Exam 2 Practice OB
Five minutes after birth, a newborn is pale; has irregular, slow respirations; has a heart rate of 120 beats/min; displays minimal flexion of the extremities; and has minimal reflex responses. What is this newborn's Apgar score?
5 The Apgar score is 5. According to the Apgar scoring system, the newborn receives 2 points for heart rate, 0 for color, 1 for respiratory effort, 1 for muscle tone, and 1 for reflex irritability. An Apgar score of 3 is low. Scores of 5 and 6 are higher, but the newborn may still require stimulation and oxygen.
A client's membranes rupture while her labor is being augmented with an oxytocin infusion. The nurse observes variable decelerations in the fetal heart rate on the fetal monitor strip. Which action should the nurse initiate next? Changing the client's position Taking the client's blood pressure Stopping the client's oxytocin infusion Preparing the client for an immediate birth
Changing the client's position Variable decelerations are usually the result of cord compression; a change of position will relieve the pressure on the cord. Variable decelerations are not related to the mother's blood pressure or to the oxytocin. Preparing the client for an immediate birth is premature; other nursing measures should be tried first.
The nurse is caring for a gravida 2 para 2 client who gave birth the previous day. During the morning assessment the nurse notes that the lochia is rubra and moderately heavy. The picture indicates where the fundus is located. What should the nurse's priority action be at this time? *Fundus is to the side* Have the woman void and reassess. Notify the provider of the risk for hemorrhage. Administer oxytocin (Pitocin) as ordered as needed. Continue the assessment because this is a normal finding at this point.
Have the woman void and reassess. The fundus is located one or two fingerbreadths above the umbilicus and to the right. This is often an indication of a full bladder. The nurse should first have the client void. Next the nurse should intervene and collect more assessment data before notifying the healthcare provider. Normally the fundus would be found midline and two fingerbreadths below the umbilicus.
What is the nurse's primary critical observation when assessing a newborn for an Apgar score? Heart rate Respiratory rate Presence of meconium Evaluation of the Moro reflex
Heart rate The heart rate is vital for life and is the most critical observation in Apgar scoring. Respiratory effort rather than rate is included in the Apgar score; the rate is very erratic. Meconium may or may not be present at this time and is not a part of Apgar scoring. Evaluation of the Moro reflex is not a part of Apgar scoring, but this reflex should be assessed later.
The nurse is performing the nursery intake assessment of a 1-hour-old newborn. The assessment reveals that the newborn's hands and feet are cyanotic, and there is circumoral pallor when the infant cries or feeds. What action should the nurse perform based on these findings? Notify the practitioner, because circumoral pallor may indicate cardiac problems Notify the practitioner, because both signs are indicative of increased intracranial pressure Take no specific action, because both signs are expected in a newborn until 2 weeks of age Take no specific action, because circumoral pallor is an expected finding during feedings and periods of crying
Notify the practitioner, because circumoral pallor may indicate cardiac problems Although acrocyanosis (cyanotic hands and feet) is common in the newborn, circumoral pallor is not a normal newborn finding. Circumoral pallor is one sign of cardiac pathology and indicates a need for further assessment and investigation by the healthcare provider. Neither circumoral pallor nor acrocyanosis is a sign of increased intracranial pressure. Circumoral pallor is not expected in the newborn; it may indicate cardiac pathology.
A mother asks the neonatal nurse why her infant must be monitored so closely for hypoglycemia when her type 1 diabetes was in excellent control during the entire pregnancy. How should the nurse best respond? "A newborn's glucose level drops after birth, so we're being especially cautious with your baby because of your diabetes." "A newborn's pancreas produces an increased amount of insulin during the first day of birth, so we're checking to see whether hypoglycemia has occurred." "Babies of mothers with diabetes do not have large stores of glucose at birth, so it's difficult for them to maintain the blood glucose level within an acceptable range." "Babies of mothers with diabetes have a higher-than-average insulin level because of the excess glucose received from the mothers during pregnancy, so the glucose level may drop."
"Babies of mothers with diabetes have a higher-than-average insulin level because of the excess glucose received from the mothers during pregnancy, so the glucose level may drop." The infant of a diabetic mother (IDM) produces a higher level of insulin in response to the increased maternal glucose level; after birth it takes several hours for the newborn to adjust to the loss of the maternal glucose. A healthy newborn's glucose level does not drop significantly after birth. A newborn's pancreas usually produces more insulin as a response to the maternal glucose level, but this response is not specific to the IDM. IDMs have the same glucose stores as other newborns; their responses to the loss of maternal glucose levels differ.
