Exam Mod 11 & 12

The induction of labor is considered an acceptable obstetric procedure if it is in the best interest to deliver the fetus. The charge nurse on the labor and delivery unit is often asked to schedule clients for this procedure and therefore must be cognizant of the specific conditions appropriate for labor induction. What are appropriate indications for induction? Select all that apply a. Rupture of membranes at or near term b. Convenience of the woman or her physician c. Chorioamnionitis (inflammation of the amniotic sac) d. Postterm pregnancy e. Fetal death

ACDE The conditions listed are all acceptable indications for induction. Other conditions include intrauterine growth restriction (IUGR), maternal-fetal blood incompatibility, hypertension, and placental abruption. Elective inductions for the convenience of thewoman or her provider are not recommended; however, they have become commonplace. Factors such as rapid labors and living a long distance from a health care facility may be valid reasons in such a circumstance. Elective delivery should not occur before 39weeks of completed gestation.

What is a maternal indication for the use of forceps-assisted birth? a. Wide pelvic outlet b. Maternal exhaustion c. History of rapid deliveries d. Failure to progress past station 0

B A mother who is exhausted may be unable to assist with the expulsion of the fetus. The client witha wide pelvic outlet will likely not require forceps extraction. With a rapid delivery, forceps extraction is not necessary. A station of 0 is too high for a forceps-assisted birth.

What is the primary purpose for the use of tocolytic therapy to suppress uterine activity? a. Drugs can be efficaciously administered up to the designated beginning of term at 37 weeks gestation b. Tocolytic therapy has no important maternal (as opposed to fetal) contraindications c. The most important function of tocolytic therapy is to provide the opportunity to administer antenatal glucocorticoids d. If the client develops pulmonary edema while receiving tocolytic therapy, then intravenous (IV) fluids should be given.

C Buying time for antenatal glucocorticoids to accelerate fetal lung development may be the best reason to use tocolytic therapy. Once the pregnancy has reached 34 weeks, however, the risks of tocolytic therapy outweigh the benefits. Important maternal contraindications to tocolytic therapy exist. Tocolytic-induced edema can be caused by IV fluids.

An infant weighing 4.1 kg was born 2 hours ago at 37 weeks of gestation. The infant appears chubby with a flushed complexion and is very tremulous. The tremors are most likely the result of: A. Birth injury B. Hypocalcemia C. Hypoglycemia D. Seizures

C The description is indicative of a macrocosmic infant. Hypoglycemia is common in the infant with macrosomia. The tremors are jitteriness that is associated with hypoglycemia. Other signs of hypoglycemia are apnea, tachypnea, and cyanosis

After giving birth to a stillborn infant, the woman turns to the nurse and says, "I just finished painting the baby's room. Do you think that caused my baby to die?" What is the nurse's best response? A. Silence. B. "That's not likely. Paint is associated with elevated pediatric lead levels." C. "I can understand your need to find an answer to what caused this. What else are you thinking about?" D. "That's an old wives' tale; lots of women are around paint during pregnancy, and this doesn't happen to them."

C The statement in D is very appropriate for the nurse. It demonstrates caring and compassion and allows the mother to vent her thoughts and feelings, which is therapeutic in the process of grieving. The nurse should resist the temptation to give advice or to use clichés in offering support to the bereaved. Trying to give bereaved parents answers when no clear answers exist or trying to squelch their guilt feelings does not help the process of grief. Additionally the response in B probably would increase the mother's feelings of guilt. One of the most important goals of the nurse is to validate the experience and feelings of the parents by encouraging them to tell their stories, and listening with care, which silence would not do.

Which factor would contribute to depletion of weight and metabolic stores in the high risk newborn? A. Frequent breast feedings B. Core temperature within normal range C. Phototherapy D. Bathing

C The use of phototherapy could lead to insensible heat loss and as a result lead to decreased weight and metabolic stores in the high risk newborn. Frequent breastfeedings and bathing would not have these effects. Maintaining a core temperature would help maintain weight and metabolic stores in the high risk newborn.

What information regarding a fractured clavicle is most important for the nurse to take into consideration when planning the infant's care? a. Prone positioning facilitates bone alignment. b. No special treatment is necessary. c. Parents should be taught range-of-motion exercises. d. The shoulder should be immobilized with a splint.

b. No special treatment is necessary. Fractures in newborns generally heal rapidly. Except for gentle handling, no accepted treatment for a fractured clavicle exists. Movement should be limited, and the infant should be gently handled. Performing range-of-motion exercises on the infant is not necessary. A fractured clavicle does not require immobilization with a splint.

A woman at 26 weeks of gestation is being assessed to determine whether she is experiencing preterm labor. Which finding indicates that preterm labor is occurring? a. Estriol is not found in maternal saliva b. Irregular, mild uterine contractions are occurring every 12 to 15 minutes c. Fetal fibronectin is present in vaginal secretions d. The cervix is effacing and dilated to 2 cm.

