Exam 3 - HESI/Quizlets/Osmosis Quizzes/Pearson

What is the low heart rate postpartum caused by?

*Hemodynamic (blood flow in organs) changes and vagal hyper reativity in response to the increased stimulation* of the sympathetic nervous system during labor

Daily Nurse Care

- Breasts - Uterus - Bladder - Bowel - Lochia - Episiotomy - Emotion

Weight Loss broken down: (read over generally)

- Fetus: 7-8 lbs - Placenta: 1 ½ - 2 lbs - Amniotic fluid: 1 lb - Blood at delivery: 1 lb - Diuresis: 4 lbs - Involution of uterus and lochial discharge: 4 lbs

Bowel

- Fiber and increase liquids. (Water is best!!) - Walking and OOB: ASAP

Episiotomy

- Ice for 24 hrs - check every shift - Turn on left and check for intactness (sutures will absorb) - Emotional (crying is normal)

What are the 3 types of Lochia?

- Rubra (day 1-3) - Serosa (day 4-9) - Alba (day 10- 3-6 weeks)

*Anatomical Change in the Post- Partum Period*

- Uterus - Cervix and Vagina - Abdominal Wall - Cardiovascular System - Urinary System - Ovulation and Menstruation - G.I. System - Weight Loss - Breasts

The increased capacity of bladder and increased pressure results in:

- over distension - incomplete emptying - residual urine

Daily Nursing Care: Breast

- soft first 1-2 days then firm - *warm compress or shower for engorgement (if breastfeeding)* - nurse every 2-3 - *no stimulation, tight bra, pain med, cabbage leave (not breastfeeding)*

12 hours after delivery, the uterus goes to ____________cm above the umbilcus

1 cm

When does ovulation occur in non-lactating women?

10-14 weeks (2-4 months)

How much is the increase of blood volume in circulating blood volume in the first 2-3 days postpartum?

15-30%

Bonding

1st step in attachment - eye contact, talking, touching, and kissing - In delivery room, hold off eye erythromycin ointment till parents make eye contact with newborn

Cervix and Vagina open about how many cm?

2 they are soft

Cervix and Vagina admit _______________ fingers and is about _________ cm thick

2 fingers and 1 cm thick

What is the average weight loss?

20-22 lbs

Postpartum the mother has transient bradycardia, for how long?

24-48 hours

In the Involution Process of uterus, how long does it take for necrotic tissue to slough off?

3 weeks (Takes 3 additional weeks for placenta site to have new regenerated endometrium)

Colostrum is secreted from breasts till ___________ days postpartum

3-4 days

How long does is take for the Vagina to regain elasticity?

3-6 weeks

How long does it take for a Episiotomy with repair to heal?

4-6 weeks

How low can the heart rate get postpartum?

50 bpm

The Uterus requires ______ weeks to return to pre-pregnancy state

6

Postpartum birth weight will go away in how many months?

6 months with routine exercise

After how many weeks postpartum can the patient exercise?

6 weeks

All weight of pregnancy usually gone by ____________ months postpartum

6-9

Prior to administering caffeine sodium benzoate, which information should the nurse include? a. indications and mechanisms of caffeine sodium benzoate b. reasons for foley catheter until the headache resolves c. PDPH is usually accompanied by nausea and Zofran is available as needed d. Strict, reclined bed rest and severe headaches may limit breastfeeding ability

A (Caffeine and sodium benzoate will constrict the cerebral blood vessels and decrease the headache.Prior to administering the medicaiton, the nurse should explain that this medicaiton is prescribed to constrict cerebral blood vesses and alleviate PDPH.)

When finding a postpartum patient in a pool of blood, what is the priority nursing action? a. massage the fundus b. take vital signs c. increase IV rate d. check the bladder

A (Massage the fundus. Since a boggy fundus is the most likely reason for this client's hemorrhaging, massaging the fundus is the most important intervention. The nurse should also call for assistance die to the amount of blood that has pooled unde the client.)

A nurse explains a mom's condition to a husband who storms off the unit shouting, "I can't beleive you incompetent people here at this hospital! First you almost let my wife bleed to death, and now I find out the epidural was put in incorrectly by an idiot! Someone is going to pay for this!" Ten minutes later he goes into the room where the mom is breastfeeding and shortly after the infant abduction alarm on the unit is activated. The nurse sees the father walking out off the door with the infant in his arms. What should the nurse do? a. notify security and direct all staff to report to their assigned exit in the hospital b. document the observation in the client record and submit an incident report to risk management c. notify the HCP d. request that pastoral care personnel locate the husband and discuss the issue

A (Notify the security personnel and direct all staff to report to their assigned exit in the hospital.)

What is the priority nursing diagnosis for someone who is experiencing risidual effects of epidural anesthesia? a. risk for injury b. impaired physical mobility c. altered urinary elimination d. risk for infection

A (Risk for injury. Causes temporary loss of voluntary movement and muscle strength in the lower extremities. Serious injury could be incurred if Mari attempts to get out of bed on her own because her legs will be unable to sustain her weight.)

What factors influence the outcomes of the at-risk newborn? (Select all that apply.) a. Birth weight b. Gestational age c. Type and length of newborn illness d. Environmental factors e. Maternal factors

All

Which parameters would the nurse use to judge how well postpartum involution is progressing? (Select all that apply.) a. Fundal height b. Fundal position c. Amount of lochia d. Odor of lochia

All (Fundal height; b. Fundal position; c. Amount of lochia; d. Odor of lochia Feedback: The nurse can make the determination that involution is progressing in a normal manner by assessing two parameters: (1) that the fundus is descending into the pelvis at a normal rate and that it is contracted; a firm, midline fundus indicates normal involution; and (2) the amount and character of lochia. Excessive or foul-smelling lochia indicates problems.)

Homan's Sign

Assess for pain in the calf of each leg - report pain - do not rub or massage leg - visually assess for redness or swelling

soft, boggy fundus above umbilicus bright red blood clots

Assessment of uterine atony would reveal what signs and symptoms?

The nurse finds out that she has transfused A negative blood, but that the patient is A positive, she in indirect Coombs Negative and non-sensitized. Based on this information, what is the correct nursing action? a. obtain RhoGam from the blood bank, and administer it as soon as possible b. allow the mom to remain at rest during the blood transfusion and administer the RhoGam as prescribed at a later time c. notify the HCP and request Coomb's positive blood test for her and her infant d. Document the finding in the client record, and pass the information on to the day shift

B (Allow Mari to rest during the blood transfusion and administer the PhoGam as prescribed at a later time.)

A mom is pale, weak, and anxious. Her fundus is firm and 1 cm above the umbilicus. She is receiving O2 via nasal cannula at 4L/min and has an O2 sat of 88%. BP is 74/44, HR is 116, RR is 26. She does not want her children to see her this way. How should the nurse communicate this to the husband? a. ask the clerk to notify the husband about the change in condition and let him know that she is going to be OK b. Call the husband from the nurses station and tell him to come to the hospital soon, without the children c. dial the phone for the patient and allow her to talk d. Wait until the husband arrives with the children and talk to him before he goes in to see her

B (Call Mr. Wilson from the nurses' station to inform him of his wife's status and request that he come to the hospital soon, without the other child.)

A postpartum patient with a history of hemorrhage, what would be the most likely cause of a headache? a. O2 administration b. epidural anesthesia c. straining during delivery d. side effect of oxytocin

B (Epidural anesthesia. Postdural puncture headache (PDPH) sometimes occurs after wpidural anesthesia.)

300mL

Bakri fill volume (less than EBB)

By 10 days of post partum, the fundus should be located where?

Below Symphysis Pubis Bone

Coagulopathy

Blood's ability to coagulate (form clots) is impaired

What mnemonic or acronym is used to remember the key points of postpartum nursing assessment?

Bubble-le

What is the best method for the nurse to use to obtain immediate assistance for a postpartum hemorrhage? a. telephone the HCP b. go the RN station and notify charge nurse c. activate the priority call light from bedside d. call for help from the doorway of the client's room

C (Activate the priority call light from the bedside. The priority call light signals to the entire nursing unit that a client is in crisis. All personnel available will respond to the distress signal.)

What is the priority nursing actions to address needs related to the repair of a 4th degree perineal laceration? a. provide prescribed oral pain medication b. encourage warm sitz baths 2 to 3 times daily c. apply perineal packs consistently for the first 24 to 48 hours d. teach proper and frequent use of the peri-bottle

C (Apply perineal ice packs consistently for the first 24 to 48 hours. Cause local vasoconstriction, resulting in decreased swelling and tissue congestion, preventing a hematoma, as well as prmoting comfort. Application of ice packs is the priority nursing action for the first 24 to 48 hours, which is the period that the tissue is most vulnerable to swelling resulting from the trauma. A hematoma formation could contribute to hypovolemia and needs to be prevented.)

The nurse has requested assistance for a postpartum hemorrhage and personnel are on their way. While waiting for help to arrive, what is the next priority action? a. obtain vital signs b. apply oxygen c. assess for bladder distention d. increase the IV infusion rate

C (Assess for bladder distention. The client is 2 hours post-delivery with an IV infusion at 125 mL/hour, which can contribute to diuresis. A distended bladder impedes uterine contraction and contributes to excesive bleeding. After the fundus is massaged, the bladder should be checked for distention.)

The nurse is aware that a PPH condition is stabilizing. Which nursing intervention would be most appropriate at this time? a. contact respiratory therapy to obtain a blood gas b. restrict oral fluid intake c. palpate the bladder and catheterize if indicated d. request an order for hourly hemoglobin and hematocrit measurements

C (Palpate Mari's bladder for fullness and catheterize if indicated.)

Fifteen minutes after blood transfusion is started temp is 985, BP goes from 78/50 to 76/48, HR goes from 110 to 112, and RR stays the same at 22. What should the nurse do in response to these assessment findings? a. decrease the rate of transfusion b. stop the transfusion c. provide a warm blanket and continue to monitor d. compare the blood type on the label with the requisition form

C (Provide a warm blanket and continue to monitor. The administration of a cold blood bommonly causes the client to feel cold but it does not constitute chills and fever, which are indicative of a febrile nonhemolytic reaction.)

Prior to discontinuing the IV oxytocin (Pitocin), which assessment is most important for the nurse to obtain? a. vital signs b. vaginal discharge c. uterine firmness d. oral intake

C (Uterine firmness.Hormone used to stimulate uterine contractions and prevent hemorrhage from the placental site.)

Lochia

Check every shift and note color and amount

What is the best thing for the nurse to do when getting ready to transfuse while it is time to breast feed? a. encourage breast feeding while proceeding with blood administration b. delay hanging the blood for 15 to 20 minutes for breastfeeding c. request that the infant be brought back in an hour for breastfeeding d. explain the situation and request that the infant be formula fed

D (Explain Mari's history and request that the infant is fed with formula in the nursery. Condition is too unstable for her to fed her infant. Even though breastfeeding will stimulate uterine contractions, this is not as important as client stability.)

Which finding is most indicative that the pitocin is reaching a therapeutic level? a. BP 74/44 b. HR 94 c. O2 sat 85% d. firm fundus

D (Firm fundus. The desired therapeutic effect of oxytocin (Pitocin) is to cause potent and selective stimulation of uterine smooth muscle. A firm fundus indicates uterine contraction during the postpartum period, which is important to prevent further hemorrhage.)

