and a dry sterile dressing. d) Allow the sac to dry out to "toughen" it.

Apply a sterile dressing moistened in a warm sterile saline solution.

Which intervention would be helpful to a bottle-feeding client who's experiencing hard or engorged breasts? a) Applying warm compresses b) Restricting fluids c) Administering bromocriptine (Parlodel) d) Applying ice

Applying ice

Which intervention would be helpful to a bottle-feeding client who's experiencing hard or engorged breasts? a) Restricting fluids b) Applying ice c) Applying warm compresses d) Administering bromocriptine (Parlodel)

Applying ice Correct Explanation: Ice promotes comfort by decreasing blood flow (vasoconstriction), numbing the area, and discouraging further letdown of milk. Restricting fluids doesn't reduce engorgement and shouldn't 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.

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?

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 identifies a nursing diagnosis of risk for injury related to possible effects of oxytocin therapy. Which of the following would the nurse do to ensure a positive outcome for the client? a) Administer hydration and sedation frequently b) Turn down oxytocin administration by half c) Assess contractions by using external monitor d) Start administering tocolytic therapy

Assess contractions by using external monitor Correct Explanation: In a client with the risk for injury, continuous assessment of contractions using external monitor and palpation to ensure the presence of a low resting tone will assist in collecting information about labor and the need for further intervention. Turning down oxytocin administration by half is required if hyperstimulation occurs, not to prevent it. Tocolytic therapy is generally employed when preterm labor has been definitively diagnosed. Administering hydration and sedation frequently, and bedrest are employed to halt preterm labor since these stop uterine activity by increasing intravascular volume and uterine blood flow.

The nurse identifies a nursing diagnosis of risk for injury related to possible effects of oxytocin therapy. Which action would the nurse perform to ensure a positive outcome for the client?

Assess contractions by using external monitor. In a client with the risk for injury, continuous assessment of contractions using external monitor and palpation to ensure the presence of a low resting tone will assist in collecting information about labor and the need for further intervention. Turning down oxytocin administration by half is required if hyperstimulation occurs not to prevent it. Tocolytic therapy is generally employed when preterm labor has been definitively diagnosed. Administering hydration and sedation frequently and bedrest are employed to halt preterm labor since these stop uterine activity by increasing intravascular volume and uterine blood flow.

A small-for-gestational age infant is admitted to the observational care unit with the nursing diagnosis of ineffective thermoregulation related to lack of fat stores as evidenced by persistent low temperatures. Which are appropriate nursing interventions? Select all that apply.

Assess the axillary temperature every hour. Review maternal history. Assess environment for sources of heat loss. Encourage skin-to-skin contact. Proper care to promote thermoregulation include assessing the axillary temperature every hour, reviewing the maternal history to identify risk factors contributing to problem, assessing the environment for sources of heat loss, avoiding bathing and exposing newborn to prevent cold stress, and encouraging kangaroo care (mother or father holds preterm infant underneath clothing skin-to-skin and upright between breasts) to provide warmth.

A nurse is assessing a client with postpartal 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.

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.

On examining a woman who gave birth 5 hours ago, the nurse finds that the woman has completely saturated a perineal pad within 15 minutes. Which action by the nurse should be implemented first? a) Assess the woman's fundus. b) Begin an IV infusion of Ringer's lactate solution. c) Assess the woman's vital signs. d) Call the woman's health care provider.

Assess the woman's fundus.

On examining a woman who gave birth 5 hours ago, the nurse finds that the woman has completely saturated a perineal pad within 15 minutes. Which action by the nurse should be implemented first? a) Call the woman's health care provider. b) Assess the woman's fundus. c) Assess the woman's vital signs. d) Begin an IV infusion of Ringer's lactate solution.

Assess the woman's fundus.

Which of the following assessments would lead you to believe a postpartal woman is developing a urinary complication? a) She has voided a total of 1000 mL in two voidings, each spaced 1 hour apart. b) At 8 hours postdelivery she has voided a total of 100 mL in four small voidings. c) Her perineum is obviously edematous on inspection. d) She tells you she is extremely thirsty.

At 8 hours postdelivery she has voided a total of 100 mL in four small voidings.

Which of the following assessments would lead you to believe a postpartal woman is developing a urinary complication? a) Her perineum is obviously edematous on inspection. b) She tells you she is extremely thirsty. c) At 8 hours postdelivery she has voided a total of 100 mL in four small voidings. d) She has voided a total of 1000 mL in two voidings, each spaced 1 hour apart.

At 8 hours postdelivery she has voided a total of 100 mL in four small voidings. Correct Explanation: Postpartal women who void in small amounts may be experiencing bladder overflow from retention.

A nurse is providing care to a couple who have experienced intrauterine fetal demise. Which action would be least effective in assisting a couple at this time?

Avoid any discussion of the situation with the couple. The nurse should encourage discussion of the loss and allow the couple to vent their feelings of grief and guilt. The nurse should allow the parents to spend unlimited time with their stillborn infant so that they can validate the death. Providing the parents and family with mementos of the infant helps validate the reality of the death. Assisting the family with arrangements is helpful to reduce the stress of coping with the situation and making decisions at this difficult time.

What is the most frequent reason for postpartum hemorrhage? A) endometritis B) uterine atony C) perineal lacerations D) disseminated intravascular coagulation

B) uterine atony When a uterus does not contract well, the denuded placental surface can bleed excessively.

A nurse is caring for an infant. A serum blood sugar of 40 was noted at birth. What care should the nurse provide to this newborn?

Begin early feedings either by the breast or bottle. The nurse should provide some nutrition to any infant born with hypoglycemia. Dextrose should be given intravenously only if the infant refuses oral feedings, not before offering the infant oral feedings. Placing the infant on a radiant warmer will not help maintain blood glucose levels. The nurse should focus on decreasing blood viscosity in an infant who is at risk for polycythemia, not hypoglycemia. pg 840

The newborn nursery nurse has admitted a large-for-gestational age infant, one hour old for observation. The initial blood glucose level is 44 mg/dl (2.44 mmol). What is the nurse's priority action?

Begin supervised feedings for the newborn. Hypoglycemia in a neonate is defined as blood glucose value below 40 mg/dL. Supervised breastfeeding or formula feeding may be initial treatment options in asymptomatic hypoglycemia. Hypoglycemia has been linked to poor neurodevelopmental outcome, and hence aggressive screening and treatment is recommended. Monitor blood glucose levels within 30 minutes of birth, and repeat the screening every hour. Recheck levels before feedings and also immediately in any infant suspected of having or showing clinical signs of hypoglycemia.

During a clinical conference, a group of nursing students are discussing a newborn that is large for gestational age. The instructor determines the students have successfully differentiated the potential cause after choosing which contributing maternal factor?

Being 30 pounds overweight before getting pregnant

Which measurement best describes delayed postpartum hemorrhage? a) Blood loss in excess of 500 ml, occurring 24 hours to 6 weeks after delivery b) Blood loss in excess of 300 ml, occurring 24 hours to 6 weeks after delivery c) Blood loss in excess of 1,000 ml, occurring 24 hours to 6 weeks after delivery d) Blood loss in excess of 800 ml, occurring 24 hours to 6 weeks after delivery

Blood loss in excess of 500 ml, occurring 24 hours to 6 weeks after delivery Correct Explanation: Postpartum hemorrhage involves blood loss in excess of 500 ml. Most delayed postpartum hemorrhages occur between the fourth and ninth days postpartum. The most common causes of a delayed postpartum hemorrhage include retained placental fragments, intrauterine infection, and fibroids.

You are caring for a postpartum woman who exhibits a large amount of bleeding. Which areas would you need to assess before the woman ambulates? a) Degree of responsiveness, respiratory rate, fundus location b) Blood pressure, pulse, complaints of dizziness c) Attachment, lochia color, complete blood cell count d) Height, level of orientation, support systems

Blood pressure, pulse, complaints of dizziness

Amniotic fluid embolism is a true medical emergency. If it occurs during labor, what sign of fetal distress is usually noted? a) Arrested fetal movement b) Tachycardia c) Tachapnea d) Bradycardia

Bradycardia Explanation: In most cases, symptoms of amniotic fluid embolism occur suddenly during or immediately after labor. The woman usually develops symptoms of acute respiratory distress, cyanosis, and hypotension. If she is in labor, the fetus typically demonstrates signs of fetal distress, with bradycardia occurring in most cases.

A nurse is caring for a client who has just undergone delivery. What is the best method for the nurse to assess this client for postpartum hemorrhage? a) By frequently assessing uterine involution b) By assessing skin turgor c) By monitoring hCG titers d) By assessing blood pressure

By frequently assessing uterine involution

The nurse is assessing the woman who has a forceps-assisted birth for complications. Which of the following would be least likely to occur in the mother? a) Perineal hematoma b) Infection of episiotomy c) Cervical lacerations d) Caput succedaneum

Caput succedaneum Correct Explanation: Caput succedaneum is a complication that may occur in the newborn of a woman who had a forceps- assisted birth. Maternal complications include tissue trauma, such as lacerations of the cervix, vagina, and perineum, hematoma, extension of episiotomy into the anus, hemorrhage, and infection.

What is the term for a small collection of blood that forms underneath the skull as a result of birth trauma?

Cephalhematoma

In the child diagnosed with hydrocephalus, an obstruction occurs that blocks the normal process of which of the following? a) Cerebrospinal fluid b) Circulatory blood flow c) Lymphatic system d) Genitourinary tract

Cerebrospinal fluid

A 16-year-old client has been in the active phase of labor for 14 hours. An ultrasound reveals that the likely cause of delay in dilatation is cephalopelvic disproportion. Which of the following interventions should the nurse most expect in this case? a) Administration of oxytocin b) Cesarean birth c) Darkening room lights and decreasing noise and stimulation d) Administration of morphine sulfate

Cesarean birth Correct Explanation: If the cause of the delay in dilatation is fetal malposition or cephalopelvic disproportion (CPD), cesarean birth may be necessary. Oxytocin would be administered to augment labor only if CPD were ruled out. Administration of morphine sulfate (an analgesic) and darkening room lights and decreasing noise and stimulation are used in the management of a prolonged latent phase caused by hypertonic contractions. These measures would not help in the case of CPD.

Before calling the primary care provider to notify him or her of 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 care provider?

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.

Before calling the physician to notify him or her of a slow progression or an arrest of labor several assessments need to be made. What other maternal assessment do you need to make prior to calling the physician? a) Make sure the epidural medication is turned down. b) Check for a full bladder. c) Make sure the patient is lying on their left side. d) Assess vital signs every 30 minutes.

Check for a full bladder. Correct Explanation: Remember that a full bladder can interfere with the progress of labor. So be sure that the patient has emptied her bladder.

The nurse notes that a client's uterus, which was firm after the fundal massage, has become "boggy." Which intervention would the nurse do next?

Check for bladder distention, while encouraging the client to void. If the nurse finds a previously firm fundus to be relaxed, displaced, and boggy, the nurse should assess for bladder distension and encourage the woman to void or initiate catheterization as indicated. Emptying a full bladder facilitates uterine contraction and decreased bleeding. The nurse should not perform a vigorous fundal massage. Excessive massage leads to overstimulation of uterine muscle, resulting in excessive bleeding. The nurse should place the client in a semi-Fowler's position to encourage uterine drainage in the client with postpartum endometritis. The nurse should offer analgesics as prescribed by the primary care provider to minimize perineal discomfort in clients experiencing postpartum lacerations.

A nurse is caring for a postpartum client diagnosed with von Willebrand disease. What should be the nurse's priority for this client?

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 (30.0° 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 preterm newborn is noted to have hypotonia, apnea, bradycardia, a bulging fontanelle, cyanosis, and increased head circumference. These signs indicate the newborn has which complication?

intraventricular hemorrhage (IVH) Signs that may accompany IVH include hypotonia, apnea, bradycardia, a full (or bulging) fontanelle, cyanosis, and increased head circumference.

Client's temperature remains below 100.4° F or 38° C orally Explanation: As fever would accompany a puerperal 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 puerperal infection as does the reduced temperature.

Which of the following is an example of developmental care in the NICU? a) Giving medications b) Holding the infant c) Giving a bath d) Cluster care and activities

Cluster care and activities Correct Explanation: Clustering care and activities in the NICU decreases stress and helps developmentally support premature and sick infants. Developmental care can decrease assistance needed and length of hospital stay. The other choices are part of basic infant care.

A pregnant woman comes to the birthing center, stating she is in labor and doesn't know far along her pregnancy is because she has not had prenatal care. A physician performs an ultrasound that indicates oligohydramnios. When the patient's membranes rupture, meconium is in the amniotic fluid. What does the nurse suspect may be occurring with this patient? a) Placental abruption b) Complications of a post-term pregnancy c) Complications of placenta previa d) Complications of preterm labor

Complications of a post-term pregnancy Correct Explanation: A post-term pregnancy carries risks for increased perinatal mortality, particularly during labor. Oligohydramnios and meconium staining of the amniotic fluid are common complications. Oligohydramnios increases the incidence of cord compression, which can lead to fetal distress during labor. Thick, meconium-stained fluid increases the risk for meconium aspiration syndrome.

One of the primary assessments you, as a postpartum nurse, make every day is for postpartum hemorrhage. What do you assess the fundus for? a) Location, shape, and content b) Consistency, shape, and location c) Content, lochia, place d) Consistency, location, and place

Consistency, shape, and location

Which of the following interventions would be most important when caring for the client with breech presentation confirmed by ultrasound? a) Continuing to monitor maternal and fetal status b) Auscultating the fetal heart rate at the level of the umbilicus c) Noting the space at the maternal umbilicus d) Applying suprapubic pressure against the fetal back

Continuing to monitor maternal and fetal status Correct 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 woman is admitted to the labor suite with contractions every five minutes lasting one minute. She is post-term and has oligohydramnios. What does this increase the risk of during delivery? a) Cord compression b) Macrosomia c) Shoulder dystocia d) Fetal hydrocephalus

Cord compression Explanation: Oligohydramnios and meconium staining of the amniotic fluid are common complications of post-term pregnancy. Oligohydramnios increases the incidence of cord compression, which can lead to fetal distress during labor.

A nurse is caring for a child born with a tracheoesophageal fistula. Which finding during pregnancy would have caused the nurse to suspect this might be present? A) a difficult second stage of labor B) bleeding at 32 weeks of pregnancy C) oligohydramnios D) hydramnios

D) hydramnios

The nurse is caring for a large-for-gestational-age newborn (also known as macrosomia). What maternal condition is the usual cause of this condition? a) Diabetes b) Celiac disease c) Alcohol use d) Hypertension

Diabetes Correct Explanation: In the condition known as macrosomia, a newborn is born large for gestational age (LGA). These newborns are those with birth weights that exceed the 90th percentile of newborns of the same gestational age. They are born most often to mothers with diabetes.

After an hour of administering oxytocin intravenously, you assess a woman's contractions to be 80 seconds in length. Your first action would be to a) Discontinue the oxytocin infusion. b) Increase the flow rate of the main line infusion. c) Slow the infusion to under 10 gtts per minute. d) Continue to monitor contraction duration every 2 hours.

Discontinue the oxytocin infusion. Explanation: 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. You would not increase the flow rate of the main line infusion or slow the infusion without the physician's order. Uterine contractions are monitored continuously.

A postpartal woman is developing a thrombophlebitis in her right leg. Which assessment should the nurse no longer use to assess for thrombophlebitis?

Dorsiflex her right foot and ask if she has pain in her calf. A positive Homans' sign (pain in the upper calf upon dorsiflexion) is not a definitive diagnostic sign as it is insensitive and nonspecific and is no longer recommended as an indicator of DVT. That is because calf pain can also be caused by other conditions. Ask the woman if she has pain or tenderness in the lower extremities and assess for reddness and warmth and if she has increased pain when she ambulates or bears weight.

A postpartal woman is developing a thrombophlebitis in her right leg. Which of the following assessments would you make to detect this? a) Bend her knee and palpate her calf for pain. b) Ask her to raise her foot and draw a circle. c) Blanch a toe and count the seconds it takes to color again. d) Dorsiflex her right foot and ask if she has pain in her calf.

Dorsiflex her right foot and ask if she has pain in her calf. Explanation: A Homans' sign (pain in the calf on dorsiflexion of the foot) is a common assessment for thrombophlebitis in conjunction with assessing for edema and calf redness. Having her raise her foot and draw a circle would not be an assessment for thrombophlebitis in her leg, nor would assessing capillary refill in a toe

Which assessment findings are most prominent in the infant with Tetralogy of Fallot and significant pulmonary stenosis?

Dyspnea on limited exertion, fatigue, cyanosis

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

Endometritis

A nurse is caring for a newborn with asphyxia. What nursing management is involved when treating a newborn with asphyxia? a) Administer surfactant as ordere b) Ensure effective resuscitation measures c) Ensure adequate tissue perfusion d) Administer IV fluids

Ensure effective resuscitation measures

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

Escherichia coli

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?

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 metritis, but some species of Klebsiella may cause urinary tract infections.

You assess that the fetus of a woman is in an occiput posterior position. Which of the following identifies the way you would expect her labor to differ from others? a) Need to have the baby manually rotated. b) Necessity for vacuum extraction for delivery. c) Shorter dilatational stage of labor. d) Experience of additional back pain.

Experience of additional back pain. Correct 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 dilatational stage of labor, it does not indicate the need to have the baby manually rotated, and it does not indicate a necessity for a vacuum extraction delivery.

The nurse is assessing a newborn suspected of having meconium aspiration syndrome. What sign or symptom would be most suggestive of this condition? a) Intermittent tachypnea b) Expiratory grunting c) Bile-stained emesis d) High-pitched shrill cry

Expiratory grunting

Initial measures to stop Jessica's bleeding have not proved successful and she is being transferred to the ICU. Her family is frightened by the IV lines and the nasal cannula; Jessica's brother suddenly says to her partner, "This is all your fault!" What is the best response by the nurse? a) Tell them that the RN will be notified, who will explain Jessica's treatment to them. b) Explain Jessica's care, focusing on any signs of improvement, while acknowledging that this is a difficult time for them. c) Leave the room quietly; this is a family matter. d) Draw the brother aside and tell him that if he can't control himself, he'll have to leave.

Explain Jessica's care, focusing on any signs of improvement, while acknowledging that this is a difficult time for them.

Over 75% of women who give birth experience postpartum depression. a) False b) True

False

A nursing student has read that cleft lip is diagnosed at birth based on inspection of physical appearance and that cleft palate is diagnosed in which way?

Feeling the palate with a gloved finger or using a tongue blade

The client is 35 weeks of gestation and is being admitted for vaginal bleeding. The patient is stable at the time of admission. The priority nursing assessment for the client is for: a) Fetal heart tones. b) Signs of shock. c) Infection. d) Uterine stabilization

Fetal heart tones. Explanation: When a patient is admitted for vaginal bleeding and is stable, the next priority assessment is to determine if the fetus is viable. Options C and D are not a higher priority than fetal heart tones.

In caring for the child with esophageal atresia the nurse recognizes the highest concern for this child is the possibility of which of the following? a) Respiratory distress b) Cardiac anomalies c) Excess bleeding d) Feeding difficulty

Respiratory distress

A nurse is caring for an infant born with polycythemia. Which intervention is most appropriate when caring for this infant? a) Check blood glucose within 2 hours of birth by reagent test strip b) Repeat screening every 2 to 3 hours or before feeds c) Focus on decreasing blood viscosity by increasing fluid volume d) Focus on monitoring and maintaining blood glucose levels

Focus on decreasing blood viscosity by increasing fluid volume

After assessing the status of a newborn, the nurse is concerned that this newborn has persistent pulmonary hypertension. When explaining it to the parents, the nurse would integrate knowledge about which event as having most likely occurred?

Foramen ovale has not closed.

After teaching a group of students about the effects of prematurity on various body systems, the instructor determines that the class was successful when the students identify which of the following as an effect of prematurity? a) Fragile cerebral blood vessels b) Enhanced ability to digest proteins c) Enlarged respiratory passages d) Rapid glomerular filtration rate

Fragile cerebral blood vessels Explanation: Preterm newborns have fragile blood vessels in the brain, and fluctuations in blood pressure can predispose these vessels to rupture, causing intracranial hemorrhage. The preterm newborn typically has smaller respiratory passages, leading to an increased risk for obstruction. Preterm newborns have a limited ability to digest proteins. The preterm newborn's renal system is immature, which reduces his or her ability to concentrate urine and slow the glomerular filtration rate.