The nurse is teaching participants in a prenatal class regarding breastfeeding versus formula feeding. A client asks, "What is the primary advantage of breastfeeding?" Which response is most appropriate? "Breastfed infants have fewer infections." "Breastfeeding inhibits ovulation in the mother." "Breastfed infants adhere more easily to a feeding schedule." "Breastfeeding provides more protein than cow's milk formula does."
"Breastfed infants have fewer infections." Maternal antibodies are transferred from the mother in breast milk, providing protection for a longer time than do antibodies transferred to the fetus by way of the placenta. The neonate is protected by the antibodies. The fetus' own antibody system is immature at birth. Women who breastfeed completely (day and night with no supplementary feedings) may avoid ovulation and resumption of the menstrual cycle. Use of formula or solid foods decreases breastfeeding frequency and can lead to ovulation. Ovulation generally occurs before menses, making it difficult to know when the menstrual cycle is resuming. Therefore, breastfeeding is considered one of the least reliable methods of contraception for the new mother. Because of the higher carbohydrate content of breast milk, which is digested rapidly, breastfed infants wake more frequently than formula-fed infants. Their feeding demands take more time to regulate than do the formula-fed infants'. Breast milk has 1.1 g protein/100 mL; cow's milk has 3.5 g/100 mL. Whole cow's milk is unsuitable for infants.
A nurse is teaching a postpartum client the characteristics of lochia and any deviations that should be reported immediately. Which client statement indicates that the teaching was effective? "If I pass any clots, I'll notify the clinic." "I'll call the clinic if my lochia changes from red to pink." "I'll notify the clinic if my lochia starts to smell bad." "If my vaginal discharge continues for 3 weeks, I'll call the clinic."
"I'll notify the clinic if my lochia starts to smell bad." Lochia has a characteristic menstrual musky or fleshy smell. A foul-smelling discharge, along with fever and uterine tenderness, suggests an infection. Passing clots is a common occurrence. Lochia changing from red to pink is expected as lochia rubra progresses to lochia serosa. Although many women have a minimal discharge after 2 weeks, it is not uncommon for lochia alba to last 6 weeks.
A client who has had a cesarean birth appears upset. She has been having difficulty breastfeeding for two days and now asks the nurse to bring her a bottle of formula. What is the nurse's initial action? Obtaining the requested formula Administering the prescribed pain medication Assessing the client's breastfeeding technique Notifying the practitioner of the client's request to switch feeding methods
Assessing the client's breastfeeding technique The nurse should assess the client to determine why she is having difficulty with breastfeeding. She may be uncomfortable or in need of assistance with her breastfeeding technique. Immediately providing the formula without assessing the situation does not meet the client's needs at this time. Pain may be a factor in the client's frustration with breastfeeding; however, this should be determined through the assessment process. Notifying the practitioner of the client's request to switch feeding methods is premature. It is the nurse's responsibility to assess the situation and arrive at a solution in collaboration with the client.
A primigravida client gave birth by vaginal delivery 24 hours ago. Which findings would be considered normal? Fundus firm at the umbilicus; moderate lochia rubra; voiding quantity sufficient; colostrum present Fundus firm, one fingerbreadth above the umbilicus; scant lochia alba; voided twice, 500 mL, 400 mL; breasts heavy Fundus firm, two fingerbreadths above the umbilicus; moderate lochia serosa; voided once, 200 mL; colostrum present Fundus firm, two fingerbreadths below the umbilicus; moderate serosa alba; voiding quantity sufficient; breasts engorged
Fundus firm at the umbilicus; moderate lochia rubra; voiding quantity sufficient; colostrum present Twenty-four hours after delivery, the fundus is usually at the umbilicus and moderate lochia rubra is expected. Colostrum is present, and the breast milk usually comes in on day 3 after delivery. A fundus two fingerbreadths above the umbilicus may indicate a full bladder, and lochia serosa occurs during days 4 through 10. Voiding just 200 mL since delivery is inadequate. The presence of colostrum is normal. A fundus that is firm at two fingerbreadths under the umbilicus is acceptable, but lochia alba occurs after the 10th postpartum day. The milk would have had to come in for the breasts to be engorged, which does not typically occur until day 3. Scant lochia alba would not occur until day 10; nor would the milk supply be established.