The charge nurse, two staff nurses and an unlicensed assistive personnel (UAP) rush in to assist the nurse with a postpartum hemorrhage. Which task is best delegated to the UAP during the crisis? a. bring IV fluids and supplies from the supply room b. change the bed linens and bathe the client c. start O2 per nasal cannula d. obtain vitals signs and O2 saturation

D (Obtain the vital signs and O2 saturation. Both are within the scope of practice for the UAP, and the nurse should interpret thses findings as indications of hypovolemia due to blood loss and should also be report the findings to the HCP.)

The increase blood volume of 50% gradually decreases OR increases till normal at about 2 weeks postpartum?

DECREASES - allows for loss of blood at delivery up to 400 cc's

After 12 hours of delivery when the uterus rises 1cm above umbilicus it begins to do what?

Decent 1cm every 24 hours

Is there a decrease OR increase in hemotocrit/hemoglobin in the early postpartum period?

Decrease (rises 5-7 days postpartum)

What desired outcome should the nurse observe with the administration of caffeine?

Decrease in apneic events

The increased GRF causes what?

Diuresis (up to 2000 mls/ day for 4-5 days)

True or False: The umbilical cord is made up of two umbilical veins and one umbilical artery. True False

False (The statement should say: The umbilical cord is made up of ONE (not two) umbilical vein and TWO (not one) umbilical arteries.)

Uterus

Firm, decreases 1cm (fingerbreathe) per day

Immediately following delivery, the cervix does takes what kind of appearance?

Fish mouth (frown) appearance

How is the Abdominal Wall postpatrum?

Flabby when standing - pouches over like a month pregnancy

What happens to the External Cervical OS 1 week postpartum?

Gradually closes

How do you calculate APGAR?

Heart Rate: absent = 0, slow (<100) = 1, Over 100 = 2 Resp Rate: absent = 0, slow/irregular = 1, good/crying = 2 Muscle Tone: flaccid = 0, some flexion of the extremeties = 1, active motion = 2 Reflex Irritability: no response = 0, grimace = 1, cry = 2 Color: blue/pale = 0, body pink/extremeties blue = 1, completely pink = 2 Total possible = 10

Episiotomy

Incision of vulva to make an enlarged opening for baby to pass through normally

Blood Volume: Increased Coagulopathy

Increase in clot formation possible, DVT in legs and PE possible - increase in plasma fibrinogen

Postpartum bladder has an increased OR decreased capacity.

Increased

to promote closure of a PDA, the nurse anticipates a Rx for which med?

Indomethacin

Postpartum is an optimal time for the bladder to have?

Infections due to urine stasis (retention)

early ambulation TED/SCD elevate legs hydration routine assessment

Interventions related to preventing thrombophlebitis

What kind of supplements do most patients get to counter the effects of blood loss?

Iron

yes

Is it ok to breast feed with mastitis?

Why is there a large decrease in hemoglobin?

Large blood loss

What size is the Uterus post partum?

Large grapefruit

During a postpartum nursing assessment, the ______________ must be assessed for DVT

Lower extremities

To ensure proper placement prior to inserting a tube for oral gastric OG feedings, what action should the nurse take?

Measure from mouth to ear to xyphoid process

fever GI upset

Misoprostol (Cytotec) may cause

secondary postpartum hemorrhage (PPH)

Misoprostol (Cytotec) should only be given orally under what circumstance?

In the Involution Process of uterus, the contraction of the uterus decreases size of what kind of cells?

Myometrial

Can the patient feel if they have to void?

No, their bladders are very sensitive from the pressure they can not feel the sensation so the nurse needs to make sure the patient voids

Lochia

Normal discharge from the uterus after childbirth

Pain from episiotomy and hemorrhoids makes bowel movements ____________________.

Painful

In the Involution Process of uterus, Autolysis occurs which does what?

Process in which the *protein material of uterine wall is broken down into simpler components which are absorbed by body*

Post Partum Period is also known as ___________

Puperial Time

During postpartum period, what happens to the urterers and the renal pelvis of kidney?

Remain dilated after delivery (return to normal in 3-6 weeks)

How is the GFR postpartum?

Remains increased combined with increased blood volume

What happens 6 weeks after delivery during the post partum period?

Return of reproductive organs to pre pregnant condition

What happens motility and tone postpartum?

Return to normal within 2 weeks of delivery

With the increase in lactation duration, what happens to the average time of ovulation?

Rises

What are features of breastfeeding?

SIDS Risk reduced Bonding Complete nutrition Convenient long term health benefits (including reduced risk for childhood cancers, hypertension, dental caries, type 1 diabetes, exzema, asthma, and allergies) antibody protection possible enhanced cognitive development

In the Exfoliation Process of uterus, it prevents what kind of tissue from forming?

Scar Tissue

What are given for the GI system during postpartum?

Stool softners

Temperature over 100.4 after the first 24 hours postpartum is considered high and prior means the patient is dehydrated. True or False

True

The Involution Process of uterus accounts for the decrease size of uterus. True or False

True

The return of mensuration after delivery follows a linear pattern. True or False

True

Oxytocin Methergine

Txa is given after?

Immediately following delivery, the fundus can be palpated about 1-2cm below the _________________.

Umbilicus

How is the Blood Pressure postpartum?

Unchanged

Bladder

Void 150 first 3 voids

high boggy

What does a uterus feel like if there are retained placental fragments?

immobility (cesarean section, cultural) trauma (flexing knees back/stirrups use)

What increases a woman's postpartum risk for thrombophlebitis?

What is ovulation & menstruation influenced by?

Whether or not a woman breast feeds

compatible with blood products

Why is normal saline indicated with IV therapy for treatment of postpartum hemorrhage?

Is constipation still common postpartum?

Yes

Is the bladder insensitive to increased pressure?

Yes

Is post partum the 4th trimester?

Yes - 6 weeks post partum (after delivery)

A client born at 27 weeks' gestation develops grunting, nasal flaring, and decreased oxygenation. Based on the client's gestational age, there is more than likely a deficiency in surfactant. Surfactant is critical for: a. Alveolar stability. b. Development of the bronchi or bronchioles in the lungs. c. Preventing the exchange of oxygen and carbon dioxide. d. Absorption and reabsorption of additional lung secretions.

a

A nurse is caring for a 48-hour-postpartum client who complains of urinary frequency and dysuria. Her temperature is 100.2°F, pulse 72, respirations 18, and blood pressure 108/72. What is the most appropriate nursing intervention? a. Obtain a clean-catch urine specimen. b. Administer antibiotics. c. Obtain a catheterized urine specimen for culture and sensitivity. d. Administer anti-inflammatory medication for discomfort.

a

The physiologic alterations of RDS (respiratory distress syndrome) can produce: a. Hypoxia. b. Respiratory alkalosis. c. Hemoglobinopathies. d. Metabolic alkalosis.

a

Which of the following laboratory findings would most likely be considered normal in the immediate postpartum period? a. Increased white blood cell (WBC) count b. Decreased erythrocyte sedimentation rate (ESR) c. Decreased hematocrit d. Increased platelet (PLT) count

a

Which question from a postpartum client indicates a need for further teaching about managing afterpains? a. "Can I get an ice pack for my belly to help with these cramps?" b. "Should I have my mom bring me a lysine supplement? She says it might help." c. "The baby's due to nurse in about an hour. Can I have some ibuprofen?" d. "I guess we can expect this to be worse after having twins that it was with my singleton, right?"

a ("Can I get an ice pack for my belly to help with these cramps?" Feedback: Application of heat is helpful in managing afterpains. Ice may make them feel worse. Lysine supplements and taking an analgesic an hour before feeding are helpful. Increased discomfort with afterpains can be expected following overdistention of the uterus, such as multiple gestation.)

You're assessing the one minute APGAR score of a newborn baby. On assessment, you note the following about your newborn patient: heart rate 101, cyanotic body and extremities, no response to stimulation, no flexion of extremities, and strong cry. What is your patient's APGAR score? A. APGAR 4 B. APGAR 6 C. APGAR 3 D. APGAR 2

a (APGAR 4.....A: 0, P: 2, G, 0, A: 0, R: 2)

Which of the following physical assessment findings indicates a need for further evaluation? a. Absence of the rooting reflex b. Hypertonia c. Brisk knee jerk d. Plantar flexion

a (Absence of the rooting reflex Feedback: Absence or delayed disappearance of reflexes will always be a concern and a reason to refer for developmental screening. Newborns tend to have more hypertonia than hypotonia. Hypotonia would be a definite need for a referral. Brisk knee jerk and plantar flexion should be found upon exam of the newborn.)

What is the nurse's chief concern when a mother who delivered 2 hours ago has a blood pressure change from 112/70 to 142/94? a. Developing preeclampsia b. Fluid overload c. Puerperal hypertension d. Worsening systolic heart murmur

a (Developing preeclampsia Feedback: This is a significant increase in the blood pressure, and the most dangerous complication at this point is the occurrence of preeclampsia. In a postpartum woman, diuresis should control the fluid volume and hypertension should not develop. A heart murmur would more likely cause symptoms of heart failure.)

The nurse is caring for a baby in the special care nursery whose mother did not have prenatal care. His gestational age is estimated to be 34 weeks and he displays features and behaviors that are consistent with Fetal Alcohol Spectrum Disorder. When reviewing his orders, which of the following should the nurse be sure is included? a. Echocardiogram (ultrasound of the heart) b. Thyroid function panel c. IV pyelogram (scan of the kidneys with contrast) d. Ophthalmology consult

a (Echocardiogram (ultrasound of the heart) Feedback: Fetal Alcohol Spectrum Disorder is associated with congenital heart malformations, so this infant should have the structure of his heart examined by ultrasound. FASD is not associated with thyroid, kidney, or eye abnormalities.)

A nurse is assigned to care for four postpartum clients. Which client would be least likely to request relief for afterpains? a. Gravida 1, para 1 with a 16-hour labor b. Gravida 2, para 1 with hydramnios c. Gravida 5, para 4 with twins d. Gravida 3, para 2 who is breastfeeding

a (Gravida 1, para 1 with a 16-hour labor Feedback: Afterpains are intermittent uterine contractions, and since a primipara's uterus is able to maintain a steady contracted state, afterpains are not as severe. Afterpains may result from hydramnios with an overdistended uterus, multiparity caused by an overdistended uterus, or breastfeeding, which stimulates the release of oxytocin during suckling. In these situations, the uterus works harder to maintain a contracted state, causing afterpains.)

Regarding neurologic conditions, which of the following is true of headaches during the postpartum period? a. Headaches are the most common neurologic symptoms demonstrated by postpartum clients. b. Spinal anesthesia is not associated with a risk for headache. c. Migraine headaches are more common during pregnancy. d. Hypertension is not associated with headaches.

a (Headaches are the most common neurologic symptoms demonstrated by postpartum clients. Feedback: It is true that headaches are the most common neurologic symptoms demonstrated by postpartum clients. Spinal anesthesia is associated with a risk for headache; migraine headaches are not more common during pregnancy; and hypertension is associated with headaches.)

Clinical manifestations that indicate a newborn may be experiencing overheating include: a. Increased heart rate, increased blood pressure, and increased restlessness. b. Decreased blood pressure and lethargy. c. Increased respiratory rate, perspiration over forehead and torso, and decreased blood pressure. d. Increased heart rate, increased blood pressure, decreased oxygen consumption.

a (Increased heart rate, increased blood pressure, and increased restlessness. Feedback: Newborns may respond to overheating with increased restlessness and, eventually, perspiration. Many newborns initially cannot perspire, so they increase their respiratory and heart rates, which increases oxygen consumption.)