The nurse is caring for a pregnant woman who is struggling with controlling her gestational diabetes mellitus. What effect does the nurse predict this situation may have on the fetus?

Grow to an unusually large size

A newborn that has a surfactant deficiency will have which assessment noted on a physical exam: a) Pink skin b) Regular respirations c) Hypertension d) Grunting

Grunting Correct Explanation: Infants that are deficient in lung surfactant will show signs of respiratory distress: grunting, retracting, tachypnea, cyanosis, poor perfusion, hypotension, and skin mottling.

A client has delivered a small for gestation age (SGA) newborn. Which of the following would the nurse expect to assess? a) Protuberant abdomen b) Brown lanugo body hair c) Round flushed face d) Head larger than body

Head larger than body

At a preconception counseling class, a client expresses concern and wonders how Healthy People 2020 will improve maternal infant outcomes. Which responses by the nurse are appropriate? Select all that apply.

Healthy People 2020 will reduce the rate of fetal and infant deaths. Healthy People 2020 will decrease the number of all infant deaths (within 1 year). Healthy People 2020 will decrease the number of neonatal deaths (within the first year). Healthy People 2020 will foster early and consistent prenatal care. One of the leading health indicators as identified by Healthy People 2020 refers to decreasing the number of infant deaths. Acquired and congenital conditions account for a significant percentage of infant deaths.

A client asks the nurse what surfactant is. Which explanation would the nurse give as the main role of surfactant in the neonate? a) Helps the lungs remain expanded after the initiation of breathing b) Promotes clearing of mucus from the respiratory tract c) Assists with ciliary body maturation in the upper airways d) Helps maintain a rhythmic breathing pattern

Helps the lungs remain expanded after the initiation of breathing Correct Explanation: Surfactant works by reducing surface tension in the lung, which allows the lung to remain slightly expanded, decreasing the amount of work required for inspiration. Surfactant hasn't been shown to influence ciliary body maturation, clearing of the respiratory tract, or regulation of the neonate's breathing pattern.

The nurse is caring for a 22-hour-old neonate male and notes on assessment at the beginning of the shift: Apgar score of 9, nursing without difficulty, and appeared healthy. As the nurse's shift goes on, subsequent assessment reveals his sclera and skin have begun to take on a yellow hue. The nurse would report this as a possible indication of what condition?

Hemolytic disease

The nurse administers methylergonovine 0.2 mg to a postpartal woman with uterine subinvolution. Which assessment should the nurse make prior to administering the medication?

Her blood pressure is below 140/90 mm Hg. Methylergonovine elevates blood pressure. It is important to assess that it is not already elevated before administration.

A male newborn is born with hypospadias. The nurse doing the newborn physical assessment notes that the penis is also curved downward. What information would the nurse provide the parents for this infant?

His ability to void and have an erection in adulthood may be impaired and surgery is needed. Hypospadias is a relatively common malformation of the male genital organ. It is an abnormal positioning of the urinary meatus on the underside of the penis. It is often accompanied by a downward bowing of the penis (chordee), which can lead to urination and erection problems in adulthood. There are no maneuvers that will improve the penis curvature, surgery is definitely warranted and needed, and infants with hypospadius are never circumcised because the foreskin may be needed for later repairs.

Which of the following is a consequence of hypothermia in a newborn? a) Skin pink and warm b) Holds breath 25 seconds c) Heart rate of 126 d) Respirations of 46

Holds breath 25 seconds Explanation: Apnea is the cessation of breathing for a specific amount of time, and in newborns it usually occurs when the breath is held for 15 seconds. Apnea, cyanosis, respiratory distress, and increased oxygen demand are all consequences of hypothermia.

At 31 weeks' gestation, a 37-year-old woman who has a history of preterm birth reports cramps, vaginal pain, and low, dull backache accompanied by vaginal discharge and bleeding. Her cervix is 2.1 cm long; she has fetal fibronectin in her cervical secretions, and her cervix is dilated 3 to 4 cm. For what do you prepare her? a) An emergency cesarean section b) Bed rest and hydration at home c) Hospitalization, tocolytic therapy, and IM corticosteroids d) Careful monitoring of fetal kick counts

Hospitalization, tocolytic therapy, and IM corticosteroids Explanation: At 31 weeks gestation, the goal would be to maintain the pregnancy as long as possible if the mother and fetus are tolerating continuation of the pregnancy. Stopping the contractions and placing the patient in the hospital allow for monitoring and a safe place if the woman continues and delivers. Administration of corticosteroids may help to develop the lungs and prepare for early preterm delivery. Sending the woman home is contraindicated in the scenario described. An emergency cesarean section is not indicated at this time. Monitoring fetal kick counts is typically done with a post-term pregnancy.

You care for a child born with a tracheoesophageal fistula. Which finding during pregnancy would have caused you to suspect this might be present? a) Oligohydramnios b) A difficult second stage of labor c) Hydramnios d) Bleeding at 32 weeks of pregnancy

Hydramnios

You care for a child born with a tracheoesophageal fistula. Which finding during pregnancy would have caused you to suspect this might be present? a) Oligohydramnios b) Bleeding at 32 weeks of pregnancy c) A difficult second stage of labor d) Hydramnios

Hydramnios

The nurse begins intermittent oral feedings for a small-for-gestational-age newborn to prevent which of the following? a) Asphyxia b) Meconium aspiration c) Hypoglycemia d) Polycythemia

Hypoglycemia Correct Explanation: Intermittent oral feedings are initiated to prevent hypoglycemia as the newborn now must assume control of glucose homeostasis. Hydration and frequent monitoring of hematocrit are important to prevent polycythemia. Resuscitation and suctioning are used to manage meconium aspiration. Immediate resuscitation is used to manage asphyxia.

An obese woman with diabetes has just given birth to a term, large for gestational age (LGA) newborn. Which of the following conditions should the nurse most expect to find in this infant? a) Hypoglycemia b) Hypertension c) Hypotension d) Hyperglycemia

Hypoglycemia Correct Explanation: LGA infants also need to be carefully assessed for hypoglycemia in the early hours of life because large infants require large amounts of nutritional stores to sustain their weight. If the mother had diabetes which was poorly controlled (the cause of the large size), the infant would have had an increased blood glucose level in utero to match the mother's; this caused the infant to produce elevated levels of insulin. After birth, these increased insulin levels will continue for up to 24 hours of life, possibly causing rebound hypoglycemia.

A woman with diabetes has just given birth. While caring for this neonate, the nurse is aware that he's at risk for which complication? a) Anemia b) Hypoglycemia c) Nitrogen loss d) Thrombosis

Hypoglycemia Correct Explanation: Neonates of mothers with diabetes are at risk for hypoglycemia due to increased insulin levels. During gestation, an increased amount of glucose is transferred to the fetus through the placenta. The neonate's liver can't initially adjust to the changing glucose levels after birth. This inability may result in an overabundance of insulin in the neonate, causing hypoglycemia. Neonates of mothers with diabetes aren't at increased risk for anemia, nitrogen loss, or thrombosis.

A nurse is caring for an infant born with an elevated bilirubin level. When planning the infant's care, what interventions will assist in reducing the bilirubin level? Select all that apply.

Increase the infant's hydration. Offer early feedings. Initiate phototherapy. Hydration, early feedings, and phototherapy are measures that the nurse should take to reduce bilirubin levels in the newborn. Stopping breastfeeding or administering vitamin supplements will not help reduce bilirubin levels in the infant.

Over the course of an eight hour shift of postoperative care for a child who has had ventriculoatrial shunt placement, the nurse notes that the child's cry has become increasingly shrill and the child has projectile vomiting. The nurse would notify the physician immediately because of the possibility that the child might be experiencing a) A sudden increase in pain b) Increased intracranial pressure c) Infection at the surgical site d) Rejection of the shunt

Increased intracranial pressure

The nurse is caring for a small-for-gestational-age infant at 1 hour old, after a difficult birth, with a glucose level of 40 mg/dL (2.5 mmol/L). Which nursing action would be the priority?

Initiate early oral feedings. Metabolic needs are increased for catch-up growth in the SGA newborn. Initiate early and frequent oral feedings. Neonatal hypoglycemia is a major cause of brain injury since the brain needs glucose continuously as a primary source of energy. A newborn stressed at birth uses up available glucose stores quickly with resulting hypoglycemia. A plasma glucose concentration at or below 40 mg/dL necessitates and frequent oral feedings. With the loss of the placenta at birth, the newborn now must assume control of glucose homeostasis through oral feedings. The others at this time are not a priority. pg 851

The nurse is performing a postpartum check on a 40-year-old client. Which nursing measure is appropriate? a) Instruct the client to empty her bladder before the examination b) Wear sterile gloves when assessing the pad and perineum c) Perform the examination as quickly as possible d) Place the client in a supine position with her arms overhead for the examination of her breasts and fundus

Instruct the client to empty her bladder before the examination

A preterm newborn is noted to have hypotonia, apnea, bradycardia, a bulging fontanelle, cyanosis, and increased head circumference. These signs indicate the newborn has which complication?

Intraventricular hemorrhage (IVH)

A nurse is teaching a 42-week nulliparous pregnant woman about labor induction which is being recommended by her health care provider. The nurse determines that the woman needs additional teaching when she identifies which assessment as being done before induction?

Leopold's maneuver Before labor induction is started, fetal maturity (dating, ultrasound, amniotic fluid studies) and cervical readiness (vaginal examination, Bishop scoring) must be assessed. Both need to be favorable for a successful induction. Leopold's maneuver is a technique for determining the position of the fetus as it moves through the labor process.

A client has had a forceps delivery which resulted in lacerations and bleeding. How can a nurse identify if the bleeding is due to laceration? a) Look for a contracted uterus with vaginal bleeding. b) Look for a boggy uterus with vaginal bleeding. c) Look for an inverted uterus with vaginal bleeding. d) Look for a subinvoluted uterus with vaginal bleeding.

Look for a contracted uterus with vaginal bleeding.

The nurse is preparing to assess an infant who is diagnosed with a ventricular septal defect. Which assessment finding should the nurse be prepared to document?

Loud, harsh murmur

Which of the following is a common finding in the child who has a ventricular septal defect? a) Bounding pulse b) Delayed growth and development c) Fatigue and dyspnea d) Loud, harsh murmur

Loud, harsh murmur

Which nursing measure is most effective in reducing newborn infections?

Maintain medical asepsis while providing care. Nurses possess the education and assessment tools to decrease the incidence of and reduce the impact of newborn infections. Nurses should implement measures for prevention and early recognition, including maintaining medical and surgical asepsis for all providing care. Nurses should outline and carry out measures to prevent hospital-acquired infections, such as thorough hand-washing hygiene for all staff.

In the infant born with a cleft lip and a cleft palate, the highest priority of the nurse is related to which of the following? a) Reducing family anxiety related to the treatment b) Promoting coping skills in the family caregivers c) Maintaining the nutritional needs if the infant d) Managing the pain level of the infant

Maintaining the nutritional needs if the infant

Which of the following actions could you initiate to reduce the discomfort of a woman in labor whose fetus is in an occiput posterior position? a) Place her in a Trendelenburg position. b) Apply ice packs to her lower back. c) Massage her lower back. d) Urge her to maintain a prone position.

Massage her lower back. Correct Explanation: Counterpressure against the woman's back by a support person can be helpful in reducing this type of pain.

When monitoring a postpartum client 2 hours after delivery, the nurse notices heavy bleeding with large clots. Which response is most appropriate initially? a) Massaging the fundus firmly b) Administering ergonovine (Ergotrate) c) Performing bimanual compressions d) Notifying the primary health care provider

Massaging the fundus firmly

When reviewing the medical record of a newborn who is large for gestational age (LGA), which of the following factors would the nurse identify as having increased the newborn's risk for being LGA? a) Fetal exposure to low estrogen levels b) Low weight gain during pregnancy c) Maternal pregravid obesity d) Low maternal birth weight

Maternal pregravid obesity Correct Explanation: The nurse should identify maternal pregravid obesity as a risk factor for the development of LGA newborns. The other risk factors for the development of LGA newborns include fetal exposure to high estrogen, excess weight gain during pregnancy, gestational diabetes and high maternal birth weight.

A laboring client has been pushing without delivering the fetal shoulders. The primary care provider determines the fetus is experiencing shoulder dystocia. What intervention can the nurse assist with to help with the birth?

McRobert's maneuver The McRobert's maneuver is frequently successful and often tried first. It requires assistance from two people. Two nurses place the client in the lithotomy position, while each holds a leg and sharply flexes the leg toward the woman's shoulders. This opens the pelvis to its widest diameters and allows the anterior shoulder to deliver in almost half of the cases.

A nurse is caring for a newborn whose chest x-ray reveals marked hyperaeration mixed with areas of atelectasis. The infant's arterial blood gas analysis indicates metabolic acidosis. The nurse should prepare for the management of which dangerous conditions when providing care to this newborn? a) Choanal atresia b) Diaphragmatic hernia c) Meconium aspiration syndrome d) Pneumonia

Meconium aspiration syndrome

Which of the following data is indicative of hypothermia of the preterm infant?

Nasal flaring Correct Explanation: Nasal flaring is a sign of respiratory distress. Infants with hypothermia show signs of respiratory distress (cyanosis, increased respirations, low oxygen saturation, nasal flaring, and grunting). The other choices are normal findings.

Which of the following data is indicative of hypothermia of the preterm infant? a) Regular respirations b) Oxygen saturation of 95% c) Nasal flaring d) Pink skin

A client arrives in the emergency department accompanied by her husband and new 10-week-old infant, crying, confused, and with possible hallucinations. The nurse recognizes this could possibly be postpartum psychosis as it can appear approximately when?

within 3 months of giving birth Postpartum psychosis generally surfaces within 3 months of giving birth

Which intervention should a nurse implement to promote thermal regulation in a preterm newborn? a) Observe for clinical signs of cold stress such as weak cry b) Check the blood pressure of the infant every 2 hours c) Assess the newborn's temperature every 8 hours until stable d) Set the temperature of the radiant warmer at a fixed level

Observe for clinical signs of cold stress such as weak cry

A woman recovering from cesarean birth in the hospital and who was catheterized complains of a feeling of burning on urination and a feeling of frequency. Which of the following should be the next nursing action? a) Administer amoxicillin, as prescribed b) Obtain a clean-catch urine specimen c) Encourage her to drink large amounts of fluid d) Suggest that she take an oral analgesic

Obtain a clean-catch urine specimen Explanation: The client in this scenario shows classic signs of a urinary tract infection. The priority nursing action at this point is to obtain a clean-catch urine specimen to confirm the infection. The other answers are therapeutic management interventions that would take place after confirmation of the infection via the clean-catch urine specimen.

What is the first action the nurse takes in surfactant administration? a) Hold feedings. b) Call pharmacy for medication. c) Obtain and document baseline vital signs. d) Change the infant's diaper.

Obtain and document baseline vital signs. Correct Explanation: Obtaining a baseline set of vital signs is the first step in surfactant administration. The nurse will need a baseline in case there is any reaction to the medication administration. The other choices are not the first thing done before instilling this medication.

A ventilated 33 weeks' gestation newborn in the neonatal intensive care unit (NICU) receives surfactant therapy. Which would the nurse expect to assess as a positive response to this therapy?

Oxygen saturation levels are at 98%. Rescue treatment is indicated for newborns with established RDS who require mechanical ventilation and supplemental oxygen. The earlier the surfactant is administered, the better the effect on gas exchange with an aim to have the O2 saturation level of 98%. Glucose level assessment does not correlate with this therapy. The HR of 60 bpm is an abnormal finding and not a positive result of the therapy. The PaCO2 indicates respiratory acidosis

A client with diabetes delivers a full-term neonate who weights 10 lb, 1 oz (4.6 kg). While caring for this large-for-gestational age (LGA) neonate, the nurse palpates the clavicles for which reason? a) Clavicles are commonly absent in neonates of mothers with diabetes. b) Neonates of mothers with diabetes have brittle bones. c) LGA neonates have glucose deposits on their clavicles. d) One of the neonate's clavicles may have been broken during delivery.

One of the neonate's clavicles may have been broken during delivery. Correct Explanation: Because of the neonate's large size, clavicular fractures are common during delivery. The nurse should assess all LGA neonates for this occurrence. None of the other options are true.

The nurse has attempted to massage a boggy uterus to firm state without success. The next intervention the nurse should anticipate is the administration of what medication? a) Ibuprofen b) Oxytocin c) Digoxin d) Penicillin

Oxytocin

Manual manipulation was used to reposition the uterus of a client who experienced uterine inversion. Which of the following would the nurse administer as ordered after repositioning? a) Magnesium sulfate b) Terbutaline c) Low-dose nitroglycerin d) Oxytoxic agent

Oxytoxic agent

When assessing the patient for postpartum hemorrhage the nurse monitors which of the following every hour? a) Pad count b) Vital signs c) Complete blood count d) Urine volume excreted

Pad count

Your patient delivered six hours ago. She calls you to her room complaining of pain "deep inside." You medicate her per orders with no relief attained. You check her vital signs and find they are markedly different then when the CNA charted them 30 minutes ago. What would you suspect? a) Uterine laceration b) Late postpartum hemorrhage c) Early postpartum hemorrhage d) Pelvic hematoma

Pelvic hematoma Explanation: A hematoma also can form deep in the pelvis where it is much more difficult to identify. The primary symptom is deep pain unrelieved by comfort measures or medication and accompanied by vital sign instability.

Which of the following places newborns at risk for ongoing health problems? a) Average weight b) Term birth c) Vaginal delivery d) Perinatal asphyxia

Perinatal asphyxia Correct Explanation: Several disorders can place newborns at risk for ongoing health problems such as prematurity, low birth weight, congenital abnormalities, perinatal asphyxia, and birth trauma. These conditions need further nursing assessment and care for optimal growth and healing. The other choices do not place a risk on the infant.

The nurse is monitoring a new mother changing her newborn's diaper and notices a musty smell to the infant's urine. Which condition should the nurse prioritize in further assessments to rule out?

Phenylketonuria

Samantha delivered her fourth child after protracted and difficult labor during which oxytocin was used to augment her contractions. The next day, her vaginal bleeding continues to be moderately heavy with numerous large clots. Palpating her fundus, you find that it is in the midline but boggy and above the level of the umbilicus. Fundal massage is indicated; what should you do first? a) Seek an order to obtain and administer an oxytocic. b) Ensure that her bladder is empty. c) Place one hand over the symphysis pubis. d) Insert uterine packing to control the hemorrhage.

Place one hand over the symphysis pubis.

A nurse is caring for a newborn client after birth who is diagnosed with myelomeningocele. Which nursing intervention would protect the newborn from injury?

Place the newborn in a prone or lateral position.

A nurse is caring for a newborn client after birth who is diagnosed with myelomeningocele. Which nursing intervention would protect the newborn from injury?

Place the newborn in a prone or lateral position. The nurse should place the newborn in a prone or lateral position to keep pressure off the spinal sac and avoid newborn injury. Parents should be allowed to hold the stable infant with assistance. The spinal sac should be kept covered and moist until surgery to avoid rupture. Collecting urine decreases the risk of urine stasis, which is sometimes common in spinal defects

Two weeks after their baby is born, Tom calls to report that his wife Sylvia is behaving strangely. She is extremely talkative and energetic and he has not observed her sleeping for more than an hour or two at a time. She is also forgetting to eat and neglecting her appearance, but worse, she seems to barely be aware of the baby's needs and appears surprised when Tom asks her about the child, "As if," Tom says, "she's forgotten that we even have a baby!" You tell him to bring her in right away, because you suspect Sylvia is suffering from what condition? a) Maladjustment b) Postpartum blues c) Postpartum psychosis d) Postpartum depression

Postpartum psychosis

The neonatal intensive care nurse admits an infant of a diabetic mother to the unit with symptoms of respiratory distress. The infant is jaundiced with a ruddy skin color. Which action would be a priority?