D Cervical changes such as shortened endocervical length, effacement, and dilation are predictors of imminent preterm labor. Changes in the cervix accompanied by regular contractions indicate labor at any gestation. Estriol is a form of estrogen produced by the fetus that is present in plasma at 9 weeks of gestation. Levels of salivary estriol have been shown to increase before preterm birth. Irregular, mild contractions that do not cause cervical change are not considered a threat. The presence of fetal fibronectin in vaginal secretions between 24 and 36 weeks of gestation could predict preterm labor, but it has only a 20% to 40% positive predictive value. Of more importance are other physiologic clues of preterm labor such as cervical changes.

When providing an infant with a gavage feeding, what should the nurse document each time? A. The infant's abdominal circumference after the feeding B. The infant's heart rate and respirations C. The infant's suck and swallow coordination D. The infant's response to the feeding

D Documentation of a gavage feeding should include the size of the feeding tube, the amount and quality of the residual from the previous feeding, the type and quantity of the fluid instilled, and the infant's response to the procedure. Some older infants may be learning to suck, but the important factor to document is the infant's response to the feeding (including attempts to suck). Abdominal circumference is not measured after a gavage feeding. Vital signs may be obtained prior to feeding, but the infant's response is more important.

Premature infants who exhibit 5 to 10 seconds of respiratory pauses followed by 10 to 15 seconds of compensatory rapid respiration are: A. Suffering from sleep or wakeful apnea B. Experiencing severe swings in blood pressure C. Trying to maintain a neutral thermal environment D. Breathing in a respiratory pattern common to premature infants

D The pattern of 5 to 10 seconds of respiratory pauses followed by 10 to 15 seconds of rapid respiration is called periodic breathing, which is common to premature infants. It may require nursing intervention such as oxygen and/or ventilation. Apnea is a cessation of respirations for 20 seconds or longer. An infant who presents with fluctuation in systemic blood pressure may have experienced a central nervous system injury. An infant attempting to maintain body temperature is likely to present with hypoglycemia, shivering, and mottled color.

A pregnant woman's amniotic membrane has ruptured and a prolapsed cord is suspected. Which intervention is the nurse's highest priority? A. Cover the cord in a sterile towel saturated with warm normal saline. B. Prepare the woman for a cesarean birth. C. Start oxygen by face mask. D. Place the woman in the knee-chest position.

D The woman is assisted into a position (e.g., modified Sims position, Trendelenburg position, or knee-chest position) in which gravity keeps the pressure of the presenting part off the cord. Relieving pressure on the cord is the nursing priority. The nurse may also use her gloved hand or two fingers to lift the presenting part off the cord. If the cord is protruding from the vagina it may be covered with a sterile towel soaked in saline. The nurse should administer O2 by facial mask at 8 to 10 L/min until delivery is complete. If the cervix is fully dilated, the nurse should prepare for immediate vaginal delivery. Cesarean birth is indicated only if cervical dilation is not complete.

A client tells the nurse about the funeral arrangements for her newborn son. The client is thereby providing the nurse with information about: Expression of loss Mourning process Family reaction Grief process

Mourning process The mourning process is reflected by traditions and rituals such as the funeral arrangements. The grief process represents the emotional expression of loss. The expression of loss is related to the meaning of perception. Providing information related to funeral arrangements is not an indicator of family reaction.

Antidepressant medication is the mainstay treatment for maternal depression, with selective serotonin reuptake inhibitors (SSRIs) being the first line of pharmacotherapy. Reports of cardiac defects have been associated with the use of which SSRI? Citalopram Fluoxetine Sertraline Paroxetine

Paroxetine The American College of Obstetricians and Gynecologists (ACOG) has issued a recommendation that paroxetine be avoided both during pregnancy and in women considering pregnancy. There have also been reports linking paroxetine to other abnormalities, such as omphalocele, craniosynostosis, and anencephaly. The absolute risk of any congenital abnormality associated with use of citalopram, fluoxetine, or sertraline is small.

A woman in preterm labor at 30 weeks of gestation receives two 12-mg intramuscular (IM) doses of betamethasone. What is the purpose of this pharmacologic intervention? a. To stimulate fetal surfactant production b. To reduce maternal and fetal tachycardia associated with ritodrine administration c. To suppress uterine contractions d. To maintain adequate maternal respiratory effort and ventilation during magnesium sulfate therapy

A Antenatal glucocorticoids administered as IM injections to the mother accelerate fetal lung maturity. Propranolol (Inderal) is given to reduce the effects of ritodrine administration. Betamethasone has no effect on uterine contractions. Calcium gluconate is given to reverse the respiratory depressive effects of magnesium sulfate therapy.