Understanding the transition from intrauterine to extrauterine life, what intervention is most appropriate when working with an infant of a diabetic mother? a. Make frequent blood glucose checks. b. Obtain lab work to look for infection. c. Administer IV fluids. d. Place under a radiant warmer bed immediately.

a (Make frequent blood glucose checks. Feedback: Lab work, IV fluids, and the radiant warmer bed may all be required for interventions for the infant of a diabetic mother, if the infant is experiencing signs of respiratory distress or sepsis. Frequent blood glucose checks need to be completed to ensure that blood glucose levels are being maintained.)

A nurse is assessing a client 2 hours postpartum. Her blood pressure is 98/60, pulse is 90, and she has saturated two pads in the last hour. What should be the immediate nursing action? a. Massage the fundus until firm. b. Increase the rate of the intravenous infusion. c. Notify the primary healthcare provider or nurse-midwife. d. Obtain an order to catheterize the client.

a (Massage the fundus until firm. Feedback: The initial action is to assist the fundus to remain contracted, which will decrease bleeding. The fundus is checked frequently for firmness, and if it is boggy, the fundus is massaged until firm. Increasing the rate of the intravenous infusion may be necessary, but it is not the immediate action. The primary healthcare provider or nurse-midwife is notified only if fundal massage is not effective. A catheterization will help if the bladder is overdistended, but would not be an initial intervention.)

A client is 24 hours postpartum and saturating a pad every 2 hours with lochia rubra. Her fundus is at the umbilicus. Based on these findings, what medication would the nurse anticipate the primary healthcare provider or nurse-midwife ordering for this client? a. Methylergonovine maleate (Methergine) b. Oxycodone (Percodan) c. Ibuprofen (Motrin) d. Carboprost (Hemabate)

a (Methylergonovine maleate (Methergine) Feedback: Methergine is the treatment of choice for subinvolution. Percodan and Motrin are ordered for pain management. Hemabate is used for immediate postpartum hemorrhage related to uterine atony.)

A newborn's one minute APGAR score is 8. Which of the following nursing interventions will you provide to this newborn? A. Routine post-delivery care B. Full resuscitation assistance is needed and reassess APGAR score C. Continue to monitor and reassess the APGAR score in 10 minutes D. Some resuscitation assistance such as oxygen

a (Scoring Interventions are as follows: 7-10: no interventions, baby doing good just needs routine post-delivery care, 4-6: some resuscitation assistance required like oxygen, suction.... stimulate the baby, rub baby's back, 0-3: needs full resuscitation *Remember the APGAR scoring is performed at 1 minute and 5 minutes after birth and reassessed at 10 minutes (5 minutes later) after birth if the score is 6 or less.)

Fill in the blank: The pressure in the fetal lungs before birth is __________, which allows blood from the _____________ to shunt into the ______________ via the __________________. A. high, pulmonary artery, aorta, ductus arteriosus B. high, pulmonary vein, aorta, ductus venosus C. low, aorta, pulmonary artery, pulmonary vein, ductus arteriosus D. low, right atrium, left atrium, foramen ovale

a (The pressure in the fetal lungs is HIGH, which allows blood from the PULMONARY ARTERY to shunt into the AORTA via the DUCTUS ARTERIOSUS.)

Fill in the blank: In fetal circulation the umbilical artery carries _____________, while the umbilical vein carries ________________. A. deoxygenated blood, oxygenated blood. B. deoxygenated/oxygenated blood, oxygen blood. C. oxygenated blood, deoxygenated blood.

a (The umbilical artery in fetal circulation carries DEOXYGENATED, while the umbilical vein carries OXYGENATED.)

Obesity places women at increased risk for which postpartum complication? a. Thrombophlebitis b. Uterine atony c. Postpartum depression d. Low milk production

a (Thrombophlebitis Feedback: Obese women are at increased risk for thrombophlebitis in the postpartum period because of decreased mobility and preexisting vascular problems. Uterine atony is caused by a full bladder, retained products of conception, or failure of the uterus to contract after overdistention from multiple pregnancy or hydramnios. Obesity does not contribute to this. Postpartum depression is multifactorial and caused by hormonal changes or psychosocial factors. Low milk production is caused by inadequate breast stimulation, postpartum hemorrhage, or breast abnormalities.)

The nurse observes that the infant is jaundiced on his face, head and chest. What action should the nurse take next? a. obtain blood for laboratory analysis b. monitor the infant for increasing jaundice c. give the infant water to promote bowel movements d. anticipate changing from milk to soy-based products

a (blood drawn for serum bilirubin provides additional data and the basis for treatment of hyperbilirubinemia, which may be physiologic or nonphysiologic)

After 14 hours of intense labor a mom is too tired to continue unassisted. The HCP uses forceps to assist. The baby was born 8 lb 5 oz. Which action should the nursery nurse take first in caring for the infant? a. dry the infant quickly with warm blankets b. use a scale to immediately weigh the infant c. apply a servomechanism temperature probe d. cover the infant's head using a soft cap

a (drying the infant has priority to prevent evaporative heat loss)

The nurse notes soft swelling of the scalp that extends across the suture lines of the fetal skull. Which action should the nurse take in response? a. document the finding b. monitor for tension and anterior fontanel. c. report the findings to the HCP d. apply cool compresses to prevent more swelling

a (the finding indicates caput succadaneum, which commonly occurs after a vaginal birth. )

The nurse checks on a room to find the mother in the bathroom and the infant in the crib with a bottle propped on a towel. What action should the nurse take? a. remove the bottle from the infant's mouth b. refer the family to social services for further evaluation c. instruct the mom not to leave the bottle propped on the towel d. take the infant to the newborn nursery

a (the primary concern is for the safety of the infant. Propping a bottle places the infant at risk for choking as well as ear infections. C should be done, but not first. D is punitive)

After 14 hours of intense labor. The infant's vital signs include 96.8 F, 136 bpm irregular with soft murmur, and 42 rr. Which action should the nurse take? a. document the findings in the electronic medical record (EMR) b. stimulate the infant to breathe by stroking his feet c. notify the heatlhcare provider about the findings d. provide oxygen by tube or mask close to infant's

a (these are normal vital sign parameters)

In the transitional care nursery, the nurse reviews the infant's prescriptions for vitamin K (Aquamephyton) 0.5 mg IM x one dose and erythromycin (Ilotycin Ophthalmic Ointment) x one dose in each eye. While administering vitamin K to the infant, which action should the nurse take? a. select the middle part of the vastus lateralis for use b. place the infant on the abdomen for better visualization c. use the V technique after cleaning the ventral gluteal area d. administer the medication using a 22 guagge, 1/2 inch needle

a (this is the preferred site in infancts for administration of injections. V technique is used for the ventral gluteal area, but injections are not given in this area for infants)

The nurse performs a newborn assessment and evaluates the infant's reflexes. How does the nurse perform the Moro reflex? a. slightly raise the infant's head and trunk to allow the infant to drop back 30 degrees b. place a finger in the infant's palm and assess whether the infant's hand closes in a fist c. stroke the lateral side of the infants foot from the heel to the ball of the foot d. hold the infant upright with his feet touching a solid surface

a (this would elicit the infant's arms and legs to extend and abduct, with fingers fanning open. b is the palmar grasp reflex. c is the babinski reflex. d is the stepping reflex)

What structures in fetal circulation play a role in shunting blood away from the LUNGS? Select all that apply: A. Ductus arteriosus B. Ductus venosus C. Umbilical artery D. Foramen ovale E. Umbilical vein

a and d (The ductus arteriosus and foramen ovale are the structures that help blood flow bypass (or shunt) away from the lungs. These structures seal off and become nonfunctional after birth. The ductus venosus plays a role with shunting blood from the LIVER (not lungs).)

After the birth of the baby, heart circulation changes due to the closure of the shunting structures in the baby's circulatory system. Select below all the reasons for the closure of these shunting structures: A. The pressure in the right side of the heart decreases compared to the left side. B. The resistance in the lungs decreases. C. Prostaglandin production increases. D. Oxygen levels in the baby's body increase.

a, b, and d (The only incorrect statement is Option C. The placenta produces prostaglandins. When it is removed the production of prostaglandin production decreases, which causes the ductus arteriosus to close)

The bilirubin serum level comes back at 8 mg/dL. The infant is diagnosed with pathologic hyperbilirubinemia. The nurse prepares the infant for placement under a bilirubin light. Which actions should the nurse implement? (select all) a. remove the infant's clothing b. anticipate starting IV fluids c. keep the infant in one position d. place eye patches on the infant e. turn off the lights and allow parents to hold infant for feeding

a, d, and e (some agencies may leave the diaper in place, but it is important to expose as much of the skin as possible. IV fluids are not needed and the position should be changed every 1 to 2 hours. Eye covering is important during phototherapy to prevent retinal injury from the phototherapy lights. Removing the infant from phototherapy for feedings and interactions with parents for periods up to one hour at a time does not decrease effectiveness of phototherapy. This also provides needed sensory stimulation for the infant.)

Oxytocin (Pitocin)

add medication to main line or give IM (10 units), 5-10 units IV bolus

When does ovulation occur in lactating women?

after at least 3 month (return gradually... usually by 36 week or 8 months)

A nurse is caring for a client who is 4 hours postpartum with postpartum hemorrhage. Which nursing diagnosis has the highest priority? a. Knowledge Deficit related to lack of information about signs of postpartum hemorrhage b. Fluid Volume Deficit related to blood loss secondary to uterine atony c. Fatigue related to anemia from postpartum bleeding d. Activity Intolerance related to enforced bedrest to control postpartum bleeding

b

A nurse is caring for a couple in the birthing center. Which parent-infant behaviors should the nurse investigate further? a. The parents change diapers when needed. b. The parents complete activities silently without looking at the baby. c. The parents position the baby comfortably. d. The parents demonstrate eye-to-eye contact with the baby.

b

The nurse is caring for an infant born precipitously at 29 weeks' gestation. The mother presented for care in active labor and was hospitalized for approximately 4 hours before the baby was born. On day 1 of life, the infant is diagnosed with respiratory distress syndrome and the mother asks what is causing this problem. What is the nurse's best response? a. "When babies are born very small, they are not strong enough to breathe properly." b. "Term babies produce a substance that allows the air sacs in their lungs to inflate. Your baby doesn't have that yet." c. "Since your baby can't nurse, low blood sugar has depressed the respiratory centers in his brain." d. "Preterm babies are very susceptible to infection. Your baby has a lung infection similar to pneumonia."

b

The nurse is counseling a woman who has been diagnosed with mastitis. Which statement from the client indicates a need for further teaching? a. "I will call if I have any more fevers over 100.4°F." b. "So, now I have to go get some formula, since the baby won't be able to nurse until this gets better." c. "I'll make sure to massage the area so it will drain better." d. "I'll let you know if it's not better in a couple of days."

b

The nurse knows that the client understands the discharge instructions after receiving a rubella vaccination when she overhears her client tell her husband: a. "I will need to keep out of the sun for 1 month." b. "I must avoid getting pregnant for 28 days." c. "I must be very cautious when I get out of bed." d. "I should avoid foods and beverages that contain caffeine."

b

The nurse weighs a breastfed infant delivered by cesarean at about 48 hours of life. The weight is 3348 g. The documented birth weight was 3600 g. The previous shift report states the infant is nursing well. What is the most appropriate nursing action? a. Supplement the baby with 2 oz of formula. b. Review the feeding record, counsel the mother as needed, and repeat the weight the next day. c. Have the mother pump her breasts and measure the output. d. Notify the primary healthcare provider.