Prepare for repeat hematocit levels q12h. Newborn infants of diabetic mothers (IDM) are at risk for polycythemia. A priority for the nurse is to observe for clinical signs of polycythemia (respiratory distress, cyanosis, jitteriness, jaundice, ruddy skin color, and lethargy) and monitor blood results with hematocrit levels repeated every 12 hours. Blood glucose levels would be monitored more often than Q6H. Bleeding disorders do not correlate with the situation. CPAP may be needed but not as the priority. pg 836

A multipara presents to the hospital after 2 hours of labor. The fetus is presenting in transverse lie. The nurse notifies the primary care provider and takes which action?

Prepare to assist with external version or prep for a cesarean birth. Transverse lie is a fetal malposition and is a cause for labor dystocia. The fetus would need to be turned to the occipital position or be born via a 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. Counter pressure applied to the lower back with a fisted hand sometimes helps the woman to cope with the "back labor" that is characteristic of occiput posterior positioning. pg 758

A nurse is assigned to care for a newborn with esophageal atresia. What preoperative nursing care is the priority for this newborn?

Prevent aspiration by elevating the head of the bed, and insert an NG tube to low suction.

A nurse is caring for a postpartum client diagnosed with von Willebrand disease. What assessment finding will the nurse expect to find in the client? a) Prolonged bleeding time b) Postpartum fundal height that is higher than expected c) Foul-smelling vaginal discharge d) A fever of 100.4° F (38.0° C) after the first 24 hours following childbirth

Prolonged bleeding time

Which action would be most appropriate for the woman who experiences dysfunctional labor in the first stage of labor?

Provide ongoing communication about what is happening. Dysfunctional labor at any point is frustrating to women. Maintaining open lines of communication at least keeps the woman well informed about what is happening.

Which intervention would be most appropriate for the woman experiencing dystocia related to problems involving the psyche? a) Preparing the woman for an amniotomy b) Administering oxytocin c) Encouraging the woman to assume a hands-and-knees position d) Providing a comfortable environment with dim lighting

Providing a comfortable environment with dim lighting Explanation: Comfort measures minimize the woman's stress and promote relaxation so that she can work more effectively with the forces of labor. 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. A hands-and-knees position helps to promote fetal head rotation with a persistent occiput posterior position.

A woman near term presents to the clinic highly agitated because her membranes have just ruptured and she felt something come out when they did. The nurse is alone with her and notices that the umbilical cord is hanging out of the vagina. What should the nurse do next?

Put her in bed immediately, call for help, and hold the presenting part of the cord. Umbilical cord prolapse occurs when the umbilical cord slips down in front of the presenting part, when the presenting part compresses the cord oxygen, and nutrients are cut off 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 the nurse does not leave the woman. A vaginal birth is contraindicated in this situation.

An 18-year-old client has given birth in the 28th week of gestation, and her newborn is showing signs of respiratory distress syndrome (RDS). Which statement is true for a newborn with RDS?

RDS is caused by a lack of alveolar surfactant. Respiratory distress syndrome (RDS) is a serious breathing disorder caused by a lack of alveolar surfactant. Betamethasone, a glucocorticosteroid, is often given to the mother 12 to 24 hours before a preterm birth to help reduce the severity of RDS, not to the newborn following birth. Respiratory symptoms in the newborn with RDS typically worsen within a short period of time after birth, not improve. Diagnosis of RDS is made based on a chest X-ray and the clinical symptoms of increasing respiratory distress, crackles, generalized cyanosis, and heart rates exceeding 150 beats per minute (not below 50 beats per minute). p 842

Your patient is showing signs and symptoms of a pulmonary embolism. What should you do? a) Lay the patient flat and start oxygen. b) Sit the patient up 90 degrees and call the RN. c) Raise the head of the bed to at least 45 degrees. d) Start oxygen at 2 to 3 liters per minute via nasal cannula.

Raise the head of the bed to at least 45 degrees.

When planning care for a postpartum patient, the nurse is aware the most common site for postpartum infection is which of the following? a) Integumentary b) Reproductive c) Breast d) Urinary

Reproductive

What would be appropriate for the nurse to document in a child suffering from meconium aspiration syndrome? a) Respirations as increased and high b) Skin as pink c) Chest expansion as normal d) Heart rate as normal

Respirations as increased and high Correct Explanation: Infants with meconium aspiration syndrome may show signs of respiratory distress (tachypnea, cyanosis, retractions, chest retractions). The other choices document normal findings.

Restless and agitated, concerned with self

Restless and agitated, concerned with self Explanation: When a woman has postpartum psychosis the signs may vary but a woman presenting with restlessness, irritability and concerned only for self needs further evaluation. Therefore options A, B, and D are incorrect...

The nurse assesses preterm infants as they come for routine well-baby checkups. The nurse will carefully assess the infant's vision to assess for which potential complication related to their birth?

Retinopathy

A woman arrives at the office for her 4-week postpartal 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 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.

You are the nurse giving an educational presentation to the local Le Leche league chapter. One woman asks you about mastitis. What would be your best response? a) Risk factors include nipple piercing. b) Risk factors include breast pumps. c) Risk factors include complete emptying of the breast d) Risk factors include frequent feeding.

Risk factors include nipple piercing.

An infant has just been born with a cleft lip and palate. The birthing room suddenly becomes very quiet, and the birth team seem somber. The physician is busy examining the newborn, but the mother is obviously aware that something is not right. Which of the following should the nurse do? a) Say to the parents, "I'm very sorry. There appears to be a problem with your son. The doctor will be over shortly to talk to you about it." b) Say to the parents, "Your son has been born with a cleft lip and palate. This condition is highly treatable by surgery, however, and he is otherwise in excellent health." c) Wait until the physician has finished examining the baby, and allow her to tell the parents. d) When the physician has finished examining the baby, take the baby over to the mother and let her hold him and bond with him before discussing the condition.

Say to the parents, "Your son has been born with a cleft lip and palate. This condition is highly treatable by surgery, however, and he is otherwise in excellent health."

Labor dystocia is an abnormally progression of labor. It is the most common cause of primary caesarian delivery. When is it most common for labor dystocia to occur? a) Fourth stage of labor b) Third stage of labor c) First stage of labor d) Second stage of labor

Second stage of labor Correct Explanation: Labor dystocia can occur in any stage of labor, although it occurs most commonly once the woman is in active labor or when she reaches the second stage of labor.

Methylergonovine is ordered for a woman experiencing postpartum hemorrhage. The nurse monitors the woman closely for which of the following adverse effects? a) Uterine hyperstimulation b) Seizures c) Flushing d) Headache

Seizures

A postpartum woman is diagnosed as having endometritis. Which position would you expect to place her in based on this diagnosis? a) Semi-Fowler's. b) On her left side. c) Flat in bed. d) Trendelenburg.

Semi-Fowler's.

What treatment can the nurse anticipate assisting with for a newborn with congenital talipes equinovarus? a) Serial casting b) Open reduction with internal fixation c) Pavlik harness d) Closed reduction

Serial casting

The nurse would prepare a client for amnioinfusion when which action occurs?

Severe variable decelerations occur and are due to cord compression. Indications for amnioinfusion include severe variable decelerations resulting from cord compression, oligohydramnios (decreased amniotic fluid), postmaturity, preterm labor with rupture of the membranes, and thick meconium fluid. Failure of the fetal presenting part to rotate fully, descend in the pelvis, abnormal fetal heart rate patterns or acute pulmonary edema, and compromised maternal pushing sensations from anesthesia are indications for forceps-assisted birth, and not for amniofusion.

A nurse is caring for a newborn with jaundice undergoing phototherapy. What intervention is appropriate when caring for the newborn? a) Shield the newborn's eyes b) Expose the newborn's skin minimally c) Discourage feeding the newborn d) Discontinue therapy if stools are loose, green, and frequent

Shield the newborn's eyes

A nurse is performing a newborn assessment and notices a small dimple on the sacral area. The infant has a normal neurological assessment and moves all extremities well. What does the nurse suspect that the dimple indicates? a) Spina bifida occulta b) A normal spinal closure c) Spina bifida with menigocele d) Spina bifida with myelomeningocele

Spina bifida occulta

A nurse is performing a newborn assessment and notices a small dimple on the sacral area. The infant has a normal neurological assessment and moves all extremities well. What does the nurse suspect that the dimple indicates? a) Spina bifida with menigocele b) Spina bifida occulta c) A normal spinal closure d) Spina bifida with myelomeningocele

Spina bifida occulta

A 6-week gestation client asks the nurse what foods she should eat to help prevent neural tube disorders in her growing baby. The nurse would recommend which foods?

Spinach, oranges, and beans Folic acid assists in preventing the incidence of neural tube disorders. These foods include green, leafy vegetables, citrus fruits, beans, and fortified breads, cereals, rice, and pasta. Milk, yogurt, and cheese are high in calcium. Bananas, avocados, and coconut are high in potassium. Pork, beans, and poultry are high in iron.

The nurse is teaching a client with newly diagnosed mastitis about her condition. The nurse would inform the client that she most likely contracted the disorder from which organism? a) Escherichia coli b) Streptococcus pyogenes c) Group beta-hemolytic streptococci (GBS) d) Staphylococcus aureus

Staphylococcus aureus

The nurse is teaching a client with newly diagnosed mastitis about her condition. The nurse would inform the client that she most likely contracted the disorder from which organism?

Staphylococcus aureus The most common cause of mastitis is S. aureus, transmitted from the neonate's mouth. Mastitis is not harmful to the neonate. E. coli, GBS, and S. pyogenes are not associated with mastitis. GBS infection is associated with neonatal sepsis and death.

The nurse is teaching a client with newly diagnosed mastitis about her condition. The nurse would inform the client that she most likely contracted the disorder from which organism? a) Staphylococcus aureus b) Streptococcus pyogenes c) Group beta-hemolytic streptococci (GBS) d) Escherichia coli

Staphylococcus aureus Correct Explanation: The most common cause of mastitis is S. aureus, transmitted from the neonate's mouth. Mastitis isn't harmful to the neonate. E. coli, GBS, and S. pyogenes aren't associated with mastitis. GBS infection is associated with neonatal sepsis and death.

You are caring for a woman who is receiving IV antibiotics and supportive care for endometritis. Which of the following findings should you report as soon as you notice it? a) Breast-feeding b) Gradually decreasing temperature and pulse rate c) Steadily decreasing volume of urine d) Excessive diaphoresis

Steadily decreasing volume of urine

A nurse is caring for a preterm newborn who has developed rapid, irregular respirations with periods of apnea. Which of the following additional signs should the nurse consider as indications of respiratory distress syndrome (RDS) in the newborn? a) Inspiratory grunt b) Deep inspiration c) Sternal retraction d) Expiratory lag

Sternal retraction Correct Explanation: The nurse should consider sternal retraction as a sign of respiratory distress syndrome in the preterm newborn. Deep inspiration is not seen during respiratory distress; rather a shallow and rapid respiration is seen. There is an inspiratory lag, instead of an expiratory lag, during respiratory distress. There is a grunting heard when the air is breathed out, which is during expiration and not during inspiration.

Which of the following would be signs of dehydration in a newborn? a) Eight wet diapers a day b) 10% weight gain c) Sunken fontanels d) Frequent feedings

Sunken fontanels Correct Explanation: Sunken fontanels in a newborn are a sign of dehydration. Other signs are sunken eyeballs, decreased urine output, lethargy, decreased skin turgor, decreased body weight, and irritability.

The nurse is developing a plan of care for a neonate experiencing symptoms of drug withdrawal. What should be included in this plan?

Swaddle the infant between feedings. Supportive interventions to promote comfort include swaddling, low lighting, gentle handling, quiet environment with minimal stimulation, use of soft voices, pacifiers to promote "self-soothing," frequent small feedings, and vertical rocking, which will soothe the newborn's neurological system.

The nurse is caring for a newborn with hyaline membrane disease. Which of the following is the best explanation of this disorder? a) The infant's lungs are immature and deficient in surfactant b) The infant's liver is unable to manage the bilirubin produced by hemolysis c) The infant has bleeding into the ventricles of the brain d) The infant has a degenerative disease of the retina

The infant's lungs are immature and deficient in surfactant

A newborn girl who was born at 38 weeks of gestation weighs 2000 g and is below the 10th percentile in weight. The nurse recognizes that this girl will most likely be classified as which of the following? a) Term, small for gestational age, and very-low-birth-weight infant b) Term, small for gestational age, and low-birth-weight infant c) Late preterm and appropriate for gestational age d) Late preterm, large for gestational age, and low-birth-weight infant

Term, small for gestational age, and low-birth-weight infant Correct Explanation: Infants born before term (before the beginning of the 38th week of pregnancy) are classified as preterm infants, regardless of their birth weight. Term infants are those born after the beginning of week 38 and before week 42 of pregnancy. Infants who fall between the 10th and 90th percentiles of weight for their gestational age, whether they are preterm, term, or postterm, are considered appropriate for gestational age (AGA). Infants who fall below the 10th percentile of weight for their age are considered small for gestational age (SGA). Those who fall above the 90th percentile in weight are considered large for gestational age (LGA). Still another term used is low-birth-weight (LBW; one weighing under 2500 g at birth). Those weighing 1000 to 1500 g are very-low-birth-weight (VLB). Those born weighing 500 to 1000 g are considered extremely very-low-birth-weight infants (EVLB).

After teaching a group of students about the physiologic jaundice in breast-fed and bottle-fed newborns, the instructor determines that the teaching was successful when the students state which of the following? a) Jaundice associated with bottle feeding occurs in two distinct patterns. b) Peak bilirubin levels occur earlier for bottle-fed newborns than for breast-fed newborns. c) The decline in bilirubin levels occurs more quickly in bottle-fed newborns. d) Breast-fed newborns tend to have more frequent bowel movements.

The decline in bilirubin levels occurs more quickly in bottle-fed newborns.

The nurse is performing a newborn assessment and the infant's lab work reveals a heelstick hematocrit of 66. What is the best response to this finding?

The hematocrit needs to be repeated as a venous stick to see what the central hematocrit level is. A hematocrit above 65% is considered elevated and polycythemia is diagnosed. However, to get an accurate venous reading, a central venous hematocrit needs to be drawn to verify the value. Drawing the blood in 8 hours does not address the problem at present, and the infant does not need a partial exchange transfusion immediately. Health care providers will decide if this is needed after monitoring the infant for symptoms and following the central hematocrit levels. p.837

The nurse is caring for a newborn with retinopathy of prematurity (ROP). Which of the following is the best explanation of this disorder? a) The infant has a degenerative disease of the retina b) The infant's lungs are immature and deficient in surfactant c) The infant has bleeding into the ventricles of the brain d) The infant's liver is unable to manage the bilirubin produced by hemolysis

The infant has a degenerative disease of the retina

The nurse is caring for a newborn with respiratory distress syndrome (RDS). Which explanation best explains this disorder?

The infant's lungs are immature and deficient in surfactant. In RDS, the premature infant's lungs are deficient in surfactant and thus collapse after each breath, greatly increasing the work of breathing. The immature liver in the preterm infant cannot manage all the bilirubin produced by hemolysis (destruction of red blood cells with the release of hemoglobin), making the infant prone to jaundice and high blood bilirubin levels. Intraventricular hemorrhage (IVH) is a complication of preterm birth in which there is bleeding into the brain's ventricles. Retinopathy of prematurity (ROP) is a form of retinopathy (degenerative disease of the retina) commonly associated with the preterm newborn.

Which of the following would be appropriate for the use of low forceps? a) The fetal scalp is visible at the introitus without spreading the labia b) The fetal head is engaged but the leading point of the skull is less than +2 c) The leading point of fetal skull is at or above station +2, not on the pelvic floor d) The fetal skull has reached the pelvic floor, with the fetal head at the perineum

The leading point of fetal skull is at or above station +2, not on the pelvic floor Correct Explanation: Low forceps are applied when the leading point of the fetal skull is at or above station +2 and not on the pelvic floor. Outlet forceps, and not low forceps, are applied when the fetal skull has reached the pelvic floor, with the fetal head at the perineum and the fetal scalp visible at the introitus without spreading the labia. Mid forceps, and not low forceps, are applied when the fetal head is engaged but the leading point of the skull is less than +2.

Which statement describes why hypertonic contractions tend to become very painful?

The myometrium becomes sensitive from the lack of relaxation and anoxia of uterine cells. Hypertonic contractions cause uterine cell anoxia, which is painful.

A 20-year-old client gave birth to a baby boy during the 43rd week of gestation. What might the nurse observe in the newborn during routine assessment?

The newborn may look wrinkled and old at birth. Postterm babies are those born past 42 weeks of gestation. These babies often appear wrinkled and old at birth. They often have long fingernails and hair, dry parched skin, and no vernix caseosa. Both the quantity of lanugo and the amount of vernix decrease with gestational age. Undescended testes are usually not seen in postterm newborns; however, they are highly prevalent in preterm infants. p.858

The nurse is caring for a newborn with hemolytic disease of the newborn who is receiving phototherapy. Which of the following nursing interventions would be most appropriate for the nurse to do? a) The nurse dresses the newborn in a lightweight gown at night b) The nurse leaves the light off for one hour 6 times a day c) The nurse turns the newborn every 3 or 4 hours d) The nurse removes and changes the eye patches every hour

The nurse turns the newborn every 3 or 4 hours

The nurse observes a neonate born at 28 weeks' gestation. Which finding would the nurse expect to see?

The pinna of the ear is soft and flat and stays folded. The ear has a soft pinna that is flat and stays folded. Pale skin with no vessels showing through and 7 to 10 mm of breast tissue are characteristic of a neonate at 40 weeks' gestation. Creases on the anterior two-thirds of the sole are characteristic of a neonate at 36 weeks' gestation. pg 835

The nurse observes a neonate delivered at 28 weeks' gestation. Which finding would the nurse expect to see? a) The pinna of the ear is soft and flat and stays folded. b) The neonate has 7 to 10 mm of breast tissue. c) The skin is pale, and no vessels show through it. d) Creases appear on the interior two-thirds of the sole.

The pinna of the ear is soft and flat and stays folded. Correct Explanation: The ear has a soft pinna that's flat and stays folded. Pale skin with no vessels showing through and 7 to 10 mm of breast tissue are characteristic of a neonate at 40 weeks' gestation. Creases on the anterior two-thirds of the sole are characteristic of a neonate at 36 weeks' gestation.

A woman delivered a healthy baby girl two days ago. This is her third child and both of the other children are also girls. Which observation by the nurse indicates the need for additional assessment and follow-up? a) The woman comments that her baby has red hair like her grandmother. b) The woman reports that she will be happy to get home because she does not like hospital food. c) The woman actively participates in the care of her baby. d) The woman tells a friend, referring to her baby, "It just cries all the time."

The woman tells a friend, referring to her baby, "It just cries all the time."

A nurse is providing information for a pregnant woman who has just discovered that the fetus she's carrying is likely to have Down syndrome. Which statement by the nurse is most accurate regarding the possible concerns for a child with Down syndrome?

They have a higher risk of developing leukemia than those in the general population.

The nurse is caring for a newborn who has transient tachypnea of the newborn. In discussing the contributing factors for this disorder which of the following statements is most accurate? a) This disorder is associated with fetal distress during labor b) This disorder is often seen in newborns born by cesarean delivery c) This disorder usually occurs when the mother has a history of hypertension d) This disorder may be seen with advanced gestational age

This disorder is often seen in newborns born by cesarean delivery

A preterm newborn has just received synthetic surfactant through an endotracheal tube by a syringe. Which of the following interventions should the nurse implement at this point? a) Tip the infant into an upright position b) Immediately suction the infant's airway c) Take a blood sample d) Place the infant supine in a radiant heat warmer

Tip the infant into an upright position Explanation: It's important the infant is tipped to an upright position following administration of surfactant and the infant's airway is not suctioned for as long a period as possible after administration of surfactant to help it reach lower lung areas and avoid suctioning the drug away. A blood sample may be taken to rule out a streptococcal infection, which mimics the signs of RDS, but this would have been done before administration of surfactant. The infant should not be placed supine in a radiant heat warmer at this time but should be held in an upright position.