Fetal heart rate tracing abnormalities are observed on the fetal monitor when a client in active labor turns to the supine position. Which nursing action is most beneficial at this time? Helping the client change her position Informing the client of the problem with the fetus Administering oxygen by mask to the client at 2 L/min Readjusting placement of the fetal monitor on the client's abdomen
Helping the client change her position Changing the maternal position is the most beneficial action, especially with late- and variable-deceleration patterns, because this position change will increase placental perfusion. Although the client should be kept informed of the fetus's condition, this may be done during or immediately after the position change; the needs of the fetus are the priority. If oxygen is used, the concentration should be greater than 2 L/min. Readjusting placement of the fetal monitor may be done after the position change; the immediate needs of the fetus are the priority.
A community health nurse visits an infant who was born at home 24 hours ago. While assessing the infant the nurse identifies slight jaundice of the face and trunk. What should the nurse do next? Obtain a stat order for a bilirubin level. Plan for immediate admission to the hospital. Document this expected finding in the infant's record. Arrange for the infant to have phototherapy in the home.
Obtain a stat order for a bilirubin level. Jaundice that appears within 24 hours of birth may be indicative of a pathological process; if the bilirubin level is high, intervention is required. Jaundice is not an indication for admission unless accompanied by a very high serum bilirubin level. In this situation bilirubin levels may be within normal limits and feedings may need to be increased to reduce jaundice. Physiologic jaundice does not appear until 72 hours after birth; this observation in the 24 hours after birth indicates pathologic hyperbilirubinemia. While it is important to document the jaundice in the infant's record, further intervention is indicated. The infant may require phototherapy after further assessment, but this is not the first action.
The nurse plans to weigh a newborn. What is the most appropriate way to obtain the newborn's weight most accurately? Placing the naked infant on the scale Removing the infant's clothes except for the diaper before weighing Weighing the infant's clothes and then subtracting that weight from the clothed infant's weight Having the mother hold the infant while on an adult scale and subtracting the mother's weight from the combined weight
Placing the naked infant on the scale Placing the naked infant on the scale is the most accurate method of weighing an infant because it removes all variables that could influence the weight. Removing the infant's clothes except for the diaper before weighing will result in an inaccurate measurement because the diaper and its contents have mass and will add to the measurement. Weighing the infant's clothes and then subtracting that weight from the infant's weight adds an unnecessary step to the procedure. An adult scale does not have the fine increments that are needed to obtain an accurate weight for an infant.
Twelve hours after a spontaneous birth a client's temperature is 100.4° F (38° C). What should the nurse suspect as the cause of this increase in temperature? Mastitis Dehydration Puerperal infection Urinary tract infection
Dehydration A client's temperature may increase to 100.4° F (38° C) during the first 24 postpartum hours as a result of dehydration and expenditure of energy during labor. Mastitis may develop after breastfeeding has been established and mature milk is present. A puerperal infection usually begins with a fever of 100.4° F (38° C) or more on 2 successive days, excluding the first 24 postpartum hours. Urinary tract infections usually become evident later in the postpartum period.
Before discharge, what suggestion should the nurse give to a nonnursing mother to help limit breast engorgement? Place raw cabbage leaves over the breast. Stop drinking milk for 1 week. Take an analgesic every 4 hours. Apply warm compresses to the breasts.
Place raw cabbage leaves over the breast. Fresh, raw cabbage leaves placed over the breasts between feedings can help relieve engorgement. It is thought that the effect of the cabbage leaves is related to the coolness of the leaves and the presence of phytoestrogens. Engorgement lasts about 3 to 5 days. Milk and fluids should not be restricted during the postpartum period. Medication will ease pain; however, it will not limit further engorgement. Cold compresses will limit further engorgement in the nonnursing mother. Large bags of frozen peas make easy ice packs.