b

The parents of a preterm baby express concern that vaccinations will "overload" the baby's immune system and tell the nurse they are thinking of declining them. What is the nurse's best response? a. "That's a wise idea. Talk to your pediatrician about a delayed vaccination schedule for when the baby is stronger." b. "Preterm babies tolerate vaccines very well and are at higher risk from vaccine-preventable diseases." c. "There is mounting evidence that vaccine safety is unproven, so many people are avoiding them altogether." d. "Not vaccinating your baby is irresponsible. Declining will trigger an inquiry from child protection agencies."

b

The preterm newborn is experiencing vomiting, diarrhea, weight loss, irritability, tremors, and tachypnea. What is the best explanation for these symptoms? a. Traumatic birth b. Maternal substance abuse c. Sepsis d. Gestational diabetes

b

Upon physical examination, the nurse notes the liver of a newborn is palpable 2-3 cm below the right costal margin. The nurse recognizes this finding and should consider which of the following? a. Notifying the primary healthcare provider b. Recognizing this as a normal physical finding c. Requesting liver enzyme testing d. Checking the results of the newborn neonatal screen

b

When transitioning a preterm, SGA infant to oral feeding, the most important nursing consideration is: a. Limiting calories to avoid overloading the GI system. b. Closely observing for signs of fatigue to avoid calorie expenditure greater than intake. c. Limiting parental involvement to be sure the proper technique is maintained. d. Making the transition as rapid as possible, so gavage feeding can be discontinued.

b

Why would a nurse place an infant under a radiant warmer and start to dry him quickly? a. heat production is increased through stimulation b. convective heat loss from evaporation is reduced c. newborns in an incubator are more difficult to access than those in a radiant warmer d. bonding is promoted by enhancing the infant's appearance

b

Why would a primary healthcare provider order a Coombs' test? a. To determine the blood type of the infant b. To determine whether jaundice is due to Rh or ABO incompatibility c. To determine a positive left shift indicating possible infection d. To check hemoglobin and hematocrit levels

b

Which women are at increased risk of developing endometritis after giving birth? (Select all that apply.) a. A woman giving birth to her first child b. A woman who had a cesarean delivery c. A woman who had an intrauterine pressure device used during labor d. A woman who had a forceps-assisted vaginal birth e. A woman who has a grand multiparity

b (A woman who had a cesarean delivery; c. A woman who had an intrauterine pressure device used during labor; A woman who had a forceps-assisted vaginal birth Feedback: Parity, being either a first-time mother or the mother of many children, is not a risk factor for uterine infection. Use of any instrumentation, such as in a cesarean birth, in a forceps-assisted delivery, or an intrauterine pressure catheter, greatly increases the chances of infection.)

You're assessing the five minute APGAR score of a newborn baby. On assessment, you note the following about your newborn patient: pink body and hands with cyanotic feet, heart rate 109, grimace to stimulation, flaccid, and irregular cry. What is your patient's APGAR score? A. APGAR 8 B. APGAR 5 C. APGAR 6 D. APGAR 3

b (APGAR 5:...A: 1, P: 2, G, 1, A: 0, R: 1)

A nurse is caring for a 6-hour-postpartum client who is experiencing perineal discomfort. Which intervention is most appropriate for the nurse to implement? a. Application of warm compresses to the perineum b. Application of an ice pack to the perineum c. Administration of Methergine 0.2 mg d. Contacting the primary healthcare provider/CNM for new orders

b (Application of an ice pack to the perineum Feedback: Ice packs applied to the perineum for the first 24 hours help reduce edema and promote comfort. Warm compresses do not help reduce edema. Methergine is used to stimulate the uterus to contract, and is not indicated for relief of perineal discomfort. There is no indication to call the primary healthcare provider/CNM, because perineal discomfort is common in postpartum women.)

The nurse caring for a postpartum client with an episiotomy notes that the client complains of rectal pressure and increasing perineal pain. What is the priority assessment for the nurse to make at this time? a. Assess bowel status for timing of last bowel movement. b. Assess for a vaginal hematoma. c. Assess the approximation of sutures. d. Assess for incomplete bladder emptying.

b (Assess for vaginal hematoma. Feedback: An enlarging vaginal hematoma causes rectal pressure and perineal pain, particularly if the hematoma is on the posterior vaginal area. If the sutures become disrupted, the client will have severe perineal pain, but usually will not have rectal pressure. Incomplete emptying of the bladder may cause increased bleeding and .)

What suggestion should the nurse provide to the client who complains of severe afterpains? a. Stay in bed with your feet elevated. b. Assume a prone position at intervals. c. Try to nurse more frequently. d. Apply ice to your abdomen for 20 minutes.

b (Assume a prone position at intervals. Feedback: Afterpains are severe in multiparous women. The prone position puts pressure on the uterus, which stimulates uterine contraction. Ambulation is more helpful than bedrest, and nursing intensifies afterpains. Ice will not be useful. Implementation; Physiological Integrity; Application)

The nurse attends the birth of a healthy, term baby at 7:15 p.m. The mother has expressed a desire to breastfeed. When is the best time to assist her with the baby's first feeding? a. Immediately, before the cord is cut b. Between 7:45 and 8 p.m. c. After 2 hours, when recovery is over and she is settled in a postpartum bed d. Any time before the baby receives any bottles or artificial nipples

b (Between 7:45 and 8 p.m. Feedback: The first period of reactivity in the newborn occurs between 30 minutes and 1 hour after birth. The baby will be in a quiet, alert state at this time, which is ideal for feeding. Breastfeeding may be initiated immediately if the mother wishes but is likely to be disrupted by the necessary assessments of mother and baby that occur immediately after birth. After the first period of reactivity, the baby is likely to enter a sleep phase where it will be difficulty to arouse and have little interest in sucking.)

Identify a potential long-term complication of the small-for-gestational-age newborn. a. Hyperglycemia b. Cognitive difficulties c. Leukocytosis d. Hyperthermia

b (Cognitive difficulties Feedback: SGA newborns often subsequently exhibit learning disabilities. The disabilities are characterized by hyperactivity, short attention span, and poor fine motor coordination. Some hearing loss and speech defects also occur. The SGA newborn is at risk for hypoglycemia and decreased temperatures. High white blood cell count is a sign of acute infection and is not a long-term complication.)

What is the best way for the nurse to determine adequate hydration in the preterm infant? a. Examination of the skin and mucous membranes b. Daily or twice-daily weight c. Urinary catheterization and measurement of urine output d. Observation for a sunken anterior fontanelle

b (Daily or twice-daily weight Feedback: The most effective method for assessing a preterm infant's hydration status is close monitoring of weight. The skin of preterm infants may be thin and friable, making identification of dehydration based on skin turgor more difficult. Urinary catheterization places the infant at a higher risk for trauma and infection. Sunken fontanelles are a late sign of dehydration. Interventions should be implemented before this occurs.)

The nurse is assessing for descent of the testes in a full-term newborn. The nurse is unable to locate the testes in the scrotal sac. What would be an appropriate intervention for this finding? a. Assess hourly until the testes descend into the scrotal sac. b. Document findings and explain to parents that this will be evaluated again before discharge and at each health supervision visit until the testes are palpable in the scrotal sac. c. Make newborn NPO in preparation for surgery. d. Note that there is an absence of rugae on the scrotum, indicating testicular development is not mature.

b (Document findings and explain to parents that this will be evaluated again before discharge and at each health supervision visit until the testes are palpable in the scrotal sac.)

The nurse is assessing a postpartum client who gave birth 10 hours ago. What assessment finding would need further investigation? a. Fundus is at the level of the umbilicus. b. Fundus is above the umbilicus and deviated to the right. c. Fundus is firm and midline. d. Fundus is 2-3 cm below umbilicus.

b (Fundus is above the umbilicus and deviated to the right. Feedback: A fundus that is above the umbilicus and deviated to the right is not a normal finding, and may be due to a full bladder. A fundus that is at the level of the umbilicus or 2-3 cm below, firm, and midline is normal.)

Which of the following is the best strategy for minimizing discomfort associated with milk production for a formula-feeding mother? a. Encourage the woman to pump milk from her breasts several times a day to relieve swelling. b. Instruct her to wear a tight-fitting bra as much as possible. c. Suggest she apply heat to her breasts to relieve soreness. d. Tell her that letting the shower run on her breasts every morning will help discourage milk production.

b (Instruct her to wear a tight-fitting bra as much as possible. Suppression of milk production is best achieved by minimizing stimulation to the breasts. Pumping, applying heat, and letting the shower run on the breasts stimulate milk production and letdown.)

A 17 year old presents to the ED with abdominal cramping. Her mother thinks she has a UTI. Her UA comes back with bacteria, positive UTI and she also is possitive for HCG. While they wait for radiology the mom asks why it is taking so long for her daughter to be seen. How should the nurse respond? a. Explain that they need to verify the pregnancy before x-ray b. instruct the mom to fill out paperwork c. inform the mother that she will not be able to have an x-ray because she is pregnant d. tell her mother to call radiology

b (Instruct isabella's mother to fill out paperwork in the registration department)

In neonatal resuscitation management, which of the following is not included as critical assessment data? a. Respiratory rate b. Skin color c. Heart rate d. Pulse oximetry measurement

b (Skin color Feedback: Skin color is not included as critical assessment data in neonatal resuscitation management. Respiratory rate, heart rate, and pulse oximetery measurement are critical data included.)

Regarding the scenario in the question above, when would you reassess the APGAR? A. 2 minutes B. 10 minutes C. 5 minutes D. No reassessment of the APGAR score is needed

b (The APGAR score is performed at 1 minute and 5 minutes after birth and reassessed at 10 minutes (5 minutes later) after birth, IF the score is 6 or less.)

Fill in the blank: The ______________ carries oxygenated blood from the placenta to the fetus. Some of the blood flow from this structure is shunted from the __________ to the ___________ via the _______________. A. umbilical artery, lungs, aorta, ductus arteriosus B. umbilical vein, liver, inferior vena cava, ductus venosus C. umbilical vein, liver, superior vena cava, ductus arteriosus D. umbilical artery, liver, inferior vena cava, ductus venosus

b (The UMBILICAL VEIN carries oxygenated blood from the placenta to the fetus. Some of the blood flow from this structure is shunted from the LIVER to the INFERIOR VENA CAVA via the DUCTUS VENOSUS.)

A nurse is assessing four postpartum clients with vaginal births. Which one is most at risk for uterine atony? a. The client who had epidural anesthesia b. The client who had an oxytocin induction c. The client who had a cerclage d. The client who had a breech presentation

b (The client who had an oxytocin induction Feedback: Oxytocin inductions may cause uterine atony after delivery. Epidural anesthesia and breech presentations are more likely to be risk factors for perineal lacerations. A cerclage is performed for an incompetent cervix, which is not a risk factor for uterine atony.)

After 14 hours of intense labor a mom is too tired to continue unassisted. The HCP uses forceps to assist. The baby was born 8 lb 5 oz. After clearing the airway with a bulb syringe and drying the infant with a warm blanket, the nurse assesses that the infant is breathing and has a heart rate of 124, but remains cyanotic. what action should the nurse take? a. apply a temperature probe b. prepare to give oxygen c. wrap the infant warmly d. secure a suction catheter

b (The infant is breathing and has a heart rate. It is the oxygen that seems to be low because of the cyanosis.)