Brenda develops mastitis 3 weeks after delivery. What part of self-care do you tell her is most important? a) To take her antibiotic medication for the full 10 days even if she begins to feel better sooner b) To breast-feed or otherwise empty her breasts every 1 to 2 hours c) To increase her fluid intake to ensure that she will continue to produce adequate milk d) To use NSAIDs, warm showers, and warm compresses to relieve her discomfort

To breast-feed or otherwise empty her breasts every 1 to 2 hours

A client with a pendulous abdomen and uterine fibroid tumors had just begun labor and arrived at the hospital. After examining the client, the physician 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? a) Occipitoposterior position b) Anterior fetal position c) Transverse lie d) Cephalic presentation

Transverse lie Correct Explanation: A transverse lie, in which the fetus is more horizontal than vertical, occurs in women with pendulous abdomens, with uterine fibroid tumors that obstruct the lower uterine segment, with contraction of the pelvic brim, with congenital abnormalities of the uterus, or with hydramnios. Anterior fetal position and cephalic presentation are normal conditions. Occipitoposterior position tends to occur in women with android, anthropoid, or contracted pelves.

Preterm infant deaths account for 80% to 90% of infant mortality in the first year of life. a) False b) True

True

Hypertonic labor is labor that is characterized by short, irregular contractions without complete relaxation of the uterine wall in between contractions. Hypertonic labor can be caused by an increased sensitivity to oxytocin. What would you do for a patient who is in hypertonic labor because of oxytocin augmentation? a) Increase the methotrexate b) Increase the pitocin c) Turn off the pitocin d) Turn off the methotrexate

Turn off the pitocin Correct Explanation: Hypertonic labor may result from an increased sensitivity of uterine muscle to oxytocin induction or augmentation. Treatment for this iatrogenic cause of hypertonic labor is to decrease or shut off the oxytocin infusion.

Hypertonic labor is labor that is characterized by short, irregular contractions without complete relaxation of the uterine wall in between contractions. Hypertonic labor can be caused by an increased sensitivity to oxytocin. What would the nurse do for a client who is in hypertonic labor because of oxytocin augmentation?

Turn off the pitocin. Hypertonic labor may result from an increased sensitivity of uterine muscle to oxytocin induction or augmentation. Treatment for this iatrogenic cause of hypertonic labor is to decrease or shut off the oxytocin infusion.

A nurse preceptor asks a student to list commonly used diagnostic tests for preterm labor risk assessment. Which tests should the student include? Select all that apply.

U/A amniotic fluid analysis CBC Commonly used diagnostic testing for preterm labor risk assessment includes a complete blood count, urinalysis, and an amniotic fluid analysis. pg 772

Which maternal factors should the nurse consider contributory to a newborn being large for gestational age? Select all that apply.

diabetes mellitus postdates gestation prepregnancy obesity Diabetes mellitus, postdates gestation, and prepregnancy obesity are the maternal factors the nurse should consider that could lead to a newborn being large for gestational age. Renal condition and maternal alcohol use are not factors associated with a newborn's being large for gestational age.

The nurse is assisting with the birth of the second child of a healthy young woman. Her pregnancy has been uneventful, and labor has been progressing well. The fetal head begins to emerge, but instead of continuing to emerge, it retracts into the vagina. What should the nurse try first?

Use McRobert's maneuver. This intervention is used with a large baby who may have shoulder dystocia and require 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's 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 out of the province of the LVN to attempt birth of the fetus by pushing one of the fetus' shoulders in a clockwise or counterclockwise motion.

A nurse is assessing a full-term client in labor and determines the fetus is occiput posterior. The client states that all her discomfort is in her lower back. What intervention can the nurse provide that will help alleviate this discomfort?

Use a fist to apply counter pressure to the lower back. Counter pressure applied to the lower back with a fisted hand sometimes helps the woman to cope with the "back labor" characteristic of the occiput posterior position. pg 767

In working with the child or family of a child with a congenital disorder, the most effective nursing intervention for this child or family would be for the nurse to a) Keep the family informed about new and effective treatments b) Use reflective listening and offer nonjudgmental support c) Help the child to understand his or her limitations d) Model good medical practices for the child's family

Use reflective listening and offer nonjudgmental support

In working with the child or family of a child with a congenital disorder, the most effective nursing intervention for this child or family would be for the nurse to a) Model good medical practices for the child's family b) Keep the family informed about new and effective treatments c) Help the child to understand his or her limitations d) Use reflective listening and offer nonjudgmental support

Use reflective listening and offer nonjudgmental support

The nurse assesses an infant. Which finding may indicate heart failure?

diminished peripheral pulses

Which of the following is the most frequent reason for postpartum hemorrhage? a) Endometritis. b) Uterine atony. c) Perineal lacerations. d) Disseminated intravascular coagulation.

Uterine atony.

Which of the following is the most frequent reason for postpartum hemorrhage? a) Endometritis. b) Uterine atony. c) Perineal lacerations. d) Disseminated intravascular coagulation.

Uterine atony. Correct Explanation: When a uterus does not contract well, the denuded placental surface can bleed excessively. Therefore options A, C, and D are incorrect.

A client in the first stage of labor is diagnosed with dystocia involving the powers of labor. What would the nurse identify as the problem?

Uterine contractions are too weak or uncoordinated. When there are problems with the powers causing dystocia during the first stage of labor, the uterine contractions are too weak or uncoordinated to cause adequate cervical effacement and dilatation. Contractions are insufficient to cause fetal descent; the fetus being in a different position or presentation, and pelvis being either android type or platypelloid type are not the results of dystocia. During the second stage of labor, the nurse should observe if the contractions and the pushing are insufficient to cause descent of the fetus. A fetus that is in a different position or presentation is a problem with the passenger. A pelvis that is either android type or platypelloid type is a problem with the passageway and is not related to dystocia.

A nurse is assigned to care for a client with a uterine prolapse. Which of the following would be most important for the nurse to assess when determining the severity of the prolapse? a) Uterine bleeding present b) Pain in the lower abdomen c) Foul smelling lochia d) Uterine protrusion into the vagina

Uterine protrusion into the vagina Explanation: To determine if the uterine prolapse in the client is mild or severe, the nurse should assess for uterine protrusion of the cervix and uterus into the vagina. As more of the uterus descends, the vagina becomes inverted. Uterine bleeding, foul-smelling lochia, and pain or tenderness in the lower abdomen are all characteristic manifestations of late postpartum hemorrhage

While in labor a woman with a prior history of cesarean birth complains of light-headedness and dizziness. The nurse assesses the patient and notes an increase in pulse and decrease in blood pressure from the vital signs 15 minutes prior. What might the nurse consider as a possible cause for the symptoms? a) Uterine rupture b) Placentea previa c) Umbilical cord compression d) Hypertonic uterus

Uterine rupture Correct Explanation: The patient 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 patient a uterine rupture needs to be a first consideration. The scenario does not indicate a hypertonic uterus, a placenta previa, nor umbilical cord compression.

When caring for a client with postpartum blues, which intervention would be most appropriate? a) Validate the client's emotions, allowing her to express them freely b) Administer antidepressants as prescribed to lessen postpartum blues c) Recommend the client to a support group or to a mental health professional d) Avoid allowing contact between the newborn and the client

Validate the client's emotions, allowing her to express them freely Explanation: When caring for a client with postpartum blues, the nurse should validate the client's emotions and allow the client to express them freely. The nurse should not administer antidepressants to the client since these drugs are administered only during depression, postpartum or otherwise. Recommending the client to a support group or a mental health professional is not an appropriate intervention when caring for a client with postpartum blues. The nurse need not avoid contact between the mother who is experiencing postpartum blues and her infant

A procedure used in the treatment of the child with hydrocephalus is to surgically insert a shunt that drains cerebrospinal fluid into a chamber in the heart. This type of shunt procedure is referred to as which of the following? a) Ventricular septal b) Ventriculoatrial c) Atrial septal d) Ventriculoperitoneal

Ventriculoatrial

A nurse is caring for a neonate of 25 weeks' gestation who is at risk for intraventricular hemorrhage (IVH). Which assessment finding should be reported immediately?

a sudden drop in hemoglobin The signs and symptoms of IVH include a sudden decrease in hematocrit, a severe and sudden unexplained deterioration of vital signs, bulging fontanels, changes in activity level, and sudden lethargy. The diagnosis is confirmed by cranial ultrasonography. Pink skin with blue extremities is not a critical sign of IVH, nor is the routine calculation of intake and output a critical assessment for IVH.

When assessing a postpartum patient who was diagnosed with a cervical laceration which has been repaired, what sign should the nurse report as a possible development of hypovolemic shock? a) Weak and rapid pulse b) Decreased respiratory rate c) Elevated blood pressure d) Warm and flushed skin

Weak and rapid pulse Correct Explanation: The sign of weak and rapid pulse is the body in compensatory mechanism attempting to increase the blood circulation. This finding needs to be reported to the health care provider and RN as soon as possible. The other options are incorrect.

An infant develops hydrocephalus at 2 weeks of age. Which of the following would you expect to assess? a) Excessive thirst b) A soft, fretful cry c) White sclera showing above the pupils d) Hypothermia in the late afternoon

White sclera showing above the pupils

An infant develops hydrocephalus at 2 weeks of age. Which of the following would you expect to assess? a) Hypothermia in the late afternoon b) White sclera showing above the pupils c) A soft, fretful cry d) Excessive thirst

White sclera showing above the pupils

A woman who has given birth to a postterm newborn asks the nurse why her baby looks so thin, with so little muscle. The nurse responds based on the understanding about which of the following? a) The newborn was exposed to an infection while in utero. b) The newborn aspirated meconium, causing the wasted appearance. c) A postterm newborn has begun to break down red blood cells more quickly. d) With postterm birth, the fetus uses stored nutrients to stay alive, and wasting occurs.

With postterm birth, the fetus uses stored nutrients to stay alive, and wasting occurs. Explanation: After 42 weeks' gestation, the placenta loses its ability to provide adequate oxygen and nutrients to the fetus, causing the fetus to use stored nutrients to stay alive. This leads to wasting. Meconium aspiration can occur with postterm newborns, but this is not the reason for the baby's wasted appearance. Hyperbilirubinemia occurs with the increased breakdown of red blood cells, but this too would not account for the wasted appearance. Exposure to an intrauterine infection is unrelated to the wasted appearance.

Jerry, who is hypertensive and who received corticosteroids during pregnancy, delivered by cesarean and subsequently developed endometritis. Her incision is red, warm, and very sensitive to touch, and she remains febrile despite antibiotic therapy. What is the most important aspect of post hospital care to teach her? a) Wound care and hand washing b) Strict adherence to antibiotic therapy c) Proper perineal care d) Use of warm compresses and sitz baths

Wound care and hand washing

A woman recovering from cesarean birth in the hospital and who was catheterized complains of a feeling of burning on urination and a feeling of frequency. Which of the following should be the next nursing action? a) Obtain a clean-catch urine specimen b) Administer amoxicillin, as prescribed c) Encourage her to drink large amounts of fluid d) Suggest that she take an oral analgesic

a)Obtain a clean-catch urine specimen Explanation: The client in this scenario shows classic signs of a urinary tract infection. The priority nursing action at this point is to obtain a clean-catch urine specimen to confirm the infection. The other answers are therapeutic management interventions that would take place after confirmation of the infection via the clean-catch urine specimen.

A woman arrives at the office for her 4-week postpartal visit. Her uterus is still enlarged and soft, and lochial discharge is still present. Which of the following is the most likely nursing diagnosis for this patient? a) Risk for fatigue related to chronic bleeding due to subinvolution b) Risk for infection related to microorganism invasion of episiotomy c) Risk for impaired breastfeeding related to development of mastitis d) Ineffective peripheral tissue perfusion related to interference with circulation secondary to development of thrombophlebitis

a)Risk for fatigue related to chronic bleeding due to subinvolution Explanation: 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.

A nurse assesses a client in labor and suspects hypotonic uterine dysfunction. Which intervention would the nurse expect to include in the plan of care for this client?

A pregnant woman gives birth to a small for gestational age neonate who is admitted to the neonatal intensive care unit with seizure activity. The neonate appears to have abnormally small eyes and a thin upper lip. The infant is noted to be microcephalic. Based on these findings, which substance would the nurse suspect the women of using during pregnancy?

alcohol

Assessment reveals that a young mother has several risk factors for giving birth to an infant with a neural tube defect. Which laboratory test would the nurse expect to be used to monitor the fetus for this birth defect?

alpha-fetoprotein levels

The nurse examines a 26-week-old premature infant. The skin temperature is lowered. What could be a consequence of the infant being cold?

apnea A premature infant has thin skin, an immature central nervous system (CNS), lack of brown fat stores, and an increased weight-to-surface area ratio. These are predisposing thermoregulation problems that can lead to hypothermia. As a result, the infant may become apneic, have respiratory distress, increase his or her oxygen need, or be cyanotic. The other choices are not specific to increased oxygen demand or respiratory distress. pg 850

A newborn with high serum bilirubin is receiving phototherapy. Which nursing intervention is the most appropriate for this client?

application of eye dressings to the infant

A preterm newborn is noted to be cyanotic. Which laboratory test will the nurse prepare the infant for to determine if the cyanosis is due to respiratory or circulatory problems?

arterial blood gases

Which situation should concern the nurse treating a postpartum client within a few days of delivery? a) The client would like to watch the nurse give the baby her first bath b) The client feels empty since she delivered the neonate c) The client would like the nurse to take her baby to the nursery so she can sleep d) The client is nervous about taking the baby home

b)The client feels empty since she delivered the neonate Explanation: A client experiencing postpartum blues may say she feels empty now that the infant is no longer in her uterus. She may also verbalize that she feels unprotected now. The other options are considered normal and wouldn't be cause for concern. Many first-time mothers are nervous about caring for their neonates by themselves after discharge. New mothers may want a demonstration before doing a task themselves. A client may want to get some uninterrupted sleep, so she may ask that the neonate be taken to the nursery.

Effective nursing management involves many aspects and being aware of subtle changes in the client. Which of the following should alert the nurse to a potential infection in the client? a)Temperature of 37.5% C or higher after the first 12 hours after childbirth b)Temperature of 39% C or higher after the first 48 hours after childbirth c)Temperature of 38.5% C or higher after the first 36 hours after childbirth d)Temperature of 38% C or higher after the first 24 hours after childbirth

d)Temperature of 38% C or higher after the first 24 hours after childbirth Explanation: Postpartum infection is defined as a fever of 38% C or 100.4% F or higher after the first 24 hours after childbirth, occurring on at least two of the first 10 days after birth, exclusive of the first 24 hours.

A nurse is caring for a client with a postpartum laceration. Which of the following nursing diagnoses would be most appropriate? Select all that apply. a) Ineffective tissue perfusion b) Risk for disuse syndrome c) Risk for injury d) Impaired tissue integrity e) Ineffective thermoregulation

d)• Impaired tissue integrity c)• Risk for injury a)• Ineffective tissue perfusion Explanation: The nursing diagnoses associated with postpartum laceration include ineffective tissue perfusion, risk for injury, and impaired tissue integrity. Ineffective thermoregulation is a nursing diagnosis associated with an infection such as urinary tract infections. Risk for disuse syndrome is a nursing diagnosis associated with thromboembolic disorders.

The nurse providing care for a woman with preterm labor on magnesium sulfate would include which assessment for safe administration of the drug?

deep tendon reflexes (DTR)s Assessing deep tendon reflexes hourly in a client receiving magnesium sulfate is appropriate as depressed DTRs are a sign of magnesium toxicity. Elevated blood glucose is a fetal side effect but not noted to assess with the mother. Assessing for depressed respiration and hypotension not tachypnea or tachycardia would be appropriate assessments needed for the safe administration of magnesium sulfate.

The nurse assesses an infant. Which finding may indicate heart failure?

diminished peripheral pulses After birth, the nurse should carefully assess the newborn's cardiovascular and respiratory systems, looking for signs and symptoms of respiratory distress, cyanosis, or congestive heart failure that might indicate a cardiac anomaly. Assess rate, rhythm, and heart sounds, reporting any abnormalities immediately. Note any signs of heart failure, including edema, diminished peripheral pulses, hepatomegaly, tachycardia, diaphoresis, respiratory distress with tachypnea, peripheral pallor, and irritability. Capillary refill time and the color of the infant's hands and feet are important to note, but do not indicate possible heart failure and neither does the blood glucose level.

A nurse is assessing a pregnant woman who has come to the clinic. The woman reports that she feels some heaviness in her thighs since yesterday. The nurse suspects that the woman may be experiencing preterm labor based on which additional assessment findings? Select all that apply.

dull low backache malodorous vaginal discharge dysuria Symptoms of preterm labor are often subtle and may include change or increase in vaginal discharge with mucus, water, or blood in it; pelvic pressure; low, dull backache; nausea, vomiting or diarrhea, and heaviness or aching in the thighs. Constipation is not known to be a sign of preterm labor. Preterm labor is assessed when there are more than six contractions per hour.

Which clinical manifestation in a woman with deep vein thombosis (DVT) should the nurse report immediately?

dyspnea Dyspnea in any client with a DVT may be an indicator the clot has moved from the original site to the lungs. This is an emergency. A client who has a DVT would be expected to have calf pain, pyrexia, and edema.

esophageal atresia Any swallowed mucus or fluid enters the blind pouch of the esophagus when a newborn suffers from esophageal atresia. The newborn with this disorder will have frothing, excessive drooling, and periods of respiratory distress with choking and cyanosis. If this happens no feedings should be given until the newborn has been examined.

A nurse is assessing a newborn for jaundice. The nurse would first notice jaundice at which area?

face

About 10 days following birth, a new mother visits her primary care provider with localized symptoms of redness, swelling, warmth, and a hard, inflamed vessel in one leg. The nurse should suspect which condition?

femoral thrombophlebitis A woman experiencing a femoral thrombophlebitis will usually have unilateral localized symptoms such as redness, swelling, warmth, and a hard, inflamed vessel in the affected leg. Symptoms for thrombophlebitis usually present about 10 days after birth. Symptoms of uterine atony are a soft fundus and hemorrhage from the vagina. Symptoms of mastitis, infection of the breast, include a painful, swollen, reddened breast; fever; and scant breast milk. Symptoms of subinvolution include an enlarged, soft uterus and lochial discharge.

The client is 35 weeks of gestation and is being admitted for vaginal bleeding. She is stable at the time of admission. The priority nursing assessment for the client is for:

has a history of abnormal blood glucose levels. Uncontrolled maternal diabetes can be a contributing factor for the infant with intrauterine growth restriction. Smoking during pregnancy could be a contributing factor, but being a previous smoker would not affect this pregnancy. Inadequate maternal nutrition is a contributing factor, but because this mother was on a food stamp program she was more likely to have had adequate nutrition during pregnancy. Previous pregnancies with a history of IUGR or other poor pregnancy outcomes would be a possible contributing factor, but not normal pregnancies.

A client has arrived to the birthing center in labor, requesting a VBAC. The nurse knows that she would be a good candidate after reading the client's previous history based on which finding?

has previous lower abdominal incision The choice of a vaginal or repeat cesarean birth can be offered to women who had a lower abdominal incision. Contraindications to BVAC include a prior classic uterine incision, prior transfundal uterine surgery, uterine scar other than low-transverse cesarean scar, contracted pelvis, and inadequate staff of facility if an emergency cesarean birth is required.

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.

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 nurse is assessing vital signs for a postpartum client 48 hours after birth. The vital signs are: T 101.2° F; (38.4° C) HR 82 beats/min.; RR 18 breaths/min.; BP 125/78 mm Hg. How will the nurse interpret the vital signs?

infection Temperatures elevated above 100.4° F (38° C) 24 hours after birth are indicative of possible infection.

A nurse assisting in a birth notices that the amniotic fluid is stained greenish black as the baby is being born. Which intervention should the nurse implement as a result of this finding?

intubation and suctioning of the trachea Although there is some dispute regarding whether all infants with meconium staining need intubation, those with severe staining are usually intubated and meconium is suctioned from their trachea and bronchi. The nurse should not administer oxygen under pressure (bag and mask) until a meconium stained infant has been intubated and suctioned, so the pressure of the oxygen does not drive small plugs of meconium farther down into the lungs, worsening the irritation and obstruction. Gently shaking the infant and flicking the sole of his foot are methods of stimulating breathing in an infant experiencing apnea. p 837

A client presents to her postpartum appointment with vague reports. The nurse suspects postpartum depression based on which assessment finding?

lack of pleasure Some signs and symptoms of postpartum depression include feeling restless, worthless, guilty, hopeless, moody, sad, overwhelmed, cry a lot, exhibit a lack of energy and motivation, experience a lack of pleasure, changes in appetite, sleep, or weight, withdraw from friends and family, feel negatively toward her baby, or shows lack of interest in her baby

At the hospital, a client is attached to the fetal monitor for uterine rupture. The nurse would assess for which pattern indicating change in the uterus impacting the fetus?

late decelerations When the fetus is being deprived of oxygen the fetus will demonstrated 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.