A newborn is experiencing cold stress while being admitted to the nursery. Which nursing goal has the highest immediate priority? Minimize shivering Prevent hyperglycemia Limit oxygen consumption Prevent metabolism of fat stores
Prevent metabolism of fat stores Newborns do not shiver. If the newborn is cold, there is increased brown fat metabolism (nonshivering thermogenesis), which increases fatty acid blood levels and predisposes the infant to acidosis. Hypoglycemia and not hyperglycemia will occur because the newborn's glycogen reserves deplete rapidly while under cold stress. Although oxygen consumption increases during cold stress, limiting oxygen consumption is not the priority; reducing nonshivering thermogenesis is more imperative.
The nurse is assessing clients on the postpartum unit for pain. The nurse knows which client will most likely complain of and/or experience more severe afterbirth pains? The client who is a grand multipara The client who is a breastfeeding primipara The client who had a vaginal birth for a first pregnancy The client who had a cesarean birth at 43 weeks' gestation
The client who is a grand multipara A multipara's uterus tends to contract and relax spasmodically, even if the uterine tone is effective, resulting in pain that may require an analgesic for relief. Although breastfeeding increases the contractile state of the postpartum uterus, the breastfeeding primipara will not have the typical afterbirth pains of a multipara. Primiparas are less likely to have afterbirth pains than multiparas. A cesarean birth has no effect on the development of afterbirth pains.
A newborn is circumcised prior to discharge from the hospital. What should the immediate postoperative care include? Keeping the infant NPO for 4 hours to prevent vomiting Encouraging the intake of alkaline fluids to reduce urine acidity Changing the dressing using dry, sterile gauze to maintain cleanliness Encouraging the mother to cuddle her baby to provide emotional support
Encouraging the mother to cuddle her baby to provide emotional support Cuddling is comforting for the mother and baby and provides an opportunity to teach the mother how to take care of the circumcision. There is no contraindication to feeding the infant after the circumcision; nutrition may be withheld before, not after, the procedure. Providing alkaline fluids is inappropriate and could lead to fluid and electrolyte imbalance. Removal of dry gauze will cause bleeding; sterile petrolatum gauze is used and replaced with each diaper change.
What is the optimal nursing action for a client in active labor whose cervix is dilated 4 cm and 100% effaced with the fetal head at 0 station? Document the fetal heart rate every 5 minutes. Call the anesthesia department to alert the staff there of an imminent birth. Assist the client's coach in helping her with the use of breathing techniques. Suggest that the client accept the as-needed (PRN) medication for pain that has been prescribed.
Assist the client's coach in helping her with the use of breathing techniques. The client is in the early part of the first stage of labor, and it is important to help the partner with the role of coach. It is not necessary to check the fetal heart rate every 5 minutes until the second stage of labor. The first stage of labor is not as stressful for the fetus as the second stage of labor. Birth is not imminent at this time; the client is only dilated 4 cm. Suggesting that there is discomfort may increase anxiety and produce greater discomfort.
After performing Leopold maneuvers on a laboring client, the nurse determines that the fetus is in the right occiput posterior (ROP) position. Where should the Doppler ultrasound transducer be placed to best auscultate fetal heart tones? Above the umbilicus in the midline Above the umbilicus on the left side Below the umbilicus on the right side Below the umbilicus near the left groin
Below the umbilicus on the right side etal heart tones are best auscultated through the fetal back. In this case the presenting part is in the right occiput posterior position; the back is below the umbilicus and on the right side. Above the umbilicus in the midline is the placement that should be used when the fetus is lying in the midline in a breech position. Placement above the umbilicus on the left side is appropriate when the fetus is in the left sacrum anterior position. Placement below the umbilicus near the left groin is appropriate when the fetus is in the left occiput anterior or left occiput posterior position.
What should the nurse include in the teaching plan for parents of an infant with phenylketonuria (PKU)? Testing for PKU is done immediately after birth. Cognitive impairment occurs if PKU is untreated. Treatment for PKU includes lifelong medications. PKU is transmitted by an autosomal dominant gene.
Cognitive impairment occurs if PKU is untreated. In PKU, the absence of the hepatic enzyme phenylalanine hydroxylase prevents metabolism (hydroxylation to tyrosine) of the amino acid phenylalanine. The increased fluid level of phenylalanine in the body and the alternate metabolic by-products (phenylketones) are associated with severe cognitive impairment if PKU is not identified and treated early. Testing for PKU cannot be done until after several days of milk ingestion. Medications are not part of therapy for PKU. PKU is transmitted by an autosomal recessive gene.