Which of the following may indicate hemolytic disease of the newborn? a. The placenta is decreased in size. b. The neonate demonstrates pleural and pericardial effusion. c. The infant's bilirubin level is decreased. d. The neonate's spleen and liver are abnormally small.

b (The neonate demonstrates pleural and pericardial effusion. Feedback: The neonate demonstrating pleural and pericardial effusion may indicate hemolytic disease. A decrease in size of the placenta, decreased bilirubin level, and abnormally small spleen and liver are not indicators of this disease.)

The mother is told that a neonatal screening test needs to be done. When asked the reason for including the PKU test in the screening, which information should the nurse provide? a. an error in metabolism of amino acids leucine, isoleucine, and valine can cause death if not detected and treated early b. a problem converting the protein phenylalanine may be present, which can lead to mental retardation if not found and treated early c. screening for an error in metabolism of the sugars galactose and lactose can prevent liver and brain damage in the newborn d. the test detects the level of thyroxin produced by the thyroid. If too little is produced or if treatment is not started early, mental retardation can result

b (a, c, and d are errors in metabolism. PKU is done to detect the level of phenylalanine in the baby's blood.

How should the nurse collect the blood needed for PKU screening? a. clean the heal with alcohol, dry with guaze, and collect blood in capillary tube b. puncture the lateral heal after warming and collect blood samples on the designated lab form c. collect heal blood using a transfer pipette, and place a drop of blood on a reflectance meter d. after grasping the baby's lower leg and foot, use a microlancet to puncture the middle portion of the heel

b (capillary tube is used for hemoglobin, not PKU. the heel should be warmed, cleaned with alcohol, dried with gauze. Then punctured with a microlancet, blood is collected on the special neonatal screening form. c is for glucose analysis, not PKU. The middle portion of the heal should never be used)

At 0000 the infant born at 2000 is crying, skin is mottled, and his hands are shaking. Which action should the nurse take first? a. assess the respiratory effort b. monitor the blood glucose levels c. give the infant some formula d. evaluate for possible seizures

b (crying is an indicator of good respiratory effort. Since it has been 2 hours since delivery, the baby may be hypoglycemic. You should attempt to nurse before offering formula. The infant is not exhibiting signs of seizure)

After 14 hours of intense labor, which information should direct the nurse to further assessment of the infant's head? a. fourteen hour of labor b. low forceps delivery c. unusual cord length d. vaginal delivery

b (low forcepts delivery is usually done with minimal risk, but there is potential for head trauma or damage to the facial nerve)

Upon admission to the transition care nursery, the baby's axillary temperature is 94.7 F (36.3C C). Which action should the nurse take? a. continue monitoring and document the findings in the record b. place the infant in the radiant warmer and monitor his temperature c. remove a blanket from the infant and heck temperature again d. notify the HCP immediately

b (normal range for an infant's temperature is 97.5 to 99. The infant should remain in the warmer until stabilized)

Which physical finding on a newborn should the nurse report to a HCP? a. present of unopened subaceous gland b. loose natal teeth that are not covered by the guns c. white, cream cheese like substance on the skin d. Enlarged breasts screening a thin, water discharge

b (pinhead sized whiteheads on the newborn are referred to as milia and they usually dissapear without treatment, not do they need to be reported. Natal teeth present at birth are an unusual occurrence that should be reported. the cream cheese like substance is the vernix caseosa and is normal. d is a temporary condition cause by the influence of mother's hormones.)

Which assessment data indicates that it is safe for the baby to be given a bath at this time? a. respiratory rate of 52 b. axillary temp of 97.9 c. apical heart rate of 166 d. pulse oximeter of 90%

b (the RR is high-normal and will rise with the activity of bathing. The heart rate is high-normal and will rise with the activity of bathing. The O2 value is below normal and could lower with the activity. The temperature will also lower with the activity and a cold baby cannot be bathed.)

While an infant received phototherapy, the stools become loose and green. What action should the nurse take? a. change from formula to electrolyte solutions b. document the findings in the EMR c. send a stool specimen to the laboratory d. reduce the amount of formula feedings

b (the loose green stools are typical response to phototherapy, so stools should continue to be monitored and results documented.)

The HCP prescribed a home phototherapy blanket for discharge of a baby treated for hyperbilirubinemia that has not resolved. The parent's appear confused and scared of using the phototherapy blanket. Which instructions should the nurse include in the discharge planning? a. the phototherapy blanket is placed over the infant's clothing b. holding the infant does not interrupt the phototherapy process c. a phototherapy blanket is more effective than the overhead lights d. the length of time required for phototherapy intervention is decreased

b (the phototherapy blanket allows the infant to be held while the process is continued)

The nurse measure's the infants head and chest. What action should the nurse take when finding that the head measures 36 cm and the chest circumference measures 35 cm? a. notify the HCP b. document the findings in the EMR c. Monitor for excessively wide sutures d. verify the findings with another nurse

b (these are within normal limits)

Upon examining an infant's extremities, which finding should the nurse report to the HCP? a. bilateral legs flexed b. diminished movement in one arm c. the infant's arms resist extension d. equal movement in extremities in a random manner

b (this may indicate nerve damage. Everything else is a normal finding)

Which findings are consistent with an infact born at 38 weeks gestation? (Select all) a. presence of abundant lanugo hair across face b. plantar creases cover 2/3 of the sole of the foot c. well defined nipples, with raised areola d. slightly soft, curved pinna with slow recoil e. skin is smooth and pink with visible veins

b and c (baby's born at 38 weeks will have minimal lanuga hair, which is the soft prenatal hair that is shed during the last few weeks of the pregnancy. The ear of the baby at 38 weeks should be well formed and firm with instant recall. option e is more consistent with an infant of earlier gestational age)

A mom has a difficult time changing her baby after a bowel movement. How should the nurse respond to the mom? (select all) a. reassure her that she will get plenty of practice b. observe the mom as she performs the diaper change c. place the baby on the bed and demonstrate how to change the diaper d. tell her that nurses can change the diapers until they go home e. advice her that classes to teach infant care, such as diapering, are available on the unit

b and e (You need to see what the mom is doing to assess why she is struggling. The mom could benefit from teaching)

What should the nurse do to prepare for a patient's blood transfusion? (Select all that apply). a. reduce complications of rapid transfusion by using a blood warmer b. start an additional IV using a 16 or 18 gauge angiocath c. prime a new y-set blood tubing using a new bag of normal saline d. monitor for fluid overload by assessing lab results, urine output, and respiratory status e. explain the blood transfusion process

b, c and e (Start an additional IV using a 16 to 18 gauge angiocath. Prime a new Y-set tubing using a new bag of normal saline. Obtain a baseline set of vital signs.)

Select the structures in fetal circulation that play a role with shunting blood away from the lungs and liver? Select all that apply: A. Umbilical vein B. Ductus venosus C. Foramen ovale D. Umbilical artery E. Ductus arteriosus

b, c, and e (These structures play a role with shunting blood from the lungs and liver. The ductus venosus shunts some blood from the LIVER, and the foramen ovale and ductus arteriosus shunt blood from the LUNGS.)

while waiting for medication

bimanual compression of uterus is completed when?

If the ___________ becomes distended, the woman is at high risk for hemorrhage

bladder

secondary postpartum hemorrhage (PPH)

blood loss that occurs 24 hours and up to 6 weeks after birth

Primary postpartum hemorrhage (PPH)

blood loss that occurs within 24 hours of birth

endometritis

bloody, foul smelling discharge uterine tenderness fever chills

S/S of hematoma postpartum

bluish bulging area under skin hypotension tachycardia anemia

A newborn has developed physiologic jaundice and hyperbilirubinemia. Which of the following supportive measures would be most effective at helping to decrease bilirubin levels? a. Give the baby a bottle of water. b. Place the baby under a radiant warmer. c. Assist with and facilitate frequent breastfeeding. d. Make the newborn NPO.

c

The nurse is called to a postpartum room by a mother who is worried about her baby's irregular breathing. What is the best explanation the nurse can give? a. "Notify the nurse whenever you see that, because infants can develop respiratory distress very quickly." b. "You can assume the baby is fine unless he is lethargic." c. "Irregular breathing and pauses up to 20 seconds are normal for a newborn." d. "Irregular breathing is normal as long as the total is at least 20 breaths per minute."

c

The nurse notices the ID number is incorrect. Which action should the nurse take to solve this problem? a. document the presence of the incorrect number on the charts for the baby and mother b. explain to the mother that there is an incorrect number on one of the bands c. redo the identification with another nurse witnessing the process d. mark the incorrect numbers in red to denote the medical correction is made

c

What is the correct way to perform external cardiac massage on an infant with a detectable heart rate? a. Place two fingers one finger-width below the nipple line and compress one half to one inch. b. Place one thumb one finger-width below the nipple line and compress at a 5:1 ratio. c. Place both thumbs over the lower third of the sternum with fingers wrapped around and supporting the back. d. Use the heel of one hand at the nipple line and compress at a ratio of 5:1.

c

Which is the most appropriate nursing diagnosis for a newborn who has meconium aspiration syndrome? a. Pain b. Hyperthermia c. Impaired Gas Exchange d. Altered Nutrition: More than Body Requirements

c

You're assessing the one minute APGAR score of a newborn baby. On assessment, you note the following about your newborn patient: heart rate 130, pink body and hands with cyanotic feet, weak cry, flexion of the arms and legs, active movement and crying when stimulated. What is your patient's APGAR score? A. APGAR 9 B. APGAR 10 C. APGAR 8 D. APGAR 5

c

Which woman having unprotected sex is most at risk for an unintentional pregnancy during the postpartum period? a. A non-nursing mother who is 4 weeks postpartum b. A nursing mother who is 6 weeks postpartum c. A non-nursing mother who is 8 weeks postpartum d. A nursing mother who is 10 weeks postpartum

c (A non-nursing mother who is 8 weeks postpartum Feedback: In non-nursing mothers, menstrual periods generally return in 6-10 weeks. They may ovulate prior to the first period. Nursing mothers usually have their first menstrual period delayed for at least 3 months, and they are prone to anovulatory cycles, putting them at lower risk for pregnancy. However, any mother can ovulate before her first period, so every mother should use protection if she wishes to delay a subsequent pregnancy.)

Which woman is most at risk for bladder distention after a normal vaginal delivery? a. A woman who had IV fluids running during labor b. A woman who had a midline episiotomy c. A woman who had epidural anesthesia d. A woman who had an active labor lasting 12 hours

c (A woman who had epidural anesthesia Feedback: Every woman is at risk following delivery, and the nurse must assess voiding patterns after delivery. However, the biggest risk factor is anesthesia, which affects the sensory nerves, because the woman is unaware of the need to empty her bladder. Nerve blocks also may affect motor nerves, making micturition difficult. IV fluids may cause more urine to be produced, but should not promote retention of urine. A midline episiotomy will not promote urinary retention, and a 12-hour labor is not abnormal.)

A 24-year-old primipara is rooming in with her new infant. Which behavior indicates a need for further assessment? a. Verbalizing concerns over the shape of the baby's head b. Reluctance to hand the baby to staff for assessment c. Allowing the baby to cry in the bassinette and learn self-soothing d. Keeping the baby constantly on her chest

c (Allowing the baby to cry in the bassinette and learn self-soothing Feedback: The mother should be responsive to the newborn at this time. Failure of the mother to respond to the infant's needs may indicate disordered bonding or the need for further teaching on normal newborn behavior. Being reluctant to give the baby to staff for assessments, verbalizing concern about possible injury to the baby, and holding it for long periods are signs of appropriate bonding.)