An Rh positive client vaginally gives birth to a 6 lb, 10 oz (3,005 g) neonate after 17 hours of labor. Which condition puts this client at risk for infection?

length of labor A prolonged length of labor places the mother at increased risk for developing an infection. The average size of the neonate, vaginal birth, and Rh status of the client do not place the mother at increased risk

When monitoring a postpartum client 2 hours after birth, the nurse notices heavy bleeding with large clots. Which response is most appropriate initially?

massaging the fundus firmly Initial management of excessive postpartum bleeding is firm massage of the fundus and administration of oxytocin. Bimanual compression is performed by a primary health care provider. Ergotrate should be used only if the bleeding does not respond to massage and oxytocin. The primary health care provider should be notified if the client does not respond to fundal massage, but other measures can be taken in the meantime.

A newborn is diagnosed with respiratory distress syndrome (RDS). While assessing the newborn, the nurse realizes that which maternal factor would most place the infant at risk for RDS?

maternal gestational diabetes Prolonged rupture of membranes, gestational or chronic maternal hypertension, maternal narcotic addiction, and the use of prenatal corticosteroids reduces the newborn's risk for RDS because of the physiologic stress imposed on the fetus. Chronic stress experienced by the fetus in utero accelerates the production of surfactant before 35 weeks' gestation and thus reduces the incidence of RDS at birth. Maternal diabetes produces high levels of insulin that inhibits surfactant production thus placing the newborn more at risk for developing RDS.

The nurse assesses a newborn considered to be large-for-gestational age. What finding corresponds with this gestational age diagnosis?

meconium-stained skin and fingernails Postterm newborns typically exhibit the following characteristics: dry, cracked, peeling, wrinkled skin; vernix caseosa and lanugo are absent; long, thin extremities; creases that cover the entire soles of the feet; abundant hair on scalp; thin umbilical cord; long fingernails; limited vernix and lanug; and meconium-stained skin and fingernails. pg 840

The perinatal nurse is assessing a large-for-gestational age infant born by breech birth and notes that the infant is irritable and does not move the right arm. For what would the nurse assess?

midclavicular fracture Midclavicular fractures most often occur during births of newborns with macrosomia. The newborn is irritable and does not move the arm on the affected side either spontaneously or when the Moro reflex is elicited. A brachial plexus injury usually presents with the extremity adducted and internally rotated with absent shoulder movement. Phrenic nerve palsy is not associated with birth injuries and is caused by lesions along the phrenic nerve. The newborn does not demonstrate signs of cranial nerve trauma, which would be evident in the face.

It would be best to place an infant with a myelomeningocele in which position prior to surgery?

on the stomach (prone)

Manual manipulation was used to reposition the uterus of a client who experienced uterine inversion. Which medication would the nurse administer as prescribed after repositioning?

oxytoxic 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 postpartal woman calls the nurse into her room because she is having a very heavy lochia flow containing large clots. The nurse's first action would be to

palpate her fundus. Palpating the fundus will cause it to contract and reduce bleeding.

A postpartal woman calls the nurse into her room because she is having a very heavy lochia flow containing large clots. The nurse's first action would be to:

palpate her fundus. Palpating the fundus will cause it to contract and reduce bleeding.

A nurse is conducting a class for a group of expectant couples on fetal growth and development. The nurse determines that additional teaching is needed when the class identifies which factor as playing an important role in fetal growth and development?

paternal factors Fetal growth is dependent on genetic, placental, and maternal factors.

When caring for a client requiring a forceps-assisted birth, the nurse would be alert for:

A nurse is providing preoperative care to a female newborn client with the congenital abnormality myelomeningocele. Which intervention is the priority?

preventing infection

The nurse is caring for a baby born to a mother with a history of alcohol abuse. For what characteristics should the nurse observe to determine if the newborn has fetal alcohol syndrome? Select all that apply.

reduced ocular growth short palpebral fissures flattened nasal bridge The newborn withdrawing from alcohol typically is hyperactive and irritable, has trouble sleeping, and may have tremors or seizures. Characteristics of fetal alcohol syndrome (FAS) include low birth weight, small height and head circumference, short palpebral fissures, reduced ocular growth, and a flattened nasal bridge.

After assessing a client's progress of labor, the nurse suspects the fetus is in a persistent occiput posterior position. Which finding would lead the nurse to suspect this condition?

reports of severe back pain 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 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. Contractions that are more forceful in the midsection of the uterus rather than in the fundus suggest hypertonic uterine dysfunction.

A newborn is being monitored for retinopathy of prematurity. Which condition predisposes an infant to this condition?

respiratory distress syndrome Retinopathy of prematurity (ROP) is a complication that can occur when high concentrations of oxygen are given during the course of treatment for respiratory distress syndrome (RDS). ROP is caused by separation and fibrosis of the retinal blood vessels and can often result in blindness.

When assessing a newborn, the nurse determines that the newborn is most likely experiencing respiratory distress syndrome (RDS) based on which finding?

see-saw respirations Typically the newborn with RDS demonstrates signs and symptoms of severe respiratory distress at birth or within a few hours of birth. Fine, inspiratory crackles are noted on auscultation of a newborn with RDS. See-saw respirations are characteristic of RDS. A newborn with RDS typically demonstrates generalized cyanosis.

A woman the nurse is caring for during labor is having contractions 2 minutes apart but rarely over 50 mm Hg in strength; the resting tone is high, 20 to 25 mm Hg. She asks what she can do to make contractions more effective. The nurse's best response would be that:

she needs to rest because her contractions are hypertonic. These contractions appear to be hypertonic because of the high resting tone. Hypertonic contractions occur because the uterus is being overstimulated or erratically stimulated. Rest is effective in helping contractions become more productive.

A woman you are caring for during labor is having contractions 2 minutes apart but rarely over 50 mm Hg in strength; the resting tone is high, 20 to 25 mm Hg. She asks what she can do to make contractions more effective. Your best response would be that a) her physician will order oxytocin to strengthen contractions. b) she needs to rest because her contractions are hypertonic. c) hypotonic contractions of this kind will strengthen by themselves. d) walking around will make her contractions more regular.

she needs to rest because her contractions are hypertonic. Explanation: These contractions appear to be hypertonic because of the high resting tone. Hypertonic contractions occur because the uterus is being overstimulated or erratically stimulated. Rest is effective in helping contractions become more productive.

Effective nursing management involves many aspects and being aware of subtle changes in the client. Which finding should alert the nurse to a potential infection in the client?

temperature of 38° C or higher after the first 24 hours after birth Postpartum infection is defined as a fever of 38° C or 100.4° F or higher after the first 24 hours after birth, occurring on at least two of the first 10 days after birth, exclusive of the first 24 hours.

A woman gives birth to a newborn at 39 weeks' gestation. The nurse classifies this newborn as:

term. A term newborn is one born from the first day of the 38th week of gestation through 42 weeks. A postterm newborn is one born after completion of 42 weeks' gestation. A preterm newborn is one born before completion of 37 weeks' gestation. A late preterm newborn is one who is born between 34 and 37 weeks' gestation.

A nurse is assessing the following antenatal clients. Which client is at highest risk for having a multiple gestation?

the 41-year-old client who conceived by in vitro fertilization The nurse should assess infertility treatment as a contributor to 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 nurse is assessing the following antenatal clients. Which client is at highest risk for having a multiple gestation?

Which newborn would the nurse suspect to be most at risk for cognitive challenge due to the mother's actions during pregnancy?

the child of a client who admits to drinking a liter of alcohol daily during the pregnancy

A client develops mastitis 3 weeks after giving birth. What part of self-care does the nurse tell her is most important?

to breastfeed or otherwise empty her breasts every 1 to 2 hours Mastitis treatment involves complete removal of the milk from the breast as often as possible but no longer than a 3 hour time span and antibiotic therapy. It is most important to have the women keep the breast empty to prevent further stasis of milk ducts and worsening mastitis. The use of analgesics, warm showers, and warm compresses to relieve discomfort may be encouraged; increasing her fluid intake will keep the mother well-hydrated and able to produce an adequate milk supply. However, these actions would not be considered the most important aspects of self-care.

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

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. pg 769

A nurse is assessing a newborn. The nurse suspects that the newborn was exposed to drugs while in utero based on which findings? Select all that apply.

tremors nasal flaring frequent yawning

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

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.

A client in her 7th 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. a) Bizarre behavior b) Inability to concentrate c) Manifestations of mania d) Loss of confidence e) Decreased interest in life

• Inability to concentrate • Loss of confidence • Decreased interest in life

The nurse is preparing to talk to a group of pregnant women about elective induction and why it is not highly recommended. Which of the following should she include in her presentation? (Check all that apply.) a) It significantly increases the risk of C-section birth. b) It significantly increases instrumented delivery. c) It significantly increases the use of epidural analgesia. d) It significantly increases the admissions to the neonatal ICU. e) It significantly increases the weight of the newborn.

• It significantly increases the risk of C-section birth. • It significantly increases instrumented delivery. • It significantly increases the use of epidural analgesia. • It significantly increases the admissions to the neonatal ICU. Explanation: Evidence is compelling that elective induction of labor significantly increases the risk of cesarean birth, instrumented delivery, use of epidural analgesia, and neonatal ICU admissions. Increased birth weight is not a factor.

What is the term for a small collection of blood that forms underneath the skull as a result of birth trauma?

cephalhematoma Vernix caseosa is a thick white substance found on a newborn. Erythema toxicum is a newborn rash. Caput succedaneum is molding or edema.

A nurse is caring for a client who has been treated for a deep vein thrombosis (DVT). Which teaching point should the nurse stress when discharging the client? a) Avoid use of oral contraceptives. b) Plan long rest periods throughout the day. c) Avoid using compression stockings. d) Avoid using products containing aspirin.

Avoid use of oral contraceptives.

A nurse is assessing vital signs for a postpartum client 48 hours after birth. The vital signs are: temp 101.2° F (38.4° C); HR 82 beats/min.; RR 18 breaths/min.; BP 125/78 mm Hg. How will the nurse interpret the vital signs?

infection Temperatures elevated above 100.4° F (38° C) 24 hours after birth are indicative of possible infection. All but the temperature for this client are within normal limits, so they are not indicative of shock or dehydration.

Which of the following would lead the nurse to suspect that a large-for-gestational-age newborn has experienced birth trauma? a) Temperature instability b) Seizures c) Feeble sucking d) Asymmetrical movement

Asymmetrical movement Correct Explanation: A birth injury is typically characterized by asymmetrical movement. Temperature instability, seizures, and feeble sucking suggest hypoglycemia.

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

Avoid over-the-counter (OTC) salicylates

A 29-year-old postpartum client is receiving anticoagulant therapy for deep venous thrombophlebitis. The nurse should include which instructions in her discharge teaching?

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.

A nurse is assigned to care for a client with deep vein thrombosis who has to undergo anticoagulation therapy. Which of the following instructions should the nurse offer the client as a caution when the client receives anticoagulation therapy? a) Refrain from performing any leg exercises b) Avoid prolonged straining during defecation c) Avoid products containing aspirin d) Sit with legs crossed over each other

Avoid products containing aspirin

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?

Cervix dilates 1 cm per hour. A simple rule for evaluating the progress of labor is expecting 1 cm per hour of cervical dilation. If the cervix fails to respond to uterine contractions by dilating and effacing, then dysfunctional labor must be ruled out.

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 she 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 of the following conditions? a) Postpartum depression b) Postpartum blues c) Postpartum panic disorder d) Postpartum psychosis

Postpartum psychosis Explanation: The client's signs and symptoms suggest that the 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 infant, 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 her life is rapidly tumbling out of control. The client thinks of herself 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 characteristics of postpartum blues.

A nurse is assessing a full-term patient in labor and determines the fetus is occiput posterior. The patient states that all her discomfort is in her lower back. What intervention can the nurse provide that will help alleviate this discomfort? a) Use a fist to apply counter pressure to the lower back. b) Apply a warm washcloth to the lower back. c) Have the physician administer a pudendal block. d) Place the patient supine with the head of bed elevated 30 degrees.

Use a fist to apply counter pressure to the lower back. Correct Explanation: Counter pressure applied to the lower back with a fisted hand sometimes helps the woman to cope with the "back labor" characteristic of the occiput posterior position.

Which safety precautions should a nurse take to prevent infection in a newborn? Select all that apply.

Use sterile gloves for an invasive procedure. Initiate universal precautions when caring for the infant. Avoid coming to work when ill. To minimize the risk of infections, the nurse should avoid coming to work when ill, use sterile gloves for an invasive procedure, and initiate universal precautions. The nurse should remove all jewelry before washing hands, not cover the jewelry. The nurse should use disposable equipment rather than avoid it. pg 852

A fundal massage is sometimes performed on a postpartum woman. Which of the following is a reason for performing a fundal massage? a) Uterine atony b) Uterine prolapse c) Uterine contraction d) Uterine subinvolution

Uterine atony

A nurse is assigned to care for a client with a uterine prolapse. Which of the following would be most important for the nurse to assess when determining the severity of the prolapse? a) Uterine bleeding present b) Pain in the lower abdomen c) Foul smelling lochia d) Uterine protrusion into the vagina

Uterine protrusion into the vagina

Tocolytic therapy will help to prevent preterm birth. a) False b) True

False Explanation: Tocolytic therapy does not typically prevent preterm birth, but instead it may delay it.

A pregnant patient at 32 weeks' gestation calls the clinic and informs the nurse that she thinks her membranes are leaking. She states that some clear fluid has run down her leg. What is the best response by the nurse? a) "There's nothing to worry about if you passed only a little bit. The membranes will seal back over." b) "It is best for you to visit a hospital immediately. They can use a nitrazine strip to determine if it is amniotic fluid." c) "You may have just passed some urine. If it were amniotic fluid, there would be much more than that." d) "Go to the hospital now, because this could be very dangerous for the baby."

"It is best for you to visit a hospital immediately. They can use a nitrazine strip to determine if it is amniotic fluid." Correct Explanation: The practitioner will perform a speculum examination, looking for pooling of amniotic fluid, and then test the fluid with nitrazine paper, which turns blue in the presence of amniotic fluid. Preterm premature rupture of membranes occurs when the rupture of the amniotic sac before the onset of labor happens in a woman who is less than 37 weeks' gestation.

A woman with a history of PKU tells the nurse that she has decided to try to become pregnant. Her serum phenylalanine level is 10 mg/dL. Which of the following is an appropriate response for the nurse to make? a) "It will be best if you cut back on vegetables and fruit before you become pregnant to get your serum phenylalanine level down under 8 mg." b) "It will be best if you cut back on meat, fish, and dairy products before you become pregnant to get your serum phenylalanine level down under 8 mg." c) "The baby won't be able to breast feed. You know breast feeding is really the best way to care for a newborn." d) "Think carefully about the decision. The child might be mentally retarded if she inherits your PKU, especially if your levels stay that high."

"It will be best if you cut back on meat, fish, and dairy products before you become pregnant to get your serum phenylalanine level down under 8 mg."

The nurse is working with an adult female who has PKU and desires to become pregnant. The nurse notes on her assessment her current serum phenylalanine level is 10 mg/dL. Which instruction should the nurse prioritize for this client?

"It will be best if you cut back on meat, fish, and dairy products before you become pregnant to get your serum phenylalanine level down under 8 mg."

A client who gave birth vaginally 16 hours ago states she does not need to void at this time. The nurse reviews the documentation and finds that the client has not voided for 7 hours. Which response by the nurse is indicated?

"It's not uncommon after birth for you to have a full bladder even though you can't sense the fullness." After a vaginal birth, the client should be encouraged to void every 4 to 6 hours. As a result of anesthesia and trauma, the client may be unable to sense the filling bladder. It is premature to catheterize the client without allowing her to attempt to void first. There is no need to contact the care provider at this time as the client is demonstrating common adaptations in the early postpartum period. Allowing the client's bladder to fill for another 2 to 3 hours might cause overdistention.

A client who gave birth vaginally 16 hours ago states she doesn't need to void at this time. The nurse reviews the documentation and finds that the client hasn't voided for 7 hours. Which response by the nurse is indicated? a) "It's not uncommon after delivery for you to have a full bladder even though you can't sense the fullness." b) "I'll check on you in a few hours." c) "I'll contact your physician." d) "If you don't attempt to void, I'll need to catheterize you."

"It's not uncommon after delivery for you to have a full bladder even though you can't sense the fullness."

A client who gave birth vaginally 16 hours ago states she doesn't need to void at this time. The nurse reviews the documentation and finds that the client hasn't voided for 7 hours. Which response by the nurse is indicated? a) "I'll contact your physician." b) "If you don't attempt to void, I'll need to catheterize you." c) "It's not uncommon after delivery for you to have a full bladder even though you can't sense the fullness." d) "I'll check on you in a few hours."

"It's not uncommon after delivery for you to have a full bladder even though you can't sense the fullness." Correct Explanation: After a vaginal delivery, the client should be encouraged to void every 4 to 6 hours. As a result of anesthesia and trauma, the client may be unable to sense the filling bladder. It's premature to catheterize the client without allowing her to attempt to void first. There's no need to contact the physician at this time as the client is demonstrating common adaptations in the early postpartum period. Allowing the client's bladder to fill for another 2 to 3 hours might cause overdistention.

A patient is 32 weeks gestation and sent home on modified bedrest for preterm labor. She is on tocolyitics and wants to know when she can have intercourse again with her husband. What is the most appropriate response by the nurse? a) "You will not be able to have intercourse again until 6 weeks after you deliver." b) "The need to keep the infant safe should be of more concern than when to have sex." c) "That is a question to ask your health care provider, at this point you are on pelvic rest to try and stop any further labor." d) "Intercourse has nothing to do with preterm labor; you can have sex with your husband."

"That is a question to ask your health care provider, at this point you are on pelvic rest to try and stop any further labor." Explanation: The patient needs to be on pelvic rest until the health care provider says otherwise. The intercourse can cause excitability in the uterus and encourage cervical softening and should be avoided unless the provider gives the OK. Option A is incorrect as it may be giving misinformation to the patient. Option B does not answer the patient's question so it is incorrect. Option D also gives misinformation to the patient and is incorrect.

A nursing student, observing care of a 30-week-gestation infant in the neonatal intensive care unit, asks the nurse, "Are premature infants more susceptible to infection as I have to wash my hands so often in this department?" What is the nurse's best response?

"That is correct; a 30-week-gestation infant lacks the protective antibody called IgG." The preterm newborn's immune system is very immature, increasing his or her susceptibility to infections. A deficiency of IgG may occur because transplacental transfer does not occur until after 34 weeks' gestation. This protection is lacking if the baby was born before this time. Preterm newborns have an impaired ability to manufacture antibodies to fight infection if they were exposed to pathogens during the birth process. The preterm newborn's thin skin and fragile blood vessels provide a limited protective barrier, adding to the increased risk for infection. Anticipating and preventing infections is the goal with frequent hand washing while caring for them the gold standard. Breastfeeding will eventually establish some protective mechanisms. pg 843

The nurse weighs the new infant and calculates his measurements. The new mom asks, "Did my baby grow well? The doctor said he was LGA: What does that mean?" What is the best explanation? a) "That means your baby is over the 90th percentile for weight." b) "That means your baby is in the 5th percentile for weight." c) "That means that your baby is lazy sometimes." d) "That means your baby is average for gestational age."

"That means your baby is over the 90th percentile for weight." Correct Explanation: LGA stands for large for gestational age. These infants are over the 90th percentile for weight. The other choices are not over the 90th percentile for weight or describe a different characteristic.

The nurse is caring for an infant diagnosed with a ventricular septal defect. Which assessment findings does the nurse anticipate?