A nonstress test (NST) is scheduled for a client with mild preeclampsia. During the test, the client asks the nurse what it means when the fetal heart rate goes up every time the fetus moves. How should the nurse respond? "These accelerations are a sign of fetal well-being." "These accelerations indicate fetal head compression." "Umbilical cord compression is causing these accelerations." "Uteroplacental insufficiency is causing these accelerations."
"These accelerations are a sign of fetal well-being." The NST is performed before labor begins. Accelerations with movement and a baseline variability of 5 to 15 beats/min indicate fetal well-being. This reactive NST is considered positive. Early decelerations are associated with fetal head compression during a contraction stress test (CST) or during labor. Variable decelerations are associated with cord compression during a CST or during labor. Late decelerations during a CST or during labor are associated with uteroplacental insufficiency.
A nurse is assessing a newborn for signs of hyperbilirubinemia (pathologic jaundice). Which clinical finding confirms this complication? Muscle irritability within 1 hour of birth Neurologic signs during the first 24 hours Jaundice that develops in the first 12 to 24 hours Jaundice that develops between 48 and 72 hours after birth
Jaundice that develops in the first 12 to 24 hours The development of jaundice in the first 24 hours indicates hemolytic disease of the newborn. Muscle irritability may or may not be present during the first 24 hours; usually it develops later. Neurologic signs may or may not be present during the first 24 hours; they are dependent on the bilirubin level. Serum bilirubin is expected to accumulate in the neonatal period because of the short life span of fetal erythrocytes, reaching a level of 7 mg/100 mL (100 mcmol/L) the second to third day when jaundice appears (physiologic jaundice).
The nurse concludes that a positive contraction stress test (CST) result may be indicative of potential fetal compromise. A CST result is considered positive when the fetal heart rate shows what during contractions? Late decelerations Early accelerations Variable decelerations Prolonged accelerations
Late decelerations A fetus with a borderline cardiac reserve will demonstrate hypoxia by a decreased heart rate when there is minimal stress, making the CST result positive. Accelerations are not defined as early, late, or prolonged. These are nonuniform drops in fetal heart rate before, during, or after a contraction; variable decelerations during a CST do not make the test result positive.
While assessing a newborn, the nurse notes that the infant's skin is mottled. What should the nurse's primary intervention be? Administer oxygen Offer an oral feeding Notify the practitioner Warm the environment
Warm the environment Mottling results from hypothermia; the newborn should be wrapped, placed under a radiant warmer, or given to the mother for skin-to-skin contact. Mottling is a phenomenon that usually indicates a decreasing temperature; the newborn requires warming, not oxygenation or medical attention. Feeding will not increase the newborn's temperature.
A newborn's Apgar score at 5 minutes is 5. Which condition correlates with this low Apgar score? Cerebral palsy Genetic defects Mental retardation Neonatal morbidity
Neonatal morbidity An Apgar score of 5 at 5 minutes is related to neonatal morbidity and mortality; by 5 minutes the healthy neonate is relatively stable, with an Apgar score of 8 to 10, and requires routine care. The presence of cerebral palsy is not related to the Apgar score. It is rarely diagnosed in the newborn. Genetic defects may or may not be apparent at this time and are not related to the Apgar score. Mental retardation has not been proved to be correlated with Apgar score, although research continues in this area.
A nurse teaches a woman who is planning to breastfeed how to relieve breast engorgement. The nurse determines that further teaching is necessary when the woman states that she will do what? Manually express breast milk Breastfeed the infant less frequently Apply warm compresses to both breasts Place cold compresses on the breasts just after breastfeeding
Breastfeed the infant less frequently Frequent nursing empties the milk ducts, relieving engorgement. Manual expression initiates milk flow, empties the ducts, and relieves engorgement. Warmth will dilate ducts and facilitate flow of milk, relieving engorgement. If the breasts remain engorged immediately after breastfeeding, cold compresses help relieve the discomfort.