The nurse receives a distressed phone call from a new father. He reports his wife is "not herself", "doesn't know what's going on", and has "said some crazy things." What is the most appropriate advice for this father? a. Make sure the mother spends as much time with the baby as possible to improve bonding. b. Reassure him that this will improve once she gets adequate sleep. c. Arrange care for the baby and take her to the emergency department for immediate evaluation. d. Advise him that a psychiatric referral will be arranged in the upcoming week.

c (Arrange care for the baby and take her to the emergency department for immediate evaluation. Feedback: Bizarre behavior, confusion, and irrational speech are signs of postpartum psychosis, which requires immediate evaluation and treatment due to the risk of harm to the client or baby. The father should not attempt to intervene at home and treatment cannot be delayed by outclient referral.)

A nurse is assessing the lochia in a 24-hour-postpartum client, and expresses blood clots with fundal massage. What would be the most appropriate initial nursing action? a. Assess activity pattern. b. Monitor vital signs. c. Ask the client to empty her bladder. d. Administer analgesics.

c (Ask the client to empty her bladder. Feedback: It is important to empty the bladder and monitor urine output to assess whether the bladder is emptying regularly, as a distended bladder may prevent the uterus from contracting, leading to a collection of blood and the formation of blood clots. Increasing activity too soon may cause persistent lochia rubra but not blood clots. Assessment of vital signs is important, but not the most immediate intervention for increased vaginal flow, especially if signs and symptoms of infection are present. Administering analgesics is an important intervention for cramping.)

The nurse conducts the change of shift assessment of the infant. Which finding by the nurse is consistent with cephalhematoma? a. head shaped into the appearance of a dunce cap b. swelling of the scalp that crosses the suture line c. well-outlined swelling that does not cross suture lines d. softening of the cranial bones that indent with pressure

c (Cephalhematomma is caused by increased pressure or trauma at birth from blood collecting beneath the periosteum of the bone and therefore does not cross the suture line)

A mom asks how she will know phototherapy is working. How should the nurse repond? a. stools are loose and bright green b. formula feedings increase c. serum bilirubin level decreases d. skin is resilient with no indications of jaundice

c (Decreasing bilirubin levels are the best indicator of phototherapy effectiveness.)

The nurse is assisting at the birth of a term baby after a normal prenatal and labor course. The membranes rupture spontaneously during the second stage and there is significant meconium staining. At birth, the baby is fully flexed and centrally pink with a lusty cry. What is the most appropriate nursing action? a. Call for transfer to the neonatal intensive care unit for further evaluation. b. Place the baby on a radiant warmer and deep suction the nose and pharynx. c. Dry the baby and continue assessment on the mother's chest. d. Place the baby on a radiant warmer and administer oxygen by mask.

c (Dry the baby and continue assessment on the mother's chest. Feedback: Newborns who are vigorous at birth in the setting of meconium-stained fluid do not require any special intervention. They are able to clear meconium from their lungs effectively and, if the Apgar scores are reassuring, are very unlikely to develop meconium aspiration syndrome. Evaluation in a special care nursery, suctioning, and supplemental oxygen are only required if the infant shows signs of asphyxia at birth)

The highest-priority intervention the nurse must perform before resuscitating a newborn with asphyxia is: a. Inserting an endotracheal tube. b. Measuring oxygen saturation. c. Establishing effective ventilations. d. Initiating chest compressions.

c (Establishing effective ventilations. Feedback: Suctioning is always performed before resuscitation so that mucus, blood, or meconium is not aspirated into the lungs.)

While the mother is in registration, the nurse confirms that the 17 year old knows she is pregnant, but hasn't told her parents. She is about 30 weeks and in active labor. Which approach should the nurse take when sharing this information with Isabella's mother? a. Talk with her mother first and inform her of the situation b. approach both the mother and daughter together c. Get permission from the daughter to speak with the mother d. ask the social worker for advice

c (Get Isabella's permission to talk with her mother about the pregnancy)

Fill in the blank: In the fetus' circulation before birth the pressure is ____________ on the right side of the heart compared to the left side. This causes some of the blood from the _________ atrium to flow into the __________ atrium via the ______________. A. lower, right, left, foramen ovale B. higher, left, right, ductus arteriosus C. higher, right, left, foramen ovale D. lower, left, right, ductus venosus

c (In the fetus before birth, the pressure in HIGHER on the right side of the heart compared to the left side. This causes the blood from the RIGHT atrium to flow into the LEFT atrium via the FORAMEN OVALE.)

What is true of physiologic jaundice? a. Jaundice usually stays visible for 20-25 days. b. Jaundice is considered an abnormal process that occurs during transition from intrauterine to extrauterine life and appears before 24 hours of life. c. It is considered a normal process that occurs during transition from intrauterine to extrauterine life and appears after 24 hours of life. d. There is no statistical difference between breastfed and bottle-fed babies regarding bilirubin levels.

c (It is considered a normal process that occurs during transition from intrauterine to extrauterine life and appears after 24 hours of life. Feedback: Jaundice stays visible until around the 10-day mark. There is a marked difference between breastfed and bottle-fed babies and bilirubin levels; breastfed babies tend to be higher. Physiologic jaundice appears after 24 hours of life. Pathologic jaundice usually occurs before 24 hours of life.)

After 14 hours of intense labor a mom is too tired to continue unassisted. The HCP uses forceps to assist. The baby was born 8 lb 5 oz. At 1 minute the infant has a heart rate of 130, has a slow weak cry, is grimacing, and has sluggish movements with acrocyanosis. What apgar score should the nurse assign? a. 10 b. 9 c. 6 d. 8

c (One point is deducted for acrocyanosis/blue hands and feet, sluggish movement, a slow weak cry, and grimacing)

A baby's head molded from the vaginal delivery. Upon seeing the baby the mom says, "He is so beautiful, but something is wrong with his head". How should the nurse respond? a. no nothing is wrong with his head. he is really beautiful b. yes, it is misshaped, but we will show you have to change it over time c. his head has been molded from delivery through the birth canal, which is normal d. i know you are concerned. Would you like to talk to the HCP?

c (Parents can be taught to change an infant's sleeping position to correct a misshaped head, but this is not correct for this scenario. In this scenario the head will become more symmetrical overtime.)

A nurse is reviewing the lab reports of a 24-hour-postpartum client. The admission hematocrit was 41% and the current hematocrit is 30%. What should be the initial nursing action? a. Notify the lab for another blood draw to verify accuracy of the report. b. Increase the intravenous infusion rate. c. Report the lab values to the primary healthcare provider or nurse-midwife. d. Administer two units of typed and crossmatched blood.

c (Report the lab values to the physician primary healthcare provider or nurse-midwife. Feedback: This is an abnormal finding, and warrants further investigation by the physician or midwife. The lab reading should be accurate, so it would be inappropriate and unnecessary to have the lab redrawn. Increasing the infusion rate may be appropriate if there are symptoms of hypovolemia, but it is not the initial action. Administering two units of blood would not be the initial action, but may be ordered later.)

A newborn's five minute APGAR score is 5. Which of the following nursing interventions will you provide to this newborn? A. Routine post-delivery care B. Continue to monitor and reassess the APGAR score in 10 minutes. C. Some resuscitation assistance such as oxygen and rubbing baby's back and reassess APGAR score. D. Full resuscitation assistance is needed and reassess APGAR score.

c (Scoring Interventions are as follows: 7-10: no interventions, baby doing good just needs routine post-delivery care, 4-6: some resuscitation assistance required like oxygen, suction.... stimulate the baby, rub baby's back, 0-3: needs full resuscitation)

What are common symptoms of polycythemia? a. Apnea, hypotension, and hyperthermia b. Orthopnea, tachypnea, and hyperbilirubinemia c. Tachycardia, respiratory distress, and hyperbilirubinemia d. Bradycardia, hypotension, and leukopenia

c (Tachycardia, respiratory distress, and hyperbilirubinemia Feedback: The following are documented symptoms of polycythemia: tachycardia and congestive heart failure due to the increase in blood volume; respiratory distress with grunting, tachypnea, and cyanosis, increased oxygen need, or respiratory hemorrhage due to pulmonary venous congestion, edema, and hypoxemia; hyperbilirubinemia due to increased numbers of red blood cells breaking down, and a decrease in peripheral pulses, discoloration of extremities, alteration in activity or neurologic depression, renal vein thrombosis with decreased urine output, hematuria, or proteinuria due to thromboembolism.)

The right ventricle pumps what type of blood up through the pulmonary artery? A. Oxygenated B. Deoxygenated C. Mixed

c (The blood pumped from the right ventricle contains both oxygenated and deoxygenated blood. Therefore, it is mixed.)

A nurse is caring for four postpartum clients who each have an order for Methergine (methylergonovine maleate). Based on the data collected during the nurse's initial shift assessment, which client would not receive the medication? a. The client with a temperature of 101°F b. The client with a hematocrit of 33% c. The client with a blood pressure of 156/94 d. The client with a white blood cell count of 22,000

c (The client with a blood pressure of 156/94 Feedback: Hypertension is a side effect of this medication; therefore, Methergine is contraindicated for women with high blood pressure. Elevated temperature and elevated blood count are not contraindications for administering Methergine. Because Methergine is given to prevent or reverse postpartum hemorrhage, it may also help prevent a decrease in hematocrit levels.)

The infant has a reddish papular rash across his face. How should the nurse respond when the mom asks about the rash? a. don't worry about it b. i see you are concerned, so i will call your pediatrician c. a newborn rash is very common, but it will disappear soon d. good question. let me take the infant's vitals and examine him

c (The infant rash, erythema toxicum, is very common and usually disappears by the third day of life.)

Which statement below accurately describes the role of the ductus arteriosus? A. "The ductus arteriosus helps connect the umbilical artery to the inferior vena cava." B. "The ductus arteriosus is found between the right and left atrium." C. "In fetal circulation the pulmonary artery and aorta are connected via the ductus arteriosus." D. "The ductus arteriosus only carries oxygenated blood from the left side of the heart to the right side."

c (This is the only correct statement about the ductus arteriosus. This structure connects the pulmonary artery and aorta, which helps carry mixed blood (oxygenated and deoxygenated blood) to the lower body and back to the placenta via the umbilical arteries (which branch off the descending aorta). This structure helps shunt blood away from the lungs.)

The nurse questions the student about vitamin K (Aqua MEPHYTON) as preparation are made for administration. Which response by the student indicates an understanding of the purpose for administering this drug? a. the purpose of this drug is to prevent hypoglycemia in the newborn b. Vitamin K is a fat-soluble vitamin and promotes a positive nutritional status c. this drug is given to the newborn to prevent and or treat hemorrhagic disease d. Vitamin K is produced and stored in the liver, which is immature in the infant

c (Vitamin K is produced in the gut, but stored in the liver. it does not prevent hypoglycemia. the vitamin does not cross the placenta and there is very little in breast milk. Supplemental vitamin k should be given to help the clot of blood.)

Upon inspection of the umbilical cord after birth, which finding should the nurse report to the HCP? a. it is covered in Wharton's jelly b. pulsations are felt at the base of the cord c. one artery and one vein are present d. the cord is glistening with a pearl like coloring

c (a, b, and d are normal findings. There should be two arteries and one vein.)

Five hours after delivery, an infant's vital signs are stable and he is taken to his family. While the nurse discusses care with the mom, the infant starts gagging. Which action should the nurse implement first? a. support the infant in side-lying position b. place the infant in supine in the crib c. use a bulb syringe to clear the mouth and nose d. secure a delee catheter to wall suctioning for use

c (gagging due to excessive mucus is a typical response during the transition period. Suctioning the mouth and nose should be done first.)