A harsh murmur

If the nurse manages a new infant with low blood sugar, which of the following would be an appropriate intervention to prevent hypoglycemia? a) Check the heart rate. b) Hold all feedings. c) Feed the infant. d) Give antibiotics.

Feed the infant. Correct Explanation: The infant could be fed early either breast milk or formula to prevent low blood sugar. If unable to feed well, the infant can receive intravenous fluids. The other choices do not raise blood sugar.

A woman with diabetes who has delivered vaginally and develops tachycardia and a fever of 101.7 degrees on the third postpartum day. The next day, she appears ill; fever is 102.9 degrees; WBC is 31,500 cells/mm3; blood cultures are negative.

A client with group AB blood whose husband has group O blood has just given birth. Which complication or test result is a major sign of ABO blood incompatibility that the nurse should look for when assessing this neonate? A) Jaundice within the first 24 hours of life B) Negative Coombs' test C) Jaundice after the first 24 hours of life D) Bleeding from the nose or ear

A) Jaundice within the first 24 hours of life The neonate with an ABO blood incompatibility with its mother will have jaundice within the first 24 hours of life. The neonate would have a positive Coombs' test result. Jaundice after the first 24 hours of life is physiologic jaundice. Bleeding from the nose and ear should be investigated for possible causes but probably isn't related to ABO incompatibility.

A nurse is assigned to care for a client with deep vein thrombosis who has to undergo anticoagulation therapy. Which of the following instructions should the nurse offer the client as a caution when the client receives anticoagulation therapy? a) Refrain from performing any leg exercises b) Avoid products containing aspirin c) Avoid prolonged straining during defecation d) Sit with legs crossed over each other

Avoid products containing aspirin Correct Explanation: The nurse should caution the client to avoid products containing aspirin, which inhibits 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. The nurse should not instruct the client to refrain from performing any leg exercises; instead the nurse should instruct the client to perform leg exercises such as flexion and extension of the feet and pushing the back of the knees into the mattress and then flexing slightly to promote venous return. The nurse should instruct the client to avoid prolonged straining during defecation and to avoid heavy lifting and exercises when caring for a client with cystocele and rectocele

A nurse is assigned to care for a client with deep vein thrombosis who has to undergo anticoagulation therapy. Which instruction should the nurse offer the client as a caution when the client receives anticoagulation therapy?

Avoid products containing aspirin. The nurse should caution the client to avoid products containing aspirin, which inhibits 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. The nurse should not instruct the client to refrain from performing any leg exercises; instead, the nurse should instruct the client to perform leg exercises such as flexion and extension of the feet and pushing the back of the knees into the mattress and then flexing slightly to promote venous return. The nurse should instruct the client to avoid prolonged straining during defecation and to avoid heavy lifting and exercises.

The nurse is caring for a newborn client newly diagnosed with dysplasia of the hip. Which response by the nurse educates the parents on the correct plan of treatment for this diagnosis? A) "Treatment will start once your child can bear weight." B) "Treatment will begin immediately." C) "Treatment will consist of surgery when your child weighs about 10 pounds." D) "Treatment will include bilateral casts at 1 month of age."

B) "Treatment will begin immediately." Dysplasia of the hip is a congenital newborn condition that requires immediate intervention. The development of the acetabulum of the hip is defective, and it may or may not be dislocated. Treatment of the defect and dislocated hips involves positioning the hip into a flexed, abducted (externally rotated) position to attempt to press the femur into the acetabulum. This involves splints and halters as the first line of treatment. Treatment should not be delayed. Surgery and casts are typically not used as the first line of treatment.

A 35-year-old client has just given birth to a healthy newborn during her 43rd week of gestation. What should the nurse expect when assessing the condition of the newborn? A) yellow appearance of the newborn's skin B) meconium aspiration in utero or at birth C) tremors, irritability, and high-pitched cry D) seizures, respiratory distress, cyanosis, and shrill cry

B) meconium aspiration in utero or at birth Infants born after 42 weeks of pregnancy are postterm. These infants are at a higher risk of swallowing or aspirating meconium in utero or after birth. As soon as the infant is born, the nurse usually suctions out the secretions and fluids in the newborn's mouth and throat before the first breath to avoid aspiration of meconium and amniotic fluid into the lungs. Seizures, respiratory distress, cyanosis, and shrill cry are signs and symptoms of infants with intracranial hemorrhage. Intracranial hemorrhage can be a dangerous birth injury that is primarily a problem for preterm newborns, not postterm neonates. Yellow appearance of the newborn's skin is usually seen in infants with jaundice. Tremors, irritability, high-pitched or weak cry, and eye rolling are seen in infants with hypoglycemia.

A nurse is assessing a newborn. The nurse suspects that the newborn was exposed to drugs while in utero based on which findings? Select all that apply. A) coordinated sucking B) tremors C) nasal flaring D) respirations of 43 breaths per minute E) frequent yawning

B) tremors C) nasal flaring E) frequent yawning Manifestations of intrauterine drug exposure in the newborn include tremors, frequent yawning, uncoordinated sucking, respirations greater than 60 breaths per minute, and nasal flaring.

Which complication is most likely responsible for a late postpartum hemorrhage? A) perineal laceration B) uterine subinvolution C) clotting deficiency D) cervical laceraion

B) uterine subinvolution Late postpartum bleeding is usually the result of subinvolution of the uterus. Retained products of conception or infection commonly cause subinvolution. Cervical or perineal lacerations can cause an immediate postpartum hemorrhage. A client with a clotting deficiency may have an immediate postpartum hemorrhage if the deficiency is not corrected at the time of birth.

The nurse is assisting with a birth, and the client has just delivered the placenta. Suddenly bright red blood gushes from the vagina. The nurse recognizes that which of the following is the most likely cause of this postpartum hemorrhage? a) Cervical laceration b) Retained placental fragment c) Disseminated intravascular coagulation d) Uterine atony

Cervical laceration Explanation: Lacerations of the cervix are usually found on the sides of the cervix, near the branches of the uterine artery. If the artery is torn, the blood loss may be so great that blood gushes from the vaginal opening. Because this is arterial bleeding, it is brighter red than the venous blood lost with uterine atony. Fortunately, this bleeding ordinarily occurs immediately after detachment of the placenta, when the primary care provider is still in attendance. 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. 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, but there is no evidence for this in the scenario.

The nurse notes that a client's uterus which was firm after the fundal massage has become "boggy." Which intervention would the nurse do next? a) Offer analgesics prescribed by primary care provider b) Check for bladder distention, while encouraging the client to void c) Use semi-Fowler's position to encourage uterine drainage d) Perform vigorous fundal massage for the client

Check for bladder distention, while encouraging the client to void Explanation: If the nurse finds a previously firm fundus to be relaxed, displaced, and boggy, the nurse should assess for bladder distension and encourage the woman to void or initiate catheterization as indicated. Emptying a full bladder facilitates uterine contraction and decreased bleeding. The nurse should not perform a vigorous fundal massage. Excessive massage leads to overstimulation of uterine muscle, resulting in excessive bleeding. The nurse should place the client in a semi-Fowler's position to encourage uterine drainage in the client with postpartum endometritis. The nurse should offer analgesics as prescribed by the primary care provider to minimize perineal discomfort in clients experiencing postpartum lacerations.

It is discovered that a new mother has developed a puerperal infection. Which of the following is the most likely expected outcome that the nurse will identify for this patient related to this condition? a) Lochia discharge amount is 6 inches or less on a perineal pad in 1 hour b) Client maintains a urinary output greater than 30 mL per hour c) Fundus remains firm and midline with progressive descent d) Client's temperature remains below 100.4° F or 38° C orally

Client's temperature remains below 100.4° F or 38° C orally

The nurse has admitted a small for gestational age infant (SGA) to the observation nursery from the birth room. Which action would the nurse prioritize in the newborn's care plan?

Closely monitor temperature. Difficulty with thermoregulation in SGA newborns is common due to less muscle mass, less brown fat, less heat-preserving subcutaneous fat, and limited ability to control skin capillaries. The priority would be to closely monitor the newborn's temperature. It is also is associated with depleted glycogen stores; therefore, this is hypoglycemia not hyperglycemia. Immaturity of CNS (temperature-regulating center) interferes with ability to regulate body temperature. Intake and output monitoring and observing feeding are not the priority. pg 850

Infants of drug-dependent women tend to be large for gestational age. a) False b) True

False Infants of drug-dependent women tend to be small for gestational age.

A woman who has given birth to a postterm newborn asks the nurse why her baby looks so thin with so little muscle. The nurse integrates understanding about which concept when responding to the mother? A) The newborn aspirated meconium, causing the wasted appearance. B) A postterm newborn has begun to break down red blood cells more quickly. C) The newborn was exposed to an infection while in utero. D) With postterm birth, the fetus uses stored nutrients to stay alive, and wasting occurs.

D) With postterm birth, the fetus uses stored nutrients to stay alive, and wasting occurs. After 42 weeks' gestation, the placenta loses its ability to provide adequate oxygen and nutrients to the fetus, causing the fetus to use stored nutrients to stay alive. This leads to wasting. Meconium aspiration can occur with postterm newborns, but this is not the reason for the baby's wasted appearance. Hyperbilirubinemia occurs with the increased breakdown of red blood cells, but this too would not account for the wasted appearance. Exposure to an intrauterine infection is unrelated to the wasted appearance.

The nurse is caring for a newborn who was small for gestational age and has been determined to have the condition intrauterine growth restriction (IUGR). It is most likely that the mother of this newborn: A) was on a food stamp program during pregnancy. B) smoked until 4 years ago. C) has been pregnancy 3 previous times. D) has a history of abnormal blood glucose levels.

D) has a history of abnormal blood glucose levels. Uncontrolled maternal diabetes can be a contributing factor for the infant with intrauterine growth restriction. Smoking during pregnancy could be a contributing factor, but being a previous smoker would not affect this pregnancy. Inadequate maternal nutrition is a contributing factor, but because this mother was on a food stamp program she was more likely to have had adequate nutrition during pregnancy. Previous pregnancies with a history of IUGR or other poor pregnancy outcomes would be a possible contributing factor, but not normal pregnancies.

Methylergonovine is prescribed for a woman experiencing postpartum hemorrhage. The nurse monitors the woman closely for which adverse A) headache B) uterine hyperstimulation C) flushing D) seizures

D) seizures Seizures, hypertension, uterine cramping, nausea, vomiting, and palpitations are adverse effects of methylergonovine. Uterine hyperstimulation is an adverse effect of oxytocin. Flushing and headache are adverse effects of carboprost.

A placenta succenturiate is a placenta in which the cord is inserted marginally rather than centrally. a) False b) True

False Correct Explanation: In a battledore placenta, the cord is inserted marginally rather than centrally. A placenta succenturiata is a placenta that has one or more accessory lobes connected to the main placenta by blood vessels.

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

Endometritis Explanation: The woman with endometritis typically looks ill and commonly develops a fever of 100.4°F (38°C) or higher (more commonly 101°F [38.4°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.

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

Escherichia coli Explanation: 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 metritis, but some species of Klebsiella may cause urinary tract infections.

External cephalic version Correct 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 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 would be less likely to be used with a fetus in breech position.

The majority of women who experience postpartal psychosis had no symptoms of mental illness before pregnancy. a) True b) False

False

Over 75% of women who give birth experience postpartum depression. a) True b) False

False Explanation: Although almost every woman notices some immediate (1 to 10 days postpartum) feelings of sadness (postpartal "blues") after childbirth, these feelings develop into postpartum depression in about 20%

A client has been in labor for 10 hours, with contractions occurring consistently about 5 minutes apart. The resting tone of the uterus remains at about 9 mm Hg, and the strength of the contractions averages 21 mm Hg. The nurse recognizes which of the following conditions in this client? a) Uncoordinated contractions b) Hypotonic contractions c) Braxton Hicks contractions d) Hypertonic contractions

Hypotonic contractions Correct Explanation: With hypotonic uterine contractions, the number of contractions is unusually infrequent (not more than two or three occurring in a 10-minute period). The resting tone of the uterus remains less than 10 mm Hg, and the strength of contractions does not rise above 25 mm Hg. Hypertonic uterine contractions are marked by an increase in resting tone to more than 15 mm Hg. However, the intensity of the contraction may be no stronger than that associated with hypotonic contractions. In contrast to hypotonic contractions, these occur frequently and are most commonly seen in the latent phase of labor. Uncoordinated contractions can occur so closely together they can interfere with the blood supply to the placenta. Because they occur so erratically such as one on top of another and then a long period without any, it may be difficult for a woman to rest between contractions or to breath effectively with contractions. Braxton Hicks contractions are sporadic contractions that occur in pregnancy before the onset of true labor.

In an infant who has hypothermia, what would be an appropriate nursing diagnosis? a) Ineffective parental attachment b) Impaired tissue perfusion c) Alteration in nutrition d) Impaired skin integrity

Impaired tissue perfusion Correct Explanation: Impaired tissue perfusion would be appropriate and may be related to cardiopulmonary, cerebral, gastrointestinal, peripheral, or renal issues.

A newborn has not passed any stools in the first 24 hours after birth, and his abdomen is becoming distended. The nurse recognizes that which of the following conditions could explain such findings? a) Imperforate anus b) Esophageal atresia c) Ankyloglossia d) Cleft palate

Imperforate anus

A nurse completes the initial assessment of a newborn. According to the due date on the antenatal record, the baby is 12 days postmature. Which of the following physical findings does not confirm that this newborn is 12 days postmature? a) Increased amounts of vernix. b) Absence of lanugo. c) Meconium aspiration. d) Hypoglycemia.

Increased amounts of vernix. Correct Explanation: Vernix caseosa is a whitish substance that serves as a protective covering over the fetal body throughout the pregnancy. Vernix usually disappears by term gestation. It is highly unusual for a 12-day postmature baby to have increased amounts of vernix. A discrepancy between EDC and gestational age by physical examination must have occurred. Meconium aspiration is a sign of fetal distress but does not coincide with gestation. The presence of lanugo is greatest at 28 to 30 weeks and begins to disappear as term gestation approaches. Therefore, an absence of lanugo on assessment would be expected with a postmature infant. Hypoglycemia can occur at any gestation.

The nurse is teaching a group of students about factors that place a pregnant woman at risk for infection in the postpartum period. Which of the following would the nurse be least likely to include? a) Retained placental fragments b) Prolonged labor with multiple vaginal examinations to evaluate progress c) Increased vaginal acidity leading to growth of bacteria d) Loss of protection with premature rupture of membranes

Increased vaginal acidity leading to growth of bacteria

An 18-year-old client has given birth to a very-low-birth-weight preterm infant. Which of the following should the nurse consider to prevent the newborn from losing body temperature? a) Hold the newborn close, rocking gently. b) Provide isolette or radiant warmer care to the newborn. c) Give the newborn a warm water bath. d) Administer vitamin K to the newborn.

Provide isolette or radiant warmer care to the newborn. Correct Explanation: The nurse should place the infant in an isolette to simulate the uterine environment as closely as possible and to keep the infant warm. The isolette maintains even levels of temperature, humidity, and oxygen. A hood covers it, and nurses can give care through portholes. Holding and frequent handling of the newborn should be avoided to prevent loss of energy. Minimal handling helps the neonate to conserve energy. Administration of vitamin K to the infant is necessary to prevent bleeding in the infant because the newborn is unable to produce its own vitamin K during the early stages of life. It does not help in providing warmth to the baby. The infant is not given baths until later because this often results in loss of body temperature.

Which of the following would be most appropriate for the woman who experiences dysfunctional labor in the first stage of labor? a) Provide ongoing communication about what is happening. b) Tell her not to feel anxious or discouraged about what is happening. c) Hold all explanations until after the birth to conserve the woman's energy. d) Limit talking to things the woman asks questions about.

Provide ongoing communication about what is happening. Correct Explanation: Dysfunctional labor at any point is frustrating to women. Maintaining open lines of communication at least keeps the woman well informed about what is happening.

An infant is suspected of having persistent pulmonary hypertension of the newborn (PPHM). What intervention implemented by the nurse would be most beneficial in treating this client?

Provide oxygen by oxygen hood or ventilator. The nurse should administer oxygen to the infant in whatever manner needed to help maintain the infant's oxygen levels. Anticonvulsants are not necessary in treating this disorder. The infant's physical environment should be warm, not cool, and stimulation should be limited for these clients.

An 18-year-old client has given birth in the 28th week of gestation, and her newborn is showing signs of respiratory distress syndrome (RDS). Which is true for a newborn with RDS? a) Respiratory symptoms of RDS typically improve within a short period of time. b) RDS is caused by a lack of alveolar surfactant. c) Glucocorticosteroid is given to the newborn following birth. d) RDS is characterized by heart rates below 50 beats per minute.

RDS is caused by a lack of alveolar surfactant. Correct Explanation: Respiratory distress syndrome (RDS) is a serious breathing disorder caused by a lack of alveolar surfactant. Betamethasone, a glucocorticosteroid, is often given to the mother 12 to 24 hours before a preterm birth to help reduce the severity of RDS, not to the newborn following birth. Respiratory symptoms in the newborn with RDS typically worsen within a short period of time after birth, not improve. Diagnosis of RDS is made based on a chest x-ray and the clinical symptoms of increasing respiratory distress, crackles, generalized cyanosis, and heart rates exceeding 150 beats per minute (not below 50 beats per minute).

Which action by the nurse would be least effective in assisting a couple who have experienced intrauterine fetal demise? a) Assist the family in making arrangements for their stillborn infant b) Refrain from discussing the situation with the couple c) Allow the couple to spend as much time as they want with their stillborn infant. d) Give the parents a lock of the infant's hair

Refrain from discussing the situation with the couple Correct Explanation: The nurse should encourage discussion of the loss and allow the couple to vent their feelings of grief and guilt. The nurse should allow the parents to spend unlimited time with their stillborn infant so that they can validate the death. Providing the parents and family with mementos of the infant helps validate the reality of the death. Assisting the family with arrangements is helpful to reduce the stress of coping with the situation and making decisions at this difficult time.

A newborn with newly diagnosed hemolytic jaundice is being treated with phototherapy. Which actions should the nurse take? Select all that apply.

Shield the newborn's genitals and eyes during phototherapy sessions. Encourage the mother to breastfeed (8 to 12 feedings per day). Supplement breast milk with formula. Expose as much of the newborn's skin as possible. For the newborn receiving phototherapy, place the newborn under the lights or on the fiber-optic blanket, exposing as much skin as possible. Cover the newborn's genitals and shield the eyes to protect these areas from becoming irritated or burned when using direct lights. Assess the intensity of the light source to prevent burns and excoriation. Turn the newborn every 2 hours to maximize the area of exposure, removing the newborn from the lights only for feedings. Maintain a neutral thermal environment to decrease energy expenditure, and assess the newborn's neurologic status frequently. Research is finding that intermittent versus continuous phototherapy is as efficacious to lower bilirubin levels. Assess the newborn's temperature every 3 to 4 hours as indicated. Monitor fluid intake and output closely.

A nurse is caring for a baby girl born at 34 weeks' gestation. Which of the following features should the nurse identify as those of a preterm newborn? a) Scant coating of vernix b) Closely approximated labia c) Paper-thin eyelids d) Shiny heels and palms

Shiny heels and palms Correct Explanation: A preterm newborn has shiny heels and palms with few creases. The eyelids of the preterm newborn are edematous, and not paper-thin. The external genitalia in the preterm baby girl appear large with widely spaced labia, and not closely approximated. Vernix is scant in post-term newborns and is excessive in premature infants.

Meconium is the first stool passed in a newborn. What would be the correct documentation of the meconium? a) Soft brown b) Sticky forest green c) Seedy yellow d) Formed green

Sticky forest green Correct Explanation: Meconium is usually a sticky, forest-green liquid. It contains bile acids, salts, and mucus. The other choices describe stool at various stages after the passage of meconium.

The nurse manager at a family clinic is identifying ways to address the 2020 National Health Goals for the prevention of birth defects. Which action should the manager encourage all staff to perform when caring for pregnant patients?

Stress the importance of taking prenatal folic acid as prescribed.