Which description most accurately describes the augmentation of labor? a. Is part of the active management of labor that is instituted when the labor process is unsatisfactory b. Relies on more invasive methods when oxytocin and amniotomy have failed c. Is a modern management term to cover up the negative connotations of forceps-assisted birth d. Uses vacuum cups

A Augmentation is part of the active management of labor that stimulates uterine contractions after labor has started but is not progressing satisfactorily. Augmentation uses amniotomy and oxytocin infusion, as well as some more gentle, noninvasive methods. Forceps-assisted births are less common than in the past and not considered a method of augmentation. A vacuum-assisted delivery occurs during childbirth if the mother is too exhausted to push. Vacuum extraction is not considered an augmentation methodology.

A nurse is caring for a pregnant client in labor using tocolytic therapy. Which statement should the nurse identify as correct? A. Its most important function is to afford the opportunity to administer antenatal glucocorticoids. B. There are no important maternal (as opposed to fetal) contraindications. C. The drugs can be given efficaciously up to the designated beginning of term at 37 weeks. D. If pulmonary edema develops while the client is receiving tocolytics, IV fluids should be given.

A Buying time for antenatal glucocorticoids to accelerate fetal lung development might be the best reason to use tocolytics. Once the pregnancy has reached 34 weeks, the risks of tocolytic therapy outweigh the benefits. There are important maternal contraindications to tocolytic therapy. Tocolytic-induced edema can be caused by IV fluids.

Which TORCH infection could be contracted by the infant because the mother owned a cat? A. Toxoplasmosis B. Varicella-zoster C. Parvovirus B19 D. Rubella

A Cats that eat birds infected with the Toxoplasma gondii protozoan excrete infective oocysts. Humans (including pregnant women) can become infected if they fail to wash their hands after cleaning a cat's litter box. The infection is passed through the placenta. The varicella-zoster virus is responsible for chickenpox and shingles. Approximately 90% of childbearing women are immune. During pregnancy, infection with parvovirus can result in abortion, fetal anemia, hydrops, intrauterine growth restriction (IUGR), and stillbirth; this virus is spread by vertical transmission, not by felines. Since vaccination for rubella was begun in 1969, cases of congenital rubella infection have been reduced significantly. Vaccination failures, lack of compliance, and the migration of nonimmunized persons result in periodic outbreaks of rubella (German measles).

A woman at 26 weeks of gestation is being assessed to determine whether she is experiencing preterm labor. What finding would indicate to the nurse that preterm labor is occurring? A. The cervix is effacing and dilated to 2 cm. B. Fetal fibronectin is present in vaginal secretions. C. Irregular, mild uterine contractions are occurring every 12 to 15 minutes. D. Estriol is not found in maternal saliva.

A Cervical changes such as shortened endocervical length, effacement, and dilation are predictors of imminent preterm labor. Changes in the cervix accompanied by regular contractions indicate labor at any gestation. Irregular, mild contractions that do not cause cervical change are not considered a threat. Estriol is a form of estrogen produced by the fetus that is present in plasma at 9 weeks of gestation. Levels of salivary estriol have been shown to increase before preterm birth. The presence of fetal fibronectin in vaginal secretions between 24 and 36 weeks of gestation could predict preterm labor, but it has only a 20% to 40% positive predictive value. Of more importance are other physiologic clues of preterm labor, such as cervical changes.

With regard to injuries to the infant's plexus during labor and birth, nurses should be aware that: A. If the nerves are stretched with no avulsion, they should recover completely in 3 to 6 months B. Erb palsy is damage to the lower plexus C. Parents of children with brachial palsy are taught to pick up the child from under the axillae D. Breastfeeding is not recommended for infants with facial nerve paralysis until the condition resolves

A If the ganglia are disconnected completely from the spinal cord, the damage is permanent. Erb palsy is damage to the upper plexus and is less serious than brachial palsy. Parents of children with brachial palsy are taught to avoid picking up the child under the axillae or by pulling on the arms. Breastfeeding is not contraindicated in facial nerve paralysis, but both mother and infant will need help from the nurse at the start.

A pregnant woman was admitted for induction of labor at 43 weeks of gestation with sure dates. A nonstress test (NST) in the obstetrician's office revealed a nonreactive tracing. On artificial rupture of membranes, thick meconium-stained fluid was noted. What should the nurse caring for the infant after birth anticipate? a. Meconium aspiration, hypoglycemia, and dry, cracked skin b. Excessive vernix caseosa covering the skin, lethargy, and RDS c. Golden yellow to green-stained skin and nails, absence of scalp hair, and an increased amount of subcutaneous fat d. Hyperglycemia, hyperthermia, and an alert, wide-eyed appearance

A Meconium aspiration, hypoglycemia, and dry, cracked skin are consistent with a postmature infant. Excessive vernix caseosa, lethargy, and RDS are consistent with a very premature infant. The skin may be meconium stained, but the infant will most likely have long hair and decreased amounts of subcutaneous fat. Postmaturity with a nonreactive NST is indicative of hypoxia. Signs and symptoms associated with fetal hypoxia are hypoglycemia, temperature instability, and lethargy.