The nurse notes a skin tag on the side of the infant's hand. What should the nurse do? a. place a string tightly around the skin tag b. call a rapid c. document the findings and notify the pediatrician d. perform a newborn hearing screen

c (skin tags are a common finding on a new born assessment and can be harmless, but the pediatrician should be informed. This is not an emergency situation.)

When returning the baby to the crib, the nurse notices that the blanket covering the baby is wet. the nurse takes the baby's temperature at 97.2. What should the nurse do next? a. put a t shirt on the baby and a cap in his head b. cover the baby with a dry blanket, but leave the cap off c. show the mom how to wrap the baby is a dry blanket for warmth and apply a cap to the head d. immediately take the baby and place him under a heat source

c (the baby is not in need of an immediate heat source and the mom needs additional teaching)

After 14 hours of intense labor. Which action should the nurse take prior to weighting the infant? a. provide a pacifier b. place a diaper on the infant c. place a cover on the scale d. keep the cap on the infant's head

c (the infant should be weighed nude, and covering the scale prevents conductive heat loss. The cap will provide height loss, but would add to the baby's weight. The diaper would also add to the weight. Pacifiers are not usually given)

While changing the infant, the mom notices the baby startles easily and asks why this happens. Which explanation should the nurse provide? a. your baby probably has a neurological deficit b. apparently your baby had some trauma at birth to cause this c. this reflex is a normal response, swaddling the baby should help d. this is unusual and I will notify the HCP

c (this is the moro reflex, a startling response to loud noise, sudden touch, or change in position)

When the nurse conducts a gestational age assessment, which findings may indicate postmaturity? (select all) a. testes descended, good rugae b. formed ears with instant recall c. peeling, parchment-like skin d. thin with loose skin and a little subcutaneous fat e. deep creases at the base of the toes extending to the heels

c, d, and e (testes develop as early as 38 week. The vernix disappears with postmaturity. Subcutaneous fat, which had been used for nourishment, is lost prior to birth. Postterm infants develop deep creases on the feet, extending from the base of the toes to the heels.

uterine inversion

caused by forceful pulling when placenta hasn't separated yet, or traction on the cord when uterus isn't contracted

cesarean section (incisions) invasive procedure (foley) PROM (endometritis) multiple SVE (vag exams) trauma (operative delivery) poor health status

causes that increase the incidence of postpartum infection

Bakri Balloon

causes vasoconstriction of the uterus, filled with fluid and inflated inside of the uterus to slow/stop postpartum hemorrhage

polyhydramnios multifetal gestation macrosomia

clinical conditions associated with over distention of uterus (leads to PPH)

maternal fever prolonged rupture of membranes (PROM)

clinical conditions associated with uterine infection which increase risk of PPH

precipitous labor prolonged labor oxytocin

clinical conditions associated with uterine muscle exhaustion which increase risk of PPH

increased respiratory rate decreased urinary output maternal anxiety

clinically significant signs and symptoms associated with early identification of postpartum hemorrhage (PPH)

endometritis

cramping abdominal pain (upon palpation) elevated WBC positive blood culture/UA

Misoprostol (Cytotec)

crushed up and made into paste that is then inserted rectally during an active hemorrhage

A nurse has assessed a 4cm vaginal hematoma on a client who is 6 hours postpartum. What initial nursing intervention would be most appropriate? a. Administer anti-inflammatory medication. b. Apply hot packs. c. Insert an indwelling Foley catheter. d. Apply ice packs every 4 hours.

d

The baby's vitals have been stabilized. After checking ID bands, and assisting with breastfeeding the nurse returns to find both the baby and mom asleep in bed. What should the nurse do next? a. puck up the baby and return her to the crib while letting mom sleep b. wake up mom and remind her that keeping the baby in the bed is unsafe c. tell the mom that the baby must be returned to the nursery for safety reasons d. remind the mom about infant safety and assist her to place the infant in the crib

d

What is the best explanation for correlating the nursing diagnosis Risk for Infection and the preterm infant? a. Preterm babies have immature cardiovascular systems. b. Preterm babies have immature neurological systems. c. Preterm babies have immature gastrointestinal systems. d. Preterm newborns have immature immune systems.

d

What is the best intervention a nurse can utilize to promote parent-infant attachment? a. Allow for privacy. b. Contact support families that have been through the same diagnosis with their own child and allow time to discuss the situation. c. Provide an extensive handbook with information related to the preterm newborn. d. Encourage rooming in.

d

What is the most appropriate nursing action for a newborn demonstrating acrocyanosis? a. Administer IV fluids. b. Suction vigorously. c. Place in the Trendelenburg position. d. Swaddle in blankets.

d

The nurse weighs a newborn who is 1 day old. It is noted that the newborn has lost 10 grams from the previous day. Which responses from the nurse to the parents are appropriate? a. "This is acceptable, and your newborn more than likely will continue to lose close to 20% of the birth weight over the next few days, but then regain it by 2 weeks." b. "I am concerned about the weight loss, and feel the physician should be notified." c. "This will be very alarming if your baby continues to lose weight over the next 2 days. We will watch closely." d. "We will continue to monitor closely, but it is expected that each baby will lose weight as fluids shift within a few days after delivery."

d ("We will continue to monitor closely, but it is expected that each baby will lose weight as fluids shift within a few days after delivery." Feedback: During the initial newborn period (first 3-4 days), there is a physiologic weight loss of about 5% to 10% for term newborns because of fluid shifts. There is no apparent reason to notify the primary healthcare provider; this type of weight loss is considered normal, even over the next 2 days.)

You're assessing the five minute APGAR score of a newborn baby. On assessment, you note the following about your newborn patient: heart rate 97, no response to stimulation, flaccid, absent respirations, cyanotic throughout. What is your patient's APGAR score? A. APGAR 2 B. APGAR 3 C. APGAR 0 D. APGAR 1

d (APGAR 1:...A: 0, P: 1, G, 0, A: 0, R: 0)

You're assessing the one minute APGAR score of a newborn baby. On assessment, you note the following about your newborn patient: weak cry, some flexion of the arm and legs, active movement and cries to stimulation, heart rate 145, and pallor all over the body and extremities. What is your patient's APGAR score? A. APGAR 5 B. APGAR 9 C. APGAR 12 D. APGAR 6

d (APGAR 6.....A: 0, P: 2, G, 2, A: 1, R: 1)

The nurse assesses an 8-hour-postpartum client. Findings include lochia rubra, with a firm fundus at the level of the umbilicus. What nursing action is indicated? a. Massage the fundus to prevent early postpartum hemorrhage. b. Administer Methergine to stop the bleeding. c. Call the primary healthcare provider/CNM and prepare for a pelvic exam. d. Document findings and continue to monitor.

d (Document findings and continue to monitor. Feedback: The client's findings are within normal limits. Document findings and continue to monitor. Early postpartum hemorrhage presents with a boggy, nonfirm fundus. Massage is used to encourage the fundus to contract, and therefore is not indicated with this client's findings. Administering Methergine to control excessive bleeding is not necessary in this situation.)

The nurse is researching the relationship between estrogen and lactation. The nurse discovers that the lactating client is more susceptible to: a. Hemorrhage. b. Infection. c. Diastasis recti. d. Dyspareunia.

d (Dyspareunia. Feedback: Lactation puts breastfeeding women in a hypoestrogenic state due to ovarian suppression, which could lead to dyspareunia (painful intercourse). There is no correlation between lactation and hemorrhage, infection, or diastasis recti.)

The nurse is talking with a mother during a routine follow-up call on postpartum day 3. The mother reports waking up with the baby every 2 hours; nipple tenderness with latch that resolves during the course of the feeding; seeing small, dime-sized blood clots on her pad when waking in the morning; and a nagging cramp in her right leg, which she attributes to her position while giving birth. Which report from the mother does the nurse need to assess further? a. Her report of nipple tenderness b. Her report of the baby's frequent night waking c. Her description of the blood clots d. Her report of leg cramps

d (Her report of leg cramps Feedback: Unilateral calf pain is a sign of thrombophlebitis or DVT. Mild nipple tenderness without persistent pain, cracking, or abrasions is common and transient in the first few days postpartum. Blood may pool in the vagina at night and form small clots that are passed when the mother arises or changes position. Frequent night waking is normal newborn behavior and ensures adequate feeding.)

Which objective data best indicates that the ductus arteriosus of a newborn has not closed? a. Rapid heart rates between 180 and 220 beats per minute b. Low blood pressure and blood pressure means c. Temperature instability ranging from 36.5°C to 38.5°C d. Labile oxygen saturations with occasional apnea/bradycardia episodes

d (Labile oxygen saturations with occasional apnea/bradycardia spells Feedback: Closing of the ductus arteriosus does not directly affect heart rate, blood pressure, or body temperature. It does affect shunting of the blood, causing unstable oxygen saturations and resulting in possible apneic and bradycardic episodes.)

The nurse is reviewing laboratory values and flowsheet data for her client on postpartum day 1. Which of the following would the nurse point out to the nurse-midwife or primary healthcare provider? a. WBC count of 25,000/mm3 b. Urine output of 3000 ml in 24 hours c. Decrease in hematocrit from 32% to 31% d. Maternal heart rate of 120 bpm

d (Maternal heart rate of 120 bpm Feedback: 120 bpm is tachycardia, which may indicate hypovolemia. Mild physiologic bradycardia is expected in the postpartum period. WBC counts of 25,000-30,000/cubic mm, increased urine output, and mild anemia with a slight decrease in hematocrit are expected findings.)

A 24-hour-postpartum client who had a cesarean birth with general anesthesia complains of abdominal discomfort and gas pains. What is the most appropriate nursing intervention? a. Administer analgesic medication to the client. b. Encourage the client to drink hot tea. c. Offer carbonated beverages to the client. d. Position the client on the left side.

d (Position the client on the left side. Feedback: Positioning the client on the left side allows for the gas to rise from the descending colon to the sigmoid colon so it may be expelled. Analgesic medication does not relieve gas, but antiflatulents such as Mylicon may help relieve gas. Hot and carbonated beverages may cause more discomfort and gas.)

The primary goal for the drug-dependent newborn is to reduce withdrawal symptoms and promote adequate respiration, temperature, and nutrition. What intervention best reflects that goal? a. Monitor for hyperthermia. b. NPO status c. Administer medications such as methadone. d. Proper positioning on right side-lying or in semi-Fowler.

d (Proper positioning on right side-lying or in semi-Fowler. Feedback: Proper positioning on the right side-lying or semi-Fowler helps avoid possible aspiration of vomitus or secretions. The nurse would monitor for hypothermia, the infant would not be made NPO because of the vomiting/diarrhea, and the infant would not be placed on methadone, because of its addictive qualities.)

Immediately after delivery, the nurse performs a fundal assessment on the new mother. Which of the following findings is considered to be normal? a. The top of fundus is in the midline and at the level of the umbilicus. b. The top of fundus is in the midline and one fingerbreadth below the umbilicus. c. The top of fundus remains in the midline and descends about one fingerbreadth per day. d. The top of fundus is in the midline about midway between the symphysis pubis and umbilicus.

d (The top of fundus is in the midline about midway between the symphysis pubis and umbilicus. Feedback: The top of fundus in the midline about midway between the symphysis pubis and umbilicus is the only finding that would be considered normal immediately after delivery.)