A nurse is assessing an infant who has experienced asphyxia at birth. Which finding indicates that the resuscitation methods have been successful? a) Heart rate of 80 bpm b) Jitteriness c) Hypotonia d) Strong cry

Strong cry

A nurse is caring for a client who has just given birth. What is the best method for the nurse to assess this client for postpartum hemorrhage?

by frequently assessing uterine involution The nurse should closely assess the woman for hemorrhage after giving birth by frequently assessing uterine involution. Assessing skin turgor and blood pressure and monitoring hCG titers will not help to determine hemorrhage.

A 39-year-old multigravida with diabetes presents to the clinic at 32 weeks' gestation because she has not felt the fetus moving lately. FHR is absent; sonogram confirms that the fetus has died. Your institution has a policy of taking photographs of such fetuses once they are delivered. You inform the woman that pictures have been taken and ask her if she wants them; she angrily tells you no, then bursts into tears. How should you respond? a) Apologize and tell her that the photos will be destroyed immediately. b) Console her with the fact that she has other children. c) Tell her that the hospital will keep the photos for her in case she changes her mind. d) Tell her that once she gets over her shock and grief, she will probably be happy to have the photos.

Tell her that the hospital will keep the photos for her in case she changes her mind. Correct Explanation: Emotional care of the woman is complex. The woman may 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 delivery. Option A is incorrect as there is no need to apologize to the patient. Option B is incorrect as it would be inappropriate to console her with the fact that she has other children. Option D is incorrect as it negates her feelings and is not supportive of the woman at this time.

Which situation should concern the nurse treating a postpartum client within a few days of delivery? a) The client is nervous about taking the baby home b) The client would like the nurse to take her baby to the nursery so she can sleep c) The client feels empty since she delivered the neonate d) The client would like to watch the nurse give the baby her first bath

The client feels empty since she delivered the neonate Explanation: A client experiencing postpartum blues may say she feels empty now that the infant is no longer in her uterus. She may also verbalize that she feels unprotected now. The other options are considered normal and wouldn't be cause for concern. Many first-time mothers are nervous about caring for their neonates by themselves after discharge. New mothers may want a demonstration before doing a task themselves. A client may want to get some uninterrupted sleep, so she may ask that the neonate be taken to the nursery

Which situation should concern the nurse treating a postpartum client within a few days of birth?

The client feels empty since she gave birth to the neonate. A client experiencing postpartum blues may say she feels empty now that the infant is no longer in her uterus. She may also verbalize that she feels unprotected now. The other options are considered normal and would not be cause for concern. Many first-time mothers are nervous about caring for their neonates by themselves after discharge. New mothers may want a demonstration before doing a task themselves. A client may want to get some uninterrupted sleep, so she may ask that the neonate be taken to the nursery.

The client brings her infant daughter to the pediatrician's office for her first visit since hospital discharge. At birth, the newborn was at the 8th percentile with a weight of 2,350 g. She was born at 36 weeks' gestation. Which documentation is most accurate?

The infant was a preterm, low birth weight and small for gestational age neonate.

The nurse is caring for a newborn with retinopathy of prematurity (ROP). Which of the following is the best explanation of this disorder? a) The infant has bleeding into the ventricles of the brain b) The infant's liver is unable to manage the bilirubin produced by hemolysis c) The infant's lungs are immature and deficient in surfactant d) The infant has a degenerative disease of the retina

The infant's lungs are immature and deficient in surfactant

A nurse is assigned to care for a newborn with hyperbilirubinemia. The newborn is relatively large in size and shows signs of listlessness. What would have most likely happened to have caused these conditions to occur in the infant? a) The infant's mother must have had a long labor. b) The infant's mother probably used alcohol. c) The infant's mother probably had diabetes. d) The infant may have experienced birth trauma.

The infant's mother probably had diabetes.

A nurse is assigned to care for a newborn with hyperbilirubinemia. The newborn is relatively large in size and shows signs of listlessness. What most likely occurred?

The infant's mother probably had diabetes. The nurse should know that the infant's mother more than likely was a diabetic. The large size of the infant born to a diabetic mother is secondary to exposure to high levels of maternal glucose crossing the placenta into the fetal circulation. Common problems among infants of diabetic mothers include macrosomia, respiratory distress syndrome, birth trauma, hypoglycemia, hypocalcemia and hypomagnesemia, polycythemia, hyperbilirubinemia, and congenital anomalies. Listlessness is also a common symptom noted in these infants. Infants born to clients who have abused alcohol, infants who have experienced birth traumas, or infants whose mothers have had long labors are not known to exhibit these particular characteristics, although these conditions do not produce very positive pregnancy outcomes. Infants with fetal alcohol syndrome or alcohol exposure during pregnancy do not usually have hypoglycemia problems.

The nurse is checking a newborn for the presence of Ortolani and Barlow signs. For which health problem are these assessments used?

The nurse is caring for a newborn with hemolytic disease of the newborn who is receiving phototherapy. Which nursing intervention would be the most appropriate for the nurse to do?

The nurse turns the newborn every 3 or 4 hours. The nurse should turn the newborn every 3 or 4 hours to rotate the area of exposure. Do not turn off the lights except to feed and to change the diaper. The infant is nude to maximize the skin surface area exposed to the light. Remove the patches every four hours to cleanse the eyes and examine for irritation, inflammation, and/or dryness. Clean and change the patches daily.

The nursing instructor is leading a discussion with a group of nursing students who are analyzing the preterm infant's physiologic immaturity and the associated difficulties the newborn and familty must deal with. The instructor determines the session is successful when the students correctly choose which body system that presents with the most critical concerns related to this immaturity?

The respiratory system

Mrs. M. has been admitted to the delivery suite in labor. She has been in labor for 12 hours and is dilated to 4 cm. The physician notes that Mrs. M. is in hypotonic labor. What does this mean? a) The uterine contractions may or may not be regular, but the quantity or quality or strength is insufficient to dilate the cervix. b) The uterine contractions may or may not be regular, but the quantity or quality or strength is sufficient to dilate the cervix. c) The uterine contractions are regular, but the quantity or quality or strength is insufficient to dilate the cervix. d) The uterine contractions are irregular, but the quantity or quality or strength is insufficient to dilate the cervix.

The uterine contractions may or may not be regular, but the quantity or quality or strength is insufficient to dilate the cervix. Explanation: There are two types of uterine dysfunction: hypotonic and hypertonic. The most common is hypotonic dysfunction. This labor pattern manifests by uterine contractions that may or may not be regular, but the quantity or strength is insufficient to dilate the cervix

In vasa previa, the umbilical vessels of a velamentous cord insertion cross the cervical os and therefore deliver before the fetus. a) False b) True

True

A fundal massage is sometimes performed on a postpartum woman. Which of the following is a reason for performing a fundal massage? a) Uterine subinvolution b) Uterine contraction c) Uterine prolapse d) Uterine atony

Uterine atony Explanation: 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.

Which factor puts a multiparous client on her first postpartum day at risk for developing hemorrhage? a) Hemoglobin level of 12 g/dl b) Moderate amount of lochia rubra c) Thrombophlebitis d) Uterine atony

Uterine atony Explanation: Multiparous women typically experience a loss of uterine tone due to frequent distentions of the uterus from previous pregnancies. As a result, this client is also at higher risk for hemorrhage. Thrombophlebitis doesn't increase the risk of hemorrhage during the postpartum period. The hemoglobin level and lochia flow are within acceptable limits.

A client in the first stage of labor is diagnosed with dystocia involving the powers of labor. Which of the following would the nurse identify as the problem? a) Contractions are insufficient to cause fetus descent b) Uterine contractions are too weak or uncoordinated c) Pelvis is either android type or platypelloid type d) Fetus is in a different position or presentation

Uterine contractions are too weak or uncoordinated Correct Explanation: When there are problems with the powers causing dystocia during the first stage of labor, the uterine contractions are too weak or uncoordinated to cause adequate cervical effacement and dilatation. Contractions are insufficient to cause fetal descent; the fetus being in a different position or presentation, and pelvis being either android type or platypelloid type are not the results of dystocia. During the second stage of labor, the nurse should observe if the contractions and the pushing are insufficient to cause descent of the fetus. A fetus that is in a different position or presentation is a problem with the passenger. A pelvis that is either android type or platypelloid type is a problem with the passageway and is not related to dystocia.

For which condition would the nurse commonly assess in an infant following surgery for a myelomeningocele?

hydrocephalus Surgery includes removing a portion of the meninges; without the surface to absorb cerebral spinal fluid, hydrocephalus can result.

A pregnant woman near term is brought to the emergency room because she's been in an automobile accident. She has sustained blunt trauma to her abdomen and has gone into labor. An epidural is started and labor is going as well as can be expected under the circumstances. Suddenly the woman complains of severe pain in her back and shoulder. What do you suspect? a) Placental abruption b) Breech presentation c) Uterine rupture d) Broken bones or torn muscles from the accident

Uterine rupture Explanation: Uterine rupture occurs when the uterus tears open, leaving the fetus and other uterine contents exposed to the peritoneal cavity. Traumatic rupture can occur in connection with a blunt trauma. Abrupt change in the fetal heart rate pattern is often the most significant sign associated with uterine rupture. Other signs are complaints of pain in the abdomen, shoulder, or back in a laboring woman who had previous good pain relief from epidural anesthesia. The scenario presented does not indicate broken bones or torn muscles from the accident, placental abruption, or a breech presentation of the fetus.

Following birth the newborn's independent circulatory system is established. If there is an abnormal opening between the chambers in the heart, which of the following cardiac defects may occur? a) Patent ductus arteriosus b) Transposition of the great vessels c) Coarctation of the aorta d) Ventricular septal defect

Ventricular septal defect

A client delivers a newborn baby at term. The nurse records the weight of the baby as 1.2 kg, interpreting this to indicate that the newborn is of: a) Normal birth weight b) Very low birth weight c) Extremely low birth weight d) Low birth weight

Very low birth weight Correct Explanation: A birth weight of 1.2 kg would be classified as very low birth weight. A normal birth weight at term ranges between 2,500 g and 4,000 g. Typically it is between 3,000 g and 4,000 g. A birth weight below 2,500 g is termed a low birth weight. A birth weight between 1,000 g and 1,500 g is termed a very low birth weight. A birth weight less than 1,000 g is termed an extremely low birth weight

When administering oxytocin to a woman in labor, the nurse would be alert for which of the following? a) Hypertension b) Uterine hypotonicity c) Fetal distress d) Water intoxication

Water intoxication Explanation: Oxytocin can lead to water intoxication and can cause hypotension. Uterine hypertonicity is a possible adverse effect of oxytocin administration. Oxytocin does not cross the placental barrier, and no fetal problems have been observed.

When assessing a postpartum patient who was diagnosed with a cervical laceration which has been repaired, what sign should the nurse report as a possible development of hypovolemic shock? a) Elevated blood pressure b) Decreased respiratory rate c) Warm and flushed skin d) Weak and rapid pulse

Weak and rapid pulse

Which instruction would the nurse include in the teaching plan for a postpartal client with a history of thromboembolism to reduce the risk of a recurrence?

Wear support hose or antiembolic stockings. When caring for a postpartal client with a history of a thromboembolic disorder, the nurse should instruct the client to wear support hose or antiembolic stockings. The nurse should instruct the client specifically to perform leg exercises such as flexion and extension of the feet and pushing the back of the knees into the mattress and then flexing slightly. The nurse should instruct the client to refrain from flexing the muscles at the groin, and the nurse should instruct the client to avoid pressure at the back of the knees, not on the thigh muscles.

A preterm newborn is noted to be cyanotic. Which laboratory test will the nurse prepare the infant for to determine if the cyanosis is due to respiratory or circulatory problems?

arterial blood gases Arterial blood gases are obtained to determine the oxygenation levels and to help differentiate lung disease from heart disease. Chest X-rays will help identify cardiac size, shape, and position. An echocardiogram will evaluate the heart anatomy and flow defects. An angiography will be conducted to prepare for cardiac surgery, if needed.

alcohol Alcohol is now recognized as the leading preventable cause of birth defects and developmental disorders in the United States. Smoking, recreational drugs, and obesity are also contributing factors.

alpha-fetoprotein levels In pregnancies in which the fetus has neural tube defect, the level of alpha-fetoprotein in the amniotic fluid and maternal serum is elevated. By monitoring this level throughout the pregnancy, it is possible to be aware of this defect before the birth. Genetic studies, folic acid levels, and cultures for infections are not utilized to detect neural tube defects.

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?

amniotomy 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.

All infants need to be observed for hypoglycemia during the newborn period. Based on the facts obtained from pregnancy histories, which infant would be most likely to develop hypoglycemia?

an infant who had difficulty establishing respirations at birth Newborns use a great many calories in their effort to achieve effective respirations. Infants who had difficulty establishing respirations need to be assessed for hypoglycemia.

After birth, an infant experiences meconium aspiration. What does the nurse anticipate the primary care provider prescribing prophylactically to prevent pneumonia?

antibiotics Prophylactic antibiotics may prevent development of pneumonia.

A newborn with high serum bilirubin is receiving phototherapy. Which nursing intervention is the most appropriate for this client?

application of eye dressings to the infant Continuous exposure to bright lights by phototherapy may be harmful to a newborn's retina, so the infant's eyes must always be covered while under bilirubin lights. Eye dressings or cotton balls can be firmly secured in place by an infant mask. The lights are placed 12 to 30 inches above the newborn's bassinet or incubator. Bilirubin is removed from the body by being incorporated into feces. Therefore, the sooner bowel elimination begins, the sooner bilirubin removal begins. Early feeding (either breast milk or formula), therefore, stimulates bowel peristalsis and helps to accomplish this. Gently shaking the infant is a method of stimulating breathing in an infant experiencing apnea.

A woman whose fetus in 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 counter pressure to the back Counter pressure 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 Hispanic woman 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 of the following causes of the hemorrhage is most likely in this client? a) Cervical laceration b) Uterine atony c) Retained placental fragment d) Disseminated intravascular coagulation

b)Uterine atony Explanation: 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.

Which complication is most likely responsible for a late postpartum hemorrhage? a) Cervical laceration b) Uterine subinvolution c) Perineal laceration d) Clotting deficiency

b)Uterine subinvolution Explanation: Late postpartum bleeding is usually the result of subinvolution of the uterus. Retained products of conception or infection commonly cause subinvolution. Cervical or perineal lacerations can cause an immediate postpartum hemorrhage. A client with a clotting deficiency may have an immediate postpartum hemorrhage if the deficiency isn't corrected at the time of delivery.

When assessing a postpartum patient who was diagnosed with a cervical laceration which has been repaired, what sign should the nurse report as a possible development of hypovolemic shock? a) Decreased respiratory rate b) Warm and flushed skin c) Elevated blood pressure d) Weak and rapid pulse

b)Weak and rapid pulse Explanation: The sign of weak and rapid pulse is the body in compensatory mechanism attempting to increase the blood circulation. This finding needs to be reported to the health care provider and RN as soon as possible. The other options are incorrect.

Jerry, who is hypertensive and who received corticosteroids during pregnancy, delivered by cesarean and subsequently developed endometritis. Her incision is red, warm, and very sensitive to touch, and she remains febrile despite antibiotic therapy. What is the most important aspect of post hospital care to teach her? a) Proper perineal care b) Wound care and hand washing c) Use of warm compresses and sitz baths d) Strict adherence to antibiotic therapy

b)Wound care and hand washing Explanation: The use of systemic corticosteroids prior to delivery has increased her risk for development of an infection. She has been treated for endometritis and is now at greater risk for infection. Hand washing is the best defense again transmission of any infection. While adherence to antibiotic therapy, proper perineal care, and use of warm compresses and sitz baths may be indicated, they would not be a higher priority than wound care and hand-washing.

Which of the following would lead the nurse to suspect that a postpartum woman has developed metritis? Select all that apply. a) Hematuria b) Leukocytosis c) Foul-smelling lochia d) Pain on both sides of the abdomen e) Flank pain

b)• Leukocytosis c)• Foul-smelling lochia d)• Pain on both sides of the abdomen Explanation: Signs and symptoms of metritis 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 parents are upset their newborn has a cleft lip. When describing the treatment, the nurse should mention that surgical repair can be done:

between the age of 6 to 12 weeks.

The parents are upset their newborn has a cleft lip. When describing the treatment, the nurse should mention that surgical repair can be done:

between the age of 6 to 12 weeks. Treatment of cleft lip is surgical repair between the ages of 6 to 12 weeks. It is important to repair this anomaly as soon as possible to facilitate bonding between the newborn and the parents and to improve nutritional status.

A nurse working with a woman in preterm labor receives a telephone report for the fetal fibronectin test done 10 hours ago. The report indicates an absence of the protein, which the nurse knows indicates:

birth is unlikely within the 2 next weeks. Fetal fibronectin is a protein that helps the placenta and fetal membranes adhere to the uterus during pregnancy. A negative result (absence of fetal fibronectin) is a reliable indicator that birth is unlikely within 2 weeks following the test. It does not diagnose infection.

A nursing student correctly identifies the problem of fetal buttocks instead of the head presenting first as which type of presentation?

A nurse is assigned to care for a client with deep vein thrombosis who has to undergo anticoagulation therapy. Which of the following instructions should the nurse offer the client as a caution when the client receives anticoagulation therapy? a) Sit with legs crossed over each other b) Refrain from performing any leg exercises c) Avoid products containing aspirin d) Avoid prolonged straining during defecation

c)Avoid products containing aspirin Explanation: The nurse should caution the client to avoid products containing aspirin, which inhibits 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. The nurse should not instruct the client to refrain from performing any leg exercises; instead the nurse should instruct the client to perform leg exercises such as flexion and extension of the feet and pushing the back of the knees into the mattress and then flexing slightly to promote venous return. The nurse should instruct the client to avoid prolonged straining during defecation and to avoid heavy lifting and exercises when caring for a client with cystocele and rectocele.

You are caring for a postpartum woman who exhibits a large amount of bleeding. Which areas would you need to assess before the woman ambulates? a) Height, level of orientation, support systems b) Attachment, lochia color, complete blood cell count c) Blood pressure, pulse, complaints of dizziness d) Degree of responsiveness, respiratory rate, fundus location

c)Blood pressure, pulse, complaints of dizziness Explanation: 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.

The nurse notes that a client's uterus which was firm after the fundal massage has become "boggy." Which intervention would the nurse do next? a) Offer analgesics prescribed by primary care provider b) Perform vigorous fundal massage for the client c) Check for bladder distention, while encouraging the client to void d) Use semi-Fowler's position to encourage uterine drainage

c)Check for bladder distention, while encouraging the client to void Explanation: If the nurse finds a previously firm fundus to be relaxed, displaced, and boggy, the nurse should assess for bladder distension and encourage the woman to void or initiate catheterization as indicated. Emptying a full bladder facilitates uterine contraction and decreased bleeding. The nurse should not perform a vigorous fundal massage. Excessive massage leads to overstimulation of uterine muscle, resulting in excessive bleeding. The nurse should place the client in a semi-Fowler's position to encourage uterine drainage in the client with postpartum endometritis. The nurse should offer analgesics as prescribed by the primary care provider to minimize perineal discomfort in clients experiencing postpartum lacerations.

The nurse recognizes that the postpartum period is a time of rapid changes for each client. Which of the following is believed to be the cause of postpartum affective disorders? a)Medications used during labor and delivery b)Lack of social support from family or friends c)Drop in estrogen and progesterone levels after birth d)Preexisting conditions in the client

c)Drop in estrogen and progesterone levels after birth Explanation: 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.

A nurse is assessing vital signs for a postpartum patient 48 hours after delivery. The vital signs are: T 101.2°F; HR 82; RR 18; BP 125/78. How will the nurse interpret the vital signs? a) Shock b) Normal vital signs c) Infection d) Dehydration

c)Infection Explanation: Temperatures elevated above 100.4°F 24 hours after delivery are indicative of possible infection.

Two weeks after their baby is born, Tom calls to report that his wife Sylvia is behaving strangely. She is extremely talkative and energetic and he has not observed her sleeping for more than an hour or two at a time. She is also forgetting to eat and neglecting her appearance, but worse, she seems to barely be aware of the baby's needs and appears surprised when Tom asks her about the child, "As if," Tom says, "she's forgotten that we even have a baby!" You tell him to bring her in right away, because you suspect Sylvia is suffering from what condition? a) Postpartum blues b) Maladjustment c) Postpartum psychosis d) Postpartum depression

c)Postpartum psychosis Explanation: Postpartum psychosis can present with a patient in extreme mood changes and odd behavior. Her sudden change in behavior from normal and lack of self care and care for the infant are a sign 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. Maladjustment is a distracter for this question.