A nurse is caring for a mother and neonate. What is the priority nursing action to prevent heat loss in the neonate immediately after birth? Bottle feeding immediately after birth Dressing the newborn in a shirt and gown immediately Bathing the newborn in warm water as soon as possible Putting the naked newborn on the mother's skin and covering the infant with a blanket
Putting the naked newborn on the mother's skin and covering the infant with a blanket Skin-to-skin contact between mother and infant is most effective in maintaining the infant's body temperature; heat is transferred by way of conduction. A radiant warmer is effective if the mother or newborn is unable to engage in immediate skin-to-skin contact. Dressing the newborn in a shirt and gown immediately is not effective; also, a blanket and radiant warmer are necessary if skin-to-skin contact with the mother is not possible. Bathing the infant should be delayed until the newborn's body temperature has been stabilized.
On the second postpartum day a client mentions that her nipples are becoming sore from breastfeeding. What is the nurse's initial action in response to this information? Assess her breastfeeding techniques to identify possible causes. Provide a nipple shield to keep the infant's mouth off the nipples. Instruct her to apply warm compresses 10 minutes before she begins to breastfeed. Explain that she should limit breastfeeding to 5 minutes per side until the soreness subsides.
Assess her breastfeeding techniques to identify possible causes. The nurse must first assess the client's breastfeeding practices; nipple soreness may occur when the newborn's mouth is not covering the entire areola; also, nipples must toughen in response to suckling. Providing a nipple shield, having the client apply warm compresses before the feeding, or limiting the time spent at breastfeeding is premature; the cause of the soreness must be determined first and will dictate the choice of intervention.
How does the nurse know that a client at 40 weeks' gestation is experiencing true labor? Cervical dilation Membrane rupture Decreased fetal heart rate Intensification of contractions
Cervical dilation True labor is marked by cervical dilation, effacement, or both. It is not uncommon for membranes to rupture before true labor begins. A change in the fetal heart rate does not indicate true labor; the rate may be slowing because the fetus is resting or fetal compromise is occurring. The client's perception of the intensity of contractions is not an indication of true labor. Because of admission to the hospital and loss of diversionary activities, the client may perceive the contractions as becoming more intense.
A client in labor is receiving an oxytocin (Pitocin) infusion. Which intervention is a priority for the nurse when repetitive late decelerations of the fetal heart rate are observed? Administer oxygen. Place the client on the left side. Discontinue the oxytocin infusion. Check the client's blood pressure.
Discontinue the oxytocin infusion. Treat the immediate potential cause of the decelerations by discontinuing the oxytocin infusion. The infusion should be stopped because it is the likely source of fetal compromise. Additional interventions including administering oxygen, placing client on left side, and monitoring vital signs should be initiated to support both the mother and the unborn child. These interventions are supportive therapy not treatment of the cause.
A primiparous client reports to the maternity unit stating that her contractions are occurring every 5 minutes. Upon further inquiry the nurse learns that the client has not attended any childbirth classes. A cervical assessment reveals that she is in true labor. When is the best time for the nurse to include education on simple breathing and relaxation techniques? During the latent phase of the first stage of labor During the active phase of the first stage of labor During the active phase of the second stage of labor During the transition phase of the first stage of labor
During the latent phase of the first stage of labor During the latent phase of the first stage of labor the client is excited and open to learning. The contractions are not as strong as they are going to be, so the client has time between contractions to absorb the nurse's teaching. Contractions are more frequent and stronger in the active phase of the first stage. The increased frequency decreases the client's ability to absorb information. During the active phase of the second stage of labor the client will be bearing down to expel the fetus, and simple breathing techniques are not appropriate. During the transition phase of the first stage of labor the contractions are at their maximum intensity, which inhibits the client's ability to listen.
The nurse admits a client in active labor to the birthing center. She is 100% effaced, dilated 3 cm, and at +1 station. What stage of labor has this client reached? First Latent Second Transitional
First The first stage of labor lasts from the onset of contractions until the cervix is fully dilated at 10 cm. The client is in the early phase of the first stage of labor. There is no latent stage of labor. The second stage of labor lasts from complete dilation to birth. There is no transitional stage of labor; transition is the last phase of the first stage of labor.