When examining the baby's GI system, which finding warrants additional assessment by the nurse? a. greenish black stool b. hyperactive bowel soudns c. small amount of regurgitation after breastfeeding d. no bowel movement in 72 hours of birth

d (a is meconium and does not require additional assessment. b and c are normal findings. The first meconium stool should pass within 40 hours. Obstruction may be suspected if no bowerl movement in first 72 hours.)

At 2 days post birth the mom and baby are ready for discharge. The baby lost 12 oz since birth and the mom is concerned. How should the nurse respond? a. I can tell you are concerned. Would you like to talk with the pediatrician? b. Yes, this is a concern. The pediatrician may want to keep the baby here for another day c. don't worry. Your baby will gain weight back in a few days when your milk comes in d. Don't be concerned. your baby's weight loss is in the typical range for all babies

d (babies may lose up to 10% of their birth weight during the first few days after birth. The mother's breast milk should have come in and you don't want to blame the mother or make her feel inadequate)

Which postpartum complication is someone most at risk for after experiencing a 4th degree perineal laceration? a. endometritis b. subinvolution c. deep vein thrombosis d. hemorrhage

d (greater than 500 mL loss after third stage of labor. causes include uterine atony (relaxation), laceration, and retained placental fragments)

On the second day of life, the nurse assesses the infant for jaundice. Which factor should alert the nurse to assess for the risk of jaundice? a. post-mature gestational age b. providing formula feedings c. passage of meconium stools d. trauma at birth

d (the presence of cephalhematoma indicates trauma during birth and bleeding has occurred. As the red blood cells break down, increased amounts of bilirubin are released into the general circulation. post-maturity does not contribute to jaundice. diminished feedings may contribute to jaundice, but not formula feeding itself. passage of meconium stools decreases the risk for jaundice)

After 14 hours of intense labor. To promote family bonding, which part of infant care should the nurse delay? a. giving vitamin K b. securing ID bands c. providing core care d. giving eye prophylaxis

d (the presence of eye ointment or drops can interfere with eye to eye parent/infant interaction. Giving eye prophylaxis can be delayed up to 2 hours after birth. c is delayed until the first bath. a and be could be delayed, but do not interfere with bonding)

The nurse instruct the family about feeding the infant. The mother asks how often the infant should be burped. Which is the best response by the nurse for how often the infant should be burped? a. it is a good time to burp the infant when he stops sucking b. the infant should be burped before and after each feeding c. burping should be done when the infant begins to get sleepy d. he needs burping at the start of feeding and after each ounce of formula

d (this gives the most specific guidelines to parents)

The nurse prepares to administer erythromycin (Ilotycin Ophthalmic Ointment). Which approach should the nurse use to administer the ointment? a. apply the ointment across the closed eyelids and rub the eye gently b. open the eye using two fingers and apply ointment to the upper lid c. apply gentle pressure to the inner canthus after applying ointment to eyes d. Cover entire lower conjunctiva with ointment after gently retracting the lid

d (to instill medication, the thumb and forefinger are used to open the eye. A ribbon of ointment is applied in the lower conjunctive from the inner and outer canthus. c is for eye drops, not ointment. b is for administering Ilotycin opthalmic ointment. Ointment)

When the mom finishes feeding her infant, she checks the diaper and it is dry. The mom expresses concern that she thinks the infant is becoming dehydrated. How should the nurse respond? a. the infant should have at least 4 to 5 voids per day b. the infant should have urine that appears dark orange c. the infant should have pink-tinged urine d. the infant should have 1 to 2 voids per day

d (to maintain fluid balance infants in the first 3 to 5 days of life should have 1 to 2 voids per day. The urine would be yellow.)

when the mom removes the diaper, the nurse notices that the baby has caked powder in the inguinal leg folds. what action should the nurse take? a. show her how to remove the caked on powder b. explore with her why the powder was used c. praise her for wanted to keep her baby dry d. instruct her that she should use plain water instead of powder

d (until the baby is 4 days old, plain water is recommended because soaps, ointments, powders, lotions, and baby wipes can disrupt the acid mantle on the skin and provide a medium for bacterial growth. Also, the use of powder placed the infant at risk for fine particle aspiration)

A nurse place an infant under a radiant warmer. Which action should the nurse take priority to drying the infant's back? a. note if the infant passed any meconium stool b observe the sacral area for possible mongolian spots c. assess the amount and location of vernix caseosa d. inspect the back for possible neurological defects

d (you should check for spina bifida before drying. Monngolian spots are normal skin pigment variation that do not hinder drying)

Fluid volume deficit Fear Risk for Infection

diagnoses associated with postpartum hemorrhage

signs and symptoms of mild blood loss (PPH)

diaphoresis increased capillary refill cool extremities

Because there is an increase in circulating blood volume postpartum, it causes the women to have:

diuresis (voiding) or sweating

tamponade ballons (EBB and Bakri)

do NOT perform fundal checks while these are placed (may dislodge), fundus should be firm and at midline while placed

rectally

during an active hemorrhage (or primary PPH) how should Misoprostol (Cytotec) be administered?

During a postpartum nursing assessment, if the woman had a/an __________________, the nurse should assess for redness, edema, ecchymosis, discharge, and approximation

episiotomy/lacteration

early identification? bonding frequent monitoring transfer back to L&D (decreased patient ratio)

evaluation of postpartum hemorrhage should include

retained placental fragments

excessive bleeding with clots may be related to?

uterine atony

failure of the uterus to contract after birth to control bleeding from the placental site

S/S of hematoma postpartum

firm uterus with bright-red blood severe perineal/pelvic pain or pressure difficulty voiding

massage until firm

first line treatment of uterine atony (boggy fundus)

wound infection

foul-smelling drainage redness/warmth of area gaping of sutures edema

full bladder

fundus above the umbilicus and deviated laterally indicates a ____, which interferes with uterine contractions to slow bleeding

laceration (genital tract)

fundus is typically firm, midline and presents with constant trickle/stream of bright red blood

uterine inversion

happens when the top of the uterus collapses into the inner cavity d/t excessive fundal pressure, or pulling on the umbilical cord when the placenta is still firmly attached to the fundus after birth

urinary tract infection (UTI)

higher risk from catheter placement

need to stay in hospital outpatient treatment with PO antibiotics

if a woman develops a UTI the woman typically does NOT

mastitis

infection of the breast connective tissue

bladder scanner straight cath (per protocol)

intervention related to urinary retention

supportive bra (no underwire) antibiotic analgesic nutrtion/rest/fluids

interventions related to mastitis

IV antibiotics perineal hygiene teaching

interventions related to postpartum infection

hand washing teach perineal hygiene aseptic technique

interventions related to the management of postpartum infection

assess/massage fundus vaginal exam (HCP)

interventions that should be completed while Oxytocin (Pitocin) is infusing

type + cross H&H (low) coagulation studies (anemia)

labs for postpartum hemorrhage

uterine atony

leading cause of postpartum hemorrhage (PPH)

days 10-17

length of lochia alba stage

first 2-3 days

length of lochia rubra stage

days 3-10

length of lochia serosa stage

EBB

less migration with balloon dual-balloon catheter fills to 750mL

during a postpartum nursing assessment, the ________________ should be assessed for color, amount, and odor during a postpartum nursing assessment

lochia

mastitis

may be caused by incomplete emptying of milk

urinary tract infection (UTI)

may be caused by postpartum urinary retention (either vaginal or cesarean)

Hemabate (Carboprost)

may cause fever, nausea, GI upset (diarrhea) very shortly after administration

uterine rupture

may occur and cause damage to the genital tract, more commonly seen in women who have had a cesarean section

Hemabate (Carboprost)

medication may cause bronchospasm (CI: asthma), must know patient history and allergies before administration due to contraindications

Hemabate (Carboprost)

medication that is not used as frequently in PPH, contraindicated in asthma

general anesthesia magnesium sulfate (vasodilator and CNS depressant)

medications that are associated with postpartum hemorrhage (PPH)

Breastfeeding must be kept up to maintain ___________________

milk supply

endometritis

most common postpartum infection

TXA

must be given IV within 3 hours of diagnosis of postpartum hemorrhage (PPH)

TXA

not a first-line treatment, always give Oxytocin first, recommended after Oxytocin and Methergine, would be given prior to balloon tamponade

decreased blood pressure increased pulse

not a good indicator of postpartum hemorrhage, late signs

Late (secondary) postpartum hemorrhage

not as severe as early, primary postpartum hemorrhage (PPH)

education assess # pads and amount when was pad last changed

nursing interventions related to late (secondary) PPH

determine cause fundus check frequent vital signs empty bladder

nursing interventions related to postpartum hemorrhage (PPH)

wound infection

occurs with infection of a repaired laceration or episiotomy

The Involution Process of uterus helps with breast feeding due to increase of _________________.

oxytocin (contractions after pains help process along)

Late (secondary) postpartum hemorrhage

patient will report prolonged lochia rubra

change pads every time they use the restroom bottle front to back

perineal hygiene teaching should include

lie down legs elevated

position that promotes venous return in postpartum hemorrhage

assess for s/s infection foul-smelling pain

postpartum assessment for postpartum infection should include

500, 1000

postpartum hemorrhage is defined as estimated blood loss (EBL) or quantified blood loss (QBL) over ___ mL in SVD and over _____ mL in a cesarean section

100.4, 2, 10

postpartum infection is defined as a temperature > ___ F after the first 24 hours on __ separate occasions in the first __ days

The Involution Process of uterus involved what process for endometrium?

regeneration of endometrium

massaging fundus before complete removal

risk factor of retained placenta

overdistended uterus medication previous hemorrhage uterine anomaly coagulopathy infection

risk factors associated with postpartum hemorrhage (PPH)

damaged nipples milk stasis (incomplete emptying)

risk factors of mastitis

IM

route of administration for methergine

vital signs (BP, P)

s/s of postpartum hemorrhage often are not easily observable by ___ d/t increased blood volume associated with pregnancy

Oxytocin (Pitocin)

set up the IV infusion to be piggybacked into a primary IV line, this ensures that the medication can be d/c readily if uterine hyperstimulation or adverse effects occur while still maintaining the IV site and primary infusion

laceration

should always be suspected with the presentation of a contracted, midline uterus with bright-red blood continuing to trickle out of the vagina

tachycardia hypotension low h/h (anemia)

signs of blood loss associated with postpartum hematoma

Oxytocin (Pitocin)

stimulates uterine contractions to control bleeding from the placental site

laceration

this type of complication produces postpartum hemorrhage with smaller volumes of blood (is not a massive bleed)

ice incision/drainage (more severe)

treatment for postpartum hematoma

stitches

treatment of laceration associated with postpartum hemorrhage

IV antibiotics I/D surgical debridement sitz bath analgesic warm compress

treatment of wound infection should involve

What follows after colostrum?

true breast milk

mastitis

unilateral hard nodule, warmth fever tachycardia

hysterectomy

untreated hemorrhage, last resort management

when monitoring for a murmur related to a patent ductus arteriosus, where should the nurse auscultate?

upper left sternal border

Dinoprostone

used to help induce labor, but may also be used to manage PPH, may be given vaginally or rectally

EBB Bakri

uterine packing and tamponade balloons for postpartum hemorrhage

Which are major risks for postpartum infection?

vaginal trauma anemia multiple vaginal exams prolonged rupture of membranes retained placental fragments cesarean birth poor health status Fever > 100.4 (38) after 24 hours

rubra

women with secondary postpartum hemorrhage (PPH) experienced a prolonged ___ stage which displays s/s similar to a heavy period