A premature infant with respiratory distress syndrome (RDS) receives artificial surfactant. How does the nurse explain surfactant therapy to the parents? a. "Surfactant improves the ability of your baby's lungs to exchange oxygen and carbon dioxide." b. "The drug keeps your baby from requiring too much sedation." c. "Surfactant is used to reduce episodes of periodic apnea." d. "Your baby needs this medication to fight a possible respiratory tract infection."

A Surfactant can be administered as an adjunct to oxygen and ventilation therapy. With the administration of an artificial surfactant, respiratory compliance is improved until the infant can generate enough surfactant on his or her own. Surfactant has no bearing on the sedation needs of the infant. Surfactant is used to improve respiratory compliance, including the exchange of oxygen and carbon dioxide. The goal of surfactant therapy in an infant with RDS is to stimulate the production of surfactant in the type 2 cells of the alveoli. The clinical presentation of RDS and neonatal pneumonia may be similar. The infant may be started on broad-spectrum antibiotics to treat infection.

A male infant at 26 weeks of gestation arrives from the delivery room intubated. The nurse weighs the infant, places him under the radiant warmer, and attaches him to the ventilator at the prescribed settings. A pulse oximeter and cardiorespiratory monitor are placed. The pulse oximeter is recording oxygen saturation values of 80%. The prescribed saturation value is 92%. The nurse's most appropriate action is to: A. Listen to breath sounds and ensure the patency of the endotracheal tube, increase oxygen, and notify a physician. B. Continue to observe and make no changes until the saturations are 75%. C. Continue with the admission process to ensure that a thorough assessment is completed. D. Notify the parents that their infant is not doing well.

A The actions described in A are appropriate nursing interventions to assist in optimal O2 saturation of the infant. Oxygenation of the infant is crucial. O2 saturation should be maintained at more than 92%, and the nurse should delay other tasks to stabilize the infant. The action described in D is not appropriate. Further assessment and intervention are warranted prior to determination of fetal status.

Which nursing intervention should be immediately performed after the forceps-assisted birth of an infant? a. Assessing the infant for signs of trauma b. Administering prophylactic antibiotic agents to the infant c. Applying a cold pack to the infant's scalp d. Measuring the circumference of the infant's head

A The infant should be assessed for bruising or abrasions at the site of application, facial palsy, and subdural hematoma. Prophylactic antibiotics are not necessary with a forceps delivery. A cold pack would place the infant at risk for cold stress and is contraindicated. Measuring the circumference of the head is part of the initial nursing assessment.

A nurse providing care to a woman in labor should be aware that cesarean birth: A. Is performed primarily for the benefit of the fetus. B. Can be either elected or refused by women as their absolute legal right. C. Is declining in frequency in the United States. D. Is more likely to be performed in the poor in public hospitals who do not receive the nurse counseling that wealthier clients do.

A The most common indications for cesarean birth are danger to the fetus related to labor and birth complications. Cesarean births are increasing in the United States. Wealthier women who have health insurance and who give birth in a private hospital are more likely to experience cesarean birth. A woman's right to elect cesarean surgery is in dispute, as is her right to refuse it if in doing so she endangers the fetus. Legal issues are not absolutely clear.

A pregnant woman's amniotic membranes have ruptured. A prolapsed umbilical cord is suspected. What intervention would be the nurse's highest priority? a. Placing the woman in the knee-chest position b. Covering the cord in sterile gauze soaked in saline c. Preparing the woman for a cesarean birth d. Starting oxygen by face mask

A The woman is assisted into a modified Sims position, Trendelenburg position, or the knee-chest position in which gravity keeps the pressure of the presenting part off the cord.Although covering the cord in sterile gauze soaked saline, preparing the woman for a cesarean, and starting oxygen by face mark are appropriate nursing interventions in the event of a prolapsed cord, the intervention of top priority would be positioning the mother to relieve cord compression.

A nurse is working with a client who is grieving over the loss of a stillborn. Which statement would the nurse identify as correct with regard to the emotional state of grief? A. Time limit for grief experiences is variable among individuals B. Aspects of grief occur simultaneously across family units C. It represents a linear process D. It is a static concept applied to loss

A There is no prescribed time limit for the expression of grief. Grief is a dynamic concept involving complex emotions. The expression of grief is individualized and may not occur simultaneously across family units. The process of grief represents an iterative process.

A nurse is caring for a laboring client who has a breech presentation. Which statement would the nurse identify as being most associated with this type of presentation? A. A rapid descent B. High rate of neuromuscular disorders C. Least common malpresentation D. Diagnosis by ultrasound only

B Fetuses with neuromuscular disorders have a higher rate of breech presentation, perhaps because they are less capable of movement within the uterus. Breech is the most common malpresentation, affecting 3% to 4% of all labors. Descent is often slow because the breech is not as good a dilating wedge as the fetal head. Diagnosis is made by abdominal palpation and vaginal examination, and is confirmed by ultrasound.

What are the complications and risks associated with cesarean births? Select all that apply a. Pulmonary edema b. Wound dehiscence c. Hemorrhage d. Urinary tract infections e. Fetal injuries

ABCDE Pulmonary edema, wound dehiscence, hemorrhage, urinary tract infections, and fetal injuries are possible complications and risks associated with cesarean births.

Women who are obese are at risk for several complications during pregnancy and birth. Which of these would the nurse anticipate with an obese client? Select all that apply a. Thromboembolism b. Cesarean birth c. Wound infection d. Breech presentation e. Hypertension

ABCE A breech presentation is not a complication of pregnancy or birth for the client who is obese. Venous thromboembolism is a known risk for obese women. Therefore, the use of thromboembolism-deterrent (TED) hose and sequential compression devices may help decrease the chance for clot formation. Women should also be encouraged to ambulate as soon as possible. In addition to having an increased risk for complications with a cesarean birth, in general, obese women are also more likely to require an emergency cesarean birth. Many obese women have a pannus(i.e., large roll of abdominal fat) that overlies a lower transverse incision made just above the pubic area. The pannus causes the areato remain moist, which encourages the development of infection. Obese women are more likely to begin pregnancy with comorbidities such as hypertension and type 2 diabetes.

Which statement related to cephalopelvic disproportion (CPD) is the least accurate? a. CPD can be related to either fetal size or fetal position b. The fetus cannot be born vaginally c. CPD can be accurately predicted d. Causes of CPD may have maternal or fetal origins

C Unfortunately, accurately predicting CPD is not possible. Although CPD is often related to excessive fetal size (macrosomia), malposition of the fetal presenting part is the problem in many cases,not true CPD. When CPD is present, the fetus cannot fit through the maternal pelvis to be born vaginally. CPD may be related to either fetal origins such as macrosomia or malposition or maternal origins such as a too small or malformed pelvis.

A woman is diagnosed with having a stillborn. At first she appears stunned by the news, cries a little, and then asks the nurse to call her mother. What phase of bereavement does the nurse identify that the woman is experiencing? Grief Reorganization Intense grief Acute distress

Acute Distress The immediate reaction to news of a perinatal loss or infant death encompasses a period of acute distress. Disbelief and denial can occur. However, parents also feel very sad and depressed. Intense outbursts of emotion and crying are normal, but lack of affect, euphoria, and calmness may occur and may reflect numbness, denial, or personal ways of coping with stress. Grief applies to the grief related to a potential loss of an infant. The parent grieves in preparation of the infant's possible death, although the parent clings to the hope that the child will survive. Intense grief occurs in the first few months after the death of the infant. This phase encompasses many different emotions, including loneliness, emptiness, yearning, guilt, anger, and fear. Reorganization occurs after a long and intense search for meaning. Parents are better able to function at work and home, experience a return of self-esteem and confidence, can cope with new challenges, and have placed the loss in perspective.

A nurse is caring for a client whose labor is being augmented with oxytocin. The nurse recognizes that the oxytocin should be discontinued immediately if there is evidence of: A. Rupture of the client's amniotic membranes. B. A fetal heart rate (FHR) of 180 with absence of variability. C. Uterine contractions occurring every 8 to 10 minutes. D. The client needing to void.

B A fetal heart rate (FHR) of 180 with absence of variability is nonreassuring; the oxytocin should be immediately discontinued and the physician should be notified. The oxytocin should also be discontinued if uterine hyperstimulation occurs. Uterine contractions that occur every 8 to 10 minutes do not qualify as hyperstimulation. The client needing to void is not an indication to discontinue the oxytocin induction immediately or to call the physician. The oxytocin does not need to be discontinued when the membranes rupture, but the physician should be notified.

A Gravida III, Para 0 is concerned about the potential outcome for this pregnancy because all of her prior pregnancies have resulted in stillborn deliveries. Which diagnostic test would the nurse identify to assess for fetal well-being now that her pregnancy is at 32 weeks gestation? A. Chorionic villi sampling (CVS) B. Ultrasound C. Kleihauer-Betke test D. Contraction stress test (CST)

B An ultrasound could be used to determine fetal well-being. The Kleihauer-Betke test is a blood test to evaluate for the presence of fetal blood in maternal circulation; there is no evidence to support the use of this test at this time. CVS testing is typically done earlier in the pregnancy, between 10 and 12 weeks. There is no evidence to support the use of a CST at this time; determination of fetal well-being would first be evaluated with a nonstress test.

A number of methods can be used for inducing labor. Which cervical ripeningmethod falls under the category of mechanical or physical? a. Prostaglandins are used to soften and thin the cervix. b. Labor can sometimes be induced with balloon catheters or laminaria tents c. Oxytocin is less expensive and more effective than prostaglandins but creates greater health risks d. Amniotomy can be used to make the cervix more favorable for labor.

B Balloon catheters or laminaria tents are mechanical means of ripening the cervix. Ripening the cervix, making it softer and thinner, increases the success rate of induced labor. Prostaglandin E1 is less expensive and more effective than oxytocin but carries a greater risk. Amniotomy is the artificial rupture of membranes, which is used to induce labor only when the cervix is already ripe.

Which of the following would be considered to be an intrapartum risk factor for neonatal sepsis? A. Mechanical ventilation B. Chorioamnionitis C. Galactosemia D. Meconium aspiration

B Chorioamnionitis would be considered to be an intrapartum risk factor. The other conditions described are neonatal risk factors.

For diagnostic and treatment purposes, nurses should know the birth weight classifications of high risk infants. For example, extremely low birth weight (ELBW) is the designation for an infant whose weight is: A. Less than 1500 g. B. Less than 1000 g. C. Less than 2000 g. D. Dependent on the gestational age

B ELBW is defined as less than 1000 g. At such weights, problems are so numerous that ethical issues regarding when to treat arise. Less than 1500 g is the designation for very low birth rate (VLBW). Less than 2000 g is less than LBW but too high for VLBW. Gestational age is a factor with weight in the condition of the preterm birth, but it is not part of the birth weight categorization.

A nurse is caring for a client who had a previous cesarian section and now presents with a transverse presentation in labor. Which information should the nurse provide to the client? A. "Because this is a repeat procedure, you are at the lowest risk for complications." B. "Even though this is your second cesarean birth, you may wish to review the preoperative and postoperative procedures." C. "You will not need preoperative teaching because this is your second cesarean birth." D. "Because this is your second cesarean birth, you will recover faster."

B Even though the client has previously had this surgical procedure, the prudent nurse should provide client teaching at this time. Maternal and fetal risks are associated with every cesarean section. Physiologic and psychologic recovery from a cesarean section is multifactorial and individual to each client each time. Preoperative teaching should always be performed regardless of whether the client has already had this procedure.

With regard to the classification of neonatal bacterial infection, nurses should be aware that: A. Congenital infection progresses slower than health care-associated infection B. Health care-associated infection can be prevented by effective handwashing; early-onset infection cannot C. Infections occur with about the same frequency in boy and girl infants, although female mortality is higher D. The clinical sign of a rapid, high fever makes infection easier to diagnose

B Handwashing is an effective preventive measure for late-onset (health care-associated) infections because these infections come from the environment around the infant. Early-onset (congenital) infections are caused by the normal flora at the maternal vaginal tract. Congenital (early-onset) infections progress more rapidly than health care-associated (late-onset) infections. Infection occurs about twice as often in boys and results in higher mortality. Clinical signs of neonatal infection are nonspecific and similar to noninfectious problems, making diagnosis difficult

A nurse is caring for a client who has a dysfunctional labor pattern. What should the nurse be aware of? A. Hypertonic uterine dysfunction is more common than hypotonic dysfunction. B. Women experiencing precipitous labor are about the only women experiencing dysfunctional labor who are not exhausted. C. Women who are underweight are more at risk. D. Abnormal labor patterns are most common in older women.

B Precipitous labor lasts less than 3 hours. Short women more than 30 pounds overweight are more at risk for dysfunctional labor. Hypotonic uterine dysfunction, in which the contractions become weaker, is more common. Abnormal labor patterns are more common in women younger than 20 years

Necrotizing enterocolitis (NEC) is an inflammatory disease of the gastrointestinal mucosa. The signs of NEC are nonspecific. Some generalized signs are: A. Hypertonia, tachycardia, and metabolic alkalosis B. Abdominal distention, temperature instability, and grossly bloody stools C. Hypertension, absence of apnea, and ruddy skin color D. Scaphoid abdomen, no residual with feedings, and increased urinary output

B Some generalized signs of NEC include decreased activity, hypotonia, pallor, recurrent apnea and bradycardia, decreased oxygen saturation values, respiratory distress, metabolic acidosis, oliguria, hypotension, decreased perfusion, temperature instability, cyanosis, abdominal distention, residual gastric aspirates, vomiting, grossly bloody stools, abdominal tenderness, and erythema of the abdominal wall.

Which nursing intervention is paramount when providing care to a client with preterm labor who has received terbutaline? a. Assess deep tendon reflexes (DTRs) b. Assess for dyspnea and crackles c. Assess for bradycardia d. Assess for hypoglycemia.

B Terbutaline is a beta2-adrenergic agonist that affects the mother's cardiopulmonary and metabolic systems. Signs of cardiopulmonary decompensation include adventitious breath sounds and dyspnea. An assessment for dyspnea and crackles is important for the nurse to perform if the woman is taking magnesium sulfate. Assessing DTRs does not address the possible respiratory side effects of using terbutaline. Since terbutaline is a beta2-adrenergic agonist, it can lead to hyperglycemia, not hypoglycemia. Beta2-adrenergic agonist drugs cause tachycardia, not bradycardia.

A pregnant client who is at term has been informed that her fetus has died and has been admitted to the obstetric unit. When developing a plan of care, the nurse would focus on which priority measure? A. Providing the client with phone numbers so as to make funeral arrangements B. Incorporating perinatal palliative care into the client's plan of care C. Including case management to participate in the client's care when she is admitted to the hospital D. Referral to a perinatologist

B The incorporation of a perinatal palliative care plan would be the priority intervention at this time to help the client and family members deal with the tragedy of the situation. At this point, a referral to a perinatologist would not be necessary because the determination has already been made that the fetus is dead. Although case management may be included in the plan of care and phone numbers may be provided to the client regarding funeral arrangements, these actions are not the priority measure.

With regard to small-for-gestational age (SGA) infants and intrauterine growth restriction (IUGR), nurses should be aware that: A. In the first trimester, diseases or abnormalities result in asymmetric IUGR B. Infants with asymmetric IUGR have the potential for normal growth and development C. In asymmetric IUGR, weight is slightly more than SGA, whereas length and head circumference are somewhat less than SGA D. Symmetric IUGR occurs in the later stages of pregnancy

B The infant with asymmetric IUGR has the potential for normal growth and development.IUGR is either symmetric or asymmetric. The symmetric form occurs in the first trimester, as a result of disease or abnormalities; SGA infants have reduced brain capacity. The asymmetric form occurs in the later stages of pregnancy. Weight is less than the 10th percentile, but the head circumference is greater than the 10th percentile (within normal limits).

A newborn was admitted to the neonatal intensive care unit (NICU) after being delivered at 29 weeks of gestation to a 28-year-old multiparous, married, Caucasian woman whose pregnancy was uncomplicated until the premature rupture of membranes and preterm birth. The newborn's parents arrive for their first visit after the birth. The parents walk toward the bedside but remain approximately 5 feet away from the bed. What is the nurse's most appropriate action? a. Wait quietly at the newborn's bedside until the parents come closer b. Go to the parents, introduce him or herself, and gently encourage them to meet their infant. Explain the equipment first, and then focus on the newborn. c. Leave the parents at the bedside while they are visiting so that they have some privacy. d. Tell the parents only about the newborn's physical condition and caution them to avoid touching their baby.

B The nurse is instrumental in the initial interactions with the infant. The nurse can help the parents seethe infant rather than focus on the equipment. The importance and purpose of the apparatus that surrounds their infant also should be explained to them. Parents often need encouragement and recognition from the nurse to acknowledge the reality of the infant's condition. Parents need to see and touch their infant as soon as possible to acknowledge the reality of the birth and the infant's appearance and condition. Encouragement from the nurse is instrumental in this process. Telling the parents to avoid touching their baby is inappropriate and unhelpful.

A pregnant woman at 29 weeks of gestation has been diagnosed with preterm labor. Her labor is being controlled with tocolytic medications. She asks when she might be able to go home. Which response by the nurse is most accurate? a. "After the baby is born." b. "When we can stabilize your preterm labor and arrange home health visits." c. "Whenever your physician says that it is okay." d. "It depends on what kind of insurance coverage you have."

B This client's preterm labor is being controlled with tocolytics. Once she is stable, home care may be a viable option for this type of client. Care of a client with preterm labor is multidisciplinary and multifactorial; the goal is to prevent delivery. In many cases, this goal may be achieved at home. Managed care may dictate an earlier hospital discharge or a shift from hospital to home care. Insurance coverage may be one factor in client care, but ultimately, client safety remains the most important factor.

A nurse is working with clients who have experienced a perinatal loss. Which statements would not be advisable for the nurse to use as a basis for therapeutic discussion? (Select all that apply.) A. "You wanted a boy anyway, so now you have another chance" B. "I'm sorry" C. "I am sad for you" D. "This must be hard for you" E. "You're young, you can have other children"

B, C, D "This must be hard for you," "I'm sorry," and "I am sad for you" are acceptable statements following perinatal loss. "You're young, you can have other children" and "You wanted a boy anyway, so now you have another chance" would not be considered therapeutic.

A nurse is reviewing the concept of uterine rupture. Which factors would the nurse identify as leading to an increased likelihood of this occurence? (Select all that apply.) A. G3P3 with all vaginal deliveries B. Client who had a primary caesarean section with a classic incision C. Short interval between pregnancies D. Client receiving a trial of labor (TOL) following a VBAC delivery E. Preterm singleton pregnancy

B, C, D The shorter the interval between pregnancies/deliveries, the higher the risk of uterine rupture. A client who is having a TOL following a VBAC and a client who has had a C section with a classic incision into the uterus are at increased risk for uterine rupture. A pregnant woman with a singleton pregnancy (one fetus), even if preterm, is not considered to be at increased risk for uterine rupture; nor is a multipara who has delivered all her infants vaginally.

Which factor increases the risk of complications for infants of diabetic mothers? A. Glycemic control B. Hemoglobin A1c level of 7 C. Duration of maternal disease D. Hemoglobin A1c level of 7 prior to pregnancy

C The duration and severity of maternal disease are significant factors in increasing the risk for complications in infants of diabetic mothers. Glycemic control would be a positive factor indicating that blood glucose levels were maintained within normal range. A hemoglobin A1c level of 7 is within normal range.

An infant at 36 weeks of gestation has increasing respirations (80 to 100 breaths per minute with significant substernal retractions). The infant is given oxygen by continuous nasal positive airway pressure (CPAP). What level of partial pressure of arterial oxygen (PaO2) indicates hypoxia? a. 67 mm Hg b. 89 mm Hg c. 45 mm Hg d. 73 mm Hg

C The laboratory value of PaO2 of 45 mm Hg is below the range for a normal neonate and indicates hypoxia in this infant. The normal range for PaO2 is 60 to 80 mm Hg; therefore, PaO2 levels of 67 and 73 mm Hg fall within the normal range, and a PaO2 of 89 mm Hg is higher than the normal range.

Which priority action implemented by the nurse would be most beneficial in helping a couple deal with fetal loss following the delivery of a stillborn? A. Provide a quiet environment for the couple for several hours restricting any visitors or family members. B. Allow all family members to come in immediately after the delivery to console the couple. C. Allow the parents to hold and view the baby following delivery if they so request. D. Take a photograph of the stillborn prior to the client's discharge to use as a keepsake.

C Bonding with the stillborn by holding and viewing after delivery is well documented by research to provide a source of comfort and closure. Although it will be important for family members to comfort the couple, it is more important for the family unit to be alone to adapt to the delivery. Providing a quiet environment is important but it not the priority action to be taken at this time. Taking a photograph is important as a keepsake but it is typically taken before the stillborn leaves the hospital.

Which priority intervention would be needed if the nurse suspected that an infant was septic? A. Administration of oxygen B. Electronic monitoring of vital signs C. Intravenous access D. Recorded intake and output

C Establishing intravenous access for the administration of antibiotics would be a priority intervention. The other actions described might be required but are not the priority intervention.

An infant is to receive gastrostomy feedings. Which intervention should the nurse institute to prevent bloating, gastrointestinal reflux into the esophagus, vomiting, and respiratory compromise? a. Rapid bolusing of the entire amount in 15 minutes b. Warmcloths to the abdomen for the first 10 minutes c. Slow, small, warm bolus feedings over 30 minutes d. Cold, medium bolus feedings over 20 minutes

C Feedings by gravity are slowly accomplished over 20-to 30-minute periods to prevent adverse reactions. Rapid bolusing would most likely lead to the adverse reactions listed. Temperature stability in the newborn is critical. Applying warm cloths to the abdomen would not be appropriate because the environment is not thermoregulated. In addition, abdominal warming is not indicated with feedings of any kind. Small feedings at room temperature are recommended to prevent adverse reactions.

Preterm infants are more likely to become septic because: A. IgG and IgA levels are adequate at birth B. Immune function is suppressed because of increased IgG levels C. IgG level is directly proportional to gestational age D. Serum complement levels are adequate

C IgG levels are directly proportional to gestational age, being decreased in preterm infants, and reflect immune function. Levels of IgG and IgA are not adequate at birth and require time to become optimal. Serum complement levels are decreased at birth in preterm infants

A nurse is working with bereaved parents. What is the most appropriate statement that the nurse can make? A. "You're young and can have other children." B. "I understand how you must feel." C. "I'm sorry." D. "You have an angel in heaven."

C One of the most important goals of the nurse is to validate the experience and feelings of the parents by encouraging them to tell their stories and listening with care. At the very least, the nurse should acknowledge the loss with a simple but sincere comment, such as, "I'm sorry." The initial impulse may be to reduce one's sense of helplessness and to say or do something that you think will reduce their pain. Although such a response may seem supportive at the time, it can stifle the further expression of emotion. The nurse should resist the temptation to give advice or to use clichés when offering support to the bereaved. The statement in C is not a therapeutic response for the nurse to make.

A nurse is reviewing the concept of complicated bereavement. Which statement would the nurse identify as being accurate? A. Occurs when, in multiple births, one child dies and the other or others live B. Is felt by the family of adolescent mothers who lose their babies C. Is an extremely intense grief reaction that persists for a long time D. Is a state in which the parents are ambivalent, as with an abortion

C Parents showing signs of complicated grief should be referred for counseling. Multiple births in which not all the babies survive creates a complicated parenting situation, abortion can generate complicated emotional responses, and families of lost adolescent pregnancies may have to deal with complicated