A vaginal examination reveals that a client's cervix is 90% effaced and dilated to 6 cm. The fetus's head is at station 0, and the fetus is in a right occiput anterior (ROA) position. The contractions are occurring every 3 to 4 minutes, are lasting 60 seconds, and are of moderate intensity. What should the nurse record about the client's stage of labor? Early first stage of labor Transition stage of labor Beginning second stage of labor Midway through first stage of labor
Midway through first stage of labor The cervix is 90% effaced and dilated 6 cm during the active phase of the first stage of labor. When the cervix is dilated 6 cm, the individual is beyond the early stage of labor. Transition is not a stage of labor; it is the last phase of the first stage of labor, which begins when the cervix is dilated 8 cm. The second stage of labor begins when the cervix is fully dilated and 100% effaced.
The nurse is assessing several postpartum clients at the very beginning of her shift. Which problem does the nurse identify that might predispose a client to postpartum hemorrhage? Preeclampsia Multifetal pregnancy Prolonged first-stage labor Cephalopelvic disproportion
Multifetal pregnancy The presence of more than one fetus overdistends the uterus, which may result in uterine atony and thus postpartum hemorrhage. Preeclampsia and prolonged labor are not associated with postpartum hemorrhage. Cephalopelvic disproportion alone does not predispose a woman to postpartum hemorrhage.
An expectant couple asks the nurse about the cause of low back pain in labor. The nurse replies that this pain occurs most often when the fetus is in what position? Breech Transverse Occiput anterior Occiput posterior
Occiput posterior A persistent occiput posterior position causes intense back pain because of fetal compression of the maternal sacral nerves. The breech position is not associated with back pain. The transverse position does not usually cause back pain. Occiput anterior is the most common fetal position and does not cause back pain.
The nurse is helping a mother breast-feed her newborn. What is the best indication that the newborn has achieved an effective attachment to the breast? The tongue is securely on top of the nipple. The mouth covers most of the areolar surface. Loud sucking sounds are heard during the 15 minutes spent at each breast. Vigorous suckling occurs for the 5 minutes the infant spends at each breast before falling asleep.
The mouth covers most of the areolar surface. Effective attachment involves covering most of the areolar surface of the breast with the newborn's mouth; effective attachment helps compress the milk glands. The nipple must be on top of the newborn's tongue. Loud sucking sounds indicate inadequate attachment. The newborn should suckle for a longer period than 5 minutes; the newborn may be sucking only on the nipple.
The nurse is assessing the newborn in the first hour after birth. Which findings does the nurse identify as normal for the newborn? Select all that apply. The newborn has a flat abdomen. The newborn weighs 6 lbs (2,700 g). The newborn's hands and feet appear cyanosed. The newborn does not blink in the presence of light. The circumference of the head is 33 cm (13 in).
The newborn weighs 6 lbs (2,700 g). The newborn's hands and feet appear cyanosed. The circumference of the head is 33 cm (13 in). The average newborn weighs between six to nine pounds (2,700 to 4,000 g). The hands and feet of the newborn are usually cyanosed during the first 24 hours after birth. The average newborn has a head circumference of 33 to 35 cm (13 to 14 inches). Newborns generally have protuberant (not flat) abdomens. Newborns exhibit a blinking reflex when light is directed toward the eye.
Which information should the nurse include in the discharge teaching of a postpartum client? The prenatal Kegel tightening exercises should be continued. The episiotomy sutures will be removed at the first postpartum visit. She may not have a bowel movement for up to a week after the birth. She should schedule a postpartum checkup as soon as her menses returns.
The prenatal Kegel tightening exercises should be continued. Kegel exercises may be resumed immediately and should be done for the rest of the client's life because they help strengthen muscles needed for urinary continence and may enhance sexual intercourse. Episiotomy sutures do not have to be removed. Bowel movements should spontaneously return in 2 to 3 days after the client gives birth; a delay of bowel movements promotes constipation, perineal discomfort, and trauma. The usual postpartum examination is 6 weeks after birth; the menses may return earlier or later than this and should not be a factor when the client is scheduling a postpartum examination.
A client is receiving an epidural anesthetic during labor. Which alteration in client status does the nurse recognize as a likely side effect of the anesthetic? Hypertension Urine retention Subnormal temperature Decreased level of consciousness
Urine retention Anesthesia blocks the sensory pathways; therefore the mother does not sense bladder distention and may be unable to void. Hypotension, not hypertension, is a side effect of epidural anesthesia. An epidural anesthetic does not influence body temperature. A decreased level of consciousness occurs with general anesthesia, not epidural anesthesia; general anesthesia is used when there is an emergency.