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 she 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 of the following conditions? a) Postpartum panic disorder b) Postpartum depression c) Postpartum psychosis d) Postpartum blues

c)Postpartum psychosis Explanation: The client's signs and symptoms suggest that the 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 infant, 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 her life is rapidly tumbling out of control. The client thinks of herself 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 characteristics of postpartum blues.

The nurse is caring for a newborn of a substance-abusing mother who is withdrawing from alcohol. Which finding would the nurse likely see in this newborn?

hyperactive and irritable The newborn that is withdrawing from alcohol typically is hyperactive, irritable, has trouble sleeping, and may have tremors or seizures. Characteristics of FAS include low birth weight, and small height and head circumference. This newborn is prone to respiratory difficulties, hypoglycemia, hypocalcemia, and hyperbilirubinemia.

Within 24 hours of delivery, Diane begins to complain of pain in the pelvic region. Comfort measures and medication fail to eliminate the pain, her pulse is rapid, and her blood pressure, hematocrit, and hemoglobin are low. Her fundus is firm, however, and her lochia is dark red and flowing in only moderate amounts; no pooling is evident. You suspect a) Deep-vein thrombosis b) Retained placental fragments c) Lacerations in the uterus d) Deep pelvic hematoma

d)Deep pelvic hematoma Explanation: The assessment data indicate a blood loss in the body, and the lack of active bleeding leads one to believe it may be a hematoma. Retained placental fragments are characterized by late postpartum bleeding. Along with an abrupt onset of bleeding, the woman's uterus is not well-contracted. The woman with DVT may have no symptoms. If she does exhibit signs, these typically include swelling and calf pain or tenderness in the affected leg. The area may be warm, tender, and red. Homans' sign (pain on dorsiflexion of the foot) may be positive. Lacerations can occur as small tears or cuts in the perineal tissue, vaginal sidewall, or cervix.

A postpartal woman with a thrombophlebitis tells you that her leg is very painful. Which of the following actions would be most appropriate to relieve this pain? a) Urge her to walk to relieve muscle spasm. b) Apply ice to her leg above the knee. c) Massage the calf of her leg. d) Keep covers off the leg.

d)Keep covers off the leg. Explanation: Pressure or cold on the leg can interfere with blood circulation. Massaging the leg or urging her to walk could cause a clot to move and become a pulmonary embolus.

While assessing a postpartum woman, the nurse palpates a contracted uterus. Perineal inspection reveals a steady stream of bright-red blood trickling out of the vagina. The woman reports mild perineal pain. She just voided 200 mL of clear yellow urine. Which of the following would the nurse suspect? a) Uterine inversion b) Uterine atony c) Hematoma d) Laceration

d)Laceration Explanation: Lacerations typically present with a firm contracted uterus and a steady stream of unclotted bright-red blood. Hematoma would present as a localized bluish bulging area just under the skin surface in the perineal area, accompanied by perineal or pelvic pain and difficulty voiding. Uterine inversion would present with the uterine fundus at or through the cervix. Uterine atony would be manifested by a noncontracted uterus.

When assessing the patient for postpartum hemorrhage the nurse monitors which of the following every hour? a) Vital signs b) Complete blood count c) Urine volume excreted d) Pad count

d)Pad count Explanation: The way to monitor for bleeding every hour is to assess pads and percent of pad saturated by blood in the previous hour. It would not be necessary to do a complete blood count every hour, nor hourly urines. Vital signs are not typically taken every hour.

Which of the following instructions should the nurse offer a client as primary preventive measures to prevent mastitis? a) Avoid massaging the breast area b) Apply cold compresses to the breast c) Avoid frequent breastfeeding d) Perform handwashing before breastfeeding

d)Perform handwashing before breastfeeding Explanation: As a primary preventive measure to prevent mastitis, the nurse should instruct the client to perform good handwashing before breastfeeding. The nurse should instruct the client to frequently breastfeed to prevent engorgement and milk stasis. If the breast is distended before feeding, the nurse should instruct the client to apply cold, not warm, moist heat to the breast. Gently massaging the affected area of the breast also helps.

Your patient is showing signs and symptoms of a pulmonary embolism. What should you do? a) Lay the patient flat and start oxygen. b) Sit the patient up 90 degrees and call the RN. c) Start oxygen at 2 to 3 liters per minute via nasal cannula. d) Raise the head of the bed to at least 45 degrees.

d)Raise the head of the bed to at least 45 degrees. Explanation: Immediate action is crucial for the woman who develops a pulmonary embolism. Immediately raise the head of the bed to at least 45 degrees to facilitate breathing. Begin oxygen therapy at 8 to 10 liters per minute via facemask and notify the physician.

When planning care for a postpartum patient, the nurse is aware the most common site for postpartum infection is which of the following? a) Urinary b) Breast c) Integumentary d) Reproductive

d)Reproductive Explanation: The most common site for a postpartum infection is the reproductive tract. This is important for teaching and education of the patients.

A postpartum woman is diagnosed as having endometritis. Which position would you expect to place her in based on this diagnosis? a) Trendelenburg. b) On her left side. c) Flat in bed. d) Semi-Fowler's.

d)Semi-Fowler's. Explanation: A semi-Fowler's 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 be contraindicated.

A 27-year-old G1, P1 woman arrives in the emergency department accompanied by her husband and new infant, crying, confused, and with possible hallucinations. The nurse recognizes this could possibly be postpartum psychosis as it can appear approximately when? a)Within 2 months of giving birth b)Within 5 months of giving birth c)Within 4 months of giving birth d)Within 3 months of giving birth

d)Within 3 months of giving birth Explanation: Postpartum psychosis general surfaces within 3 months of giving birth.

In reviewing the postpartum G3, P3 woman's history the nurse notes it is positive for obesity and smoking. The nurse recognizes this client is at risk for which complication?

deep venous thrombosis Factors that can increase a woman's risk for DVT include prolonged bed rest, diabetes, obesity, cesarean birth, progesterone-induced distensibility of the veins of the lower legs during pregnancy, severe anemia, varicose veins, advanced maternal age (older than 35), and multiparity.

The nurse notices while holding him upright that a day-old newborn has a significantly indented anterior fontanelle. She immediately brings it to the attention of the primary care provider. What does this finding indicate?

dehydration The anterior fontanelle can be felt as a soft spot. It should not appear indented (a sign of dehydration) or bulging (a sign of increased intracranial pressure) when the infant is held upright. Vernix caseosa is the white, cream cheese-like substance that serves as a skin lubricant in utero. Some of it is invariably noticeable on a term newborn's skin, at least in the skin folds, at birth. Cyanosis is a condition of decreased oxygenation that results in the skin having a blue hue. pg 851

A nurse discovers a perineal hematoma in a woman who has recently given birth. Which of the following interventions should the nurse make in this case? (Select all that apply.) a) Perform fundal massage b) Administer methotrexate c) Estimate the size of the hematoma and report it d) Apply an ice pack to the site e) Administer an antibiotic f) Administer a mild analgesic as prescribed

f)• Administer a mild analgesic as prescribed d)• Apply an ice pack to the site c)• Estimate the size of the hematoma and report it Explanation: Report the presence of a perineal hematoma, its estimated size, and the degree of the woman's discomfort to her primary care provider. Administer a mild analgesic as prescribed for pain relief. Applying an ice pack (covered with a towel to prevent thermal injury to the skin) may prevent further bleeding. Usually a hematoma is absorbed over the next 3 or 4 days. An antibiotic is not required, as there is no indication of infection. Fundal massage is indicated for uterine atony, and methotrexate is used to destroy retained placental fragments when removal is not possible.

A nurse is assessing the fluid status of a preterm newborn. Which parameter would be most appropriate for the nurse to assess?

fontanels When assessing the fluid status of a preterm newborn, the nurse palpates the fontanels. Sunken fontanels suggest dehydration; bulging fontanels suggest overhydration

A nurse is conducting an in-service presentation for a group of neonatal nurses. After teaching the group about the effects of prematurity on various body systems, the nurse determines that the class was successful when the group identifies which condition as an effect of prematurity?

fragile cerebral blood vessels Preterm newborns have fragile blood vessels in the brain, and fluctuations in blood pressure can predispose these vessels to rupture, causing intracranial hemorrhage. The preterm newborn typically has smaller respiratory passages, leading to an increased risk for obstruction. Preterm newborns have a limited ability to digest proteins. The preterm newborn's renal system is immature, which reduces his or her ability to concentrate urine and slow the glomerular filtration rate. pg 842

The newborn nursery nurse suspects a newborn of having neonatal abstinence syndrome. What assessment findings would most correlate with the diagnosis?

frequent yawning and sneezing Manifestations of neonatal abstinence syndrome include: CNS dysfunction such as hyperactive reflexes resulting in exaggerated Babinski and Moro reflexes; hypertonic muscle tone and constant movement; metabolic, vasomotor, and respiratory disturbances with frequent yawning and sneezing; gastrointestinal dysfunction, including poor feeding; and frantic sucking or rooting. Acrocyanosis is a normal newborn finding which is cyanotic discoloration of the extremities.

hospitalization, tocolytic therapy, and IM corticosteroids At 31 weeks gestation, the goal would be to maintain the pregnancy as long as possible if the mother and fetus are tolerating continuation of the pregnancy. Stopping the contractions and placing the client in the hospital allow for monitoring and a safe place if the woman continues and gives birth. Administration of corticosteroids may help to develop the lungs and prepare for early preterm birth. Sending the woman home is contraindicated in the scenario described. An emergency cesarean birth is not indicated at this time. Monitoring fetal kick counts is typically done with a postterm pregnancy.

hydrocephalus A significant number of newborns with PVH-INH will incur brain injury, leading to complications that may include hydrocephalus. The nurse should monitor for the incidence of hydrocephalus in this high-risk newborn. Urinary tract infection is not condition that persists after discharge. Spina bifida is most often noted at birth and would not to need to be assessed for by the nurse. Formula intolerance is not specific to high-risk newborns.

hypotonic contractions With hypotonic uterine contractions, the number of contractions is unusually infrequent (not more than two or three occurring in a 10-minute period). The resting tone of the uterus remains less than 10 mm Hg, and the strength of contractions does not rise above 25 mm Hg. Hypertonic uterine contractions are marked by an increase in resting tone to more than 15 mm Hg. However, the intensity of the contraction may be no stronger than that associated with hypotonic contractions. In contrast to hypotonic contractions, these occur frequently and are most commonly seen in the latent phase of labor. Uncoordinated contractions can occur so closely together they can interfere with the blood supply to the placenta. Because they occur so erratically, such as one on top of another and then a long period without any, it may be difficult for a woman to rest between contractions or to breath effectively with contractions. Braxton Hicks contractions are sporadic contractions that occur in pregnancy before the onset of true labor.

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 nurse completes the initial assessment of a newborn. According to the due date on the antenatal record, the baby is 12 days' postmature. Which physical finding does not confirm that this newborn is 12 days' postmature?

increased amounts of vernix Vernix caseosa is a whitish substance that serves as a protective covering over the fetal body throughout the pregnancy. Vernix usually disappears by term gestation. It is highly unusual for a 12-day postmature baby to have increased amounts of vernix. A discrepancy between EDC and gestational age by physical examination must have occurred. Meconium aspiration is a sign of fetal distress but does not coincide with gestation. The presence of lanugo is greatest at 28 to 30 weeks and begins to disappear as term gestation approaches. Therefore, an absence of lanugo on assessment would be expected with a postmature infant. Hypoglycemia can occur at any gestation.

A woman who has a history of cocaine abuse gives birth to a newborn. Which of the following would the nurse expect to assess in the newborn? Select all that apply. a) Prolonged periods of sleeping b) Inconsolable c) Flaccid positioning d) Poor sucking e) Piercing cry

• Piercing cry • Poor sucking • Inconsolable

Which assessment finding would best validate a problem in a small-for-gestational age newborn secondary to meconium in the amniotic fluid?

respiratory rate of 60 to 70 bpm The nurse should identify respiratory complications such as tachypnea as a symptom of meconium aspiration in the newborn that results from presence of meconium in the amniotic fluid. Tachycardia, elevated bilirubin levels, and polycythemia are some of the common problems faced by an SGA newborn, but these are not related to meconium in the amniotic fluid.

A nursing instructor identifies which of the following as increasing the chances of infection when coupled with prolonged labor? a) multiple births b) number of previous pregnancies c) age of mother d) ruptured membranes

ruptured membranes Correct Explanation: The risk for infection increases during prolonged labor particularly in association with ruptured membranes. The other options do not increase the risk of infection during labor.

Labor dystocia is an abnormal progression of labor. It is the most common cause of primary cesarean birth. When is it most common for labor dystocia to occur?

second stage of labor Labor dystocia can occur in any stage of labor, although it occurs most commonly once the woman is in active labor or when she reaches the second stage of labor.

What treatment can the nurse anticipate assisting with for a newborn with congenital talipes equinovarus?

serial casting Treatment for congenital talipes equinovarus starts during the neonatal period. Correction can usually be accomplished by manipulation and bandaging or by application of a cast. Casts are changed frequently to provide gradual, atraumatic correction—every few days for the first several weeks.

A nurse is caring for a preterm newborn who has developed rapid, irregular respirations with periods of apnea. Which additional sign should the nurse consider as an indication of respiratory distress syndrome (RDS) in the newborn?

sternal retraction The nurse should consider sternal retraction as a sign of respiratory distress syndrome in the preterm newborn. Deep inspiration is not seen during respiratory distress; rather, a shallow and rapid respiration is seen. There is an inspiratory lag, instead of an expiratory lag, during respiratory distress. There is a grunting heard when the air is breathed out, which is during expiration and not during inspiration. pg 845

A pregnant woman has just presented to the emergency department with various reports and in distress. Which finding would lead the nurse to suspect that she is experiencing an amniotic fluid embolism? Select all that apply.

sudden onset of respiratory distress hypotension tachycardia The woman with an amniotic fluid embolism commonly reports difficulty breathing. Other signs include hypotension, tachycardia, cyanosis, seizures, coagulation difficulties, and uterine atony with subsequent hemorrhage. A sudden onset of fetal distress and acute continuous abdominal pain is associated with uterine rupture

A Hispanic 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?

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

While in labor a woman with a prior history of cesarean birth reports light-headedness and dizziness. The nurse assesses the client and notes an increase in pulse and decrease in blood pressure from the vital signs 15 minutes prior. What might the nurse consider as a possible cause for the symptoms?

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 client just delivered a preterm baby in the 30th week of gestation. The nurse knows that which nursing measures will be performed for this infant? Select all that apply. a) Estimate the urinary flow by weighing the diaper. b) Dress the baby in a stockinette cap. c) Dress the baby to keep the body warm. d) Place the baby under isolette care. e) Carry and handle the baby frequently.

• Dress the baby in a stockinette cap. • Place the baby under isolette care. • Estimate the urinary flow by weighing the diaper. Explanation: The nurse should dress the baby in a stockinette cap, place the baby under isolette care, and estimate the urinary flow by weighing the diaper. Controlling the temperature in high-risk newborns is often difficult; therefore, special care should be taken to keep these babies warm by dressing then in a stockinette cap and recording their temperature often. Isolette care simulates the uterine environment as closely as possible, thus maintaining even levels of temperature, humidity, and oxygen for the child. The isolette is transparent, so the newborn is visible at all times. The kidneys of preterm infants are not fully developed; hence, they may have difficulty eliminating wastes. The nurse should determine accurate output by weighing the diaper before and after the infant urinates. The diaper's weight difference in grams is approximately equal to the number of milliliters voided. Frequently carrying and handling the baby should be avoided so that the infant can conserve energy. Generally, preterm newborns in the high-risk category are not dressed, so the attending nurse can observe their breathing.

The nurse in the NICU is caring for preterm newborns. Which of the following are recommended guidelines for care of these newborns? Select all that apply. a) Take the newborn's temperature often. b) Discourage contact with parents to maintain asepsis. c) Dress the newborn in ways to preserve warmth. d) Supply oxygen for the newborn, if necessary. e) Handle the newborn as much as possible. f) Give the newborn a warm bath immediately.

• Dress the newborn in ways to preserve warmth. • Take the newborn's temperature often. • Supply oxygen for the newborn, if necessary. Explanation: Controlling the temperature of preterm newborns is often difficult; therefore, special care should be taken to keep these babies warm. Nurses should dress them in a stockinette cap, take their temperature often, and supply oxygen, if necessary. To conserve the energy of small newborns, the nurse should handle them as little as possible. Usually, they will not give them a bath immediately. Parents should be encouraged to bond with their infants.

A nurse discovers a perineal hematoma in a woman who has recently given birth. Which of the following interventions should the nurse make in this case? (Select all that apply.) a) Administer methotrexate b) Apply an ice pack to the site c) Administer a mild analgesic as prescribed d) Administer an antibiotic e) Estimate the size of the hematoma and report it f) Perform fundal massage

• Estimate the size of the hematoma and report it • Administer a mild analgesic as prescribed • Apply an ice pack to the site Explanation: Report the presence of a perineal hematoma, its estimated size, and the degree of the woman's discomfort to her primary care provider. Administer a mild analgesic as prescribed for pain relief. Applying an ice pack (covered with a towel to prevent thermal injury to the skin) may prevent further bleeding. Usually a hematoma is absorbed over the next 3 or 4 days. An antibiotic is not required, as there is no indication of infection. Fundal massage is indicated for uterine atony, and methotrexate is used to destroy retained placental fragments when removal is not possible.

A client in her 42nd week of pregnancy is undergoing a scheduled induction of labor based on consideration of which of the following factors? Select all that apply. a) Abnormal fetal presentation b) Gestational age c) Fetal size d) Cervical ripeness e) Complete placenta previa

• Gestational age • Fetal size • Cervical ripeness Correct Explanation: Factors that the care provider should consider when deciding if and when to induce labor include cervical ripeness, gestational age and fetal size, fetal pulmonary maturity, fetal ability to tolerate labor, uterine sensitivity to the proposed induced method, and maternal condition. The health care provider does not confirm abnormal fetal presentation and complete placenta previa when deciding to induce labor. Abnormal fetal presentation and complete placenta previa are considered contraindications to the induction of labor and not as positive factors.

A nurse is caring for an infant born with an elevated bilirubin level. When planning the infant's care, what interventions will assist in reducing the bilirubin level? Select all that apply. a) Offer early feedings b) Stop breastfeeding until jaundice resolves c) Increase the infant's hydration d) Initiate phototherapy e) Administer vitamin supplements

• Increase the infant's hydration • Offer early feedings • Initiate phototherapy

A nurse is caring for a large for gestational age newborn. Which of the following signs would lead the nurse to suspect that the newborn is experiencing hypoglycemia? Select all that apply. a) Bulging fontanels b) Lethargy and stupor c) Appearance of central cyanosis d) Respiratory difficulty e) High-pitched shrill cry

• Lethargy and stupor • Respiratory difficulty • Appearance of central cyanosis Explanation: The features indicating hypoglycemia in LGA infants include lethargy, stupor and fretfulness, respiratory difficulty and central cyanosis. The other features include poor feeding in a previously well feeding infant and weak whimpering cry. High-pitched shrill cry and bulging fontanels are seen in increased intracranial pressure following head trauma in LGA infants.

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

• Monitor client's vital signs • Get a pad count • Assess client's uterine tone

A mother brings her 1-month-old daughter in for a visit to the doctor's office and mentions that her daughter tends to tilt her head to one side and rotates her chin to the opposite side. The nurse explains that this is a condition called torticollis and explains the interventions that are commonly used to correct this condition. Which of the following should she mention to the mother? (Select all that apply.) a) Administering botulism injections b) Feeding the child in such a way as to cause her to look toward the affected shoulder c) Placing a mobile on the child's crib on the affected side d) Applying an ice pack to the shoulder on the affected side 15 minutes daily e) Speaking to the child from the unaffected side f) Performing passive stretching exercises

• Performing passive stretching exercises • Feeding the child in such a way as to cause her to look toward the affected shoulder • Placing a mobile on the child's crib on the affected side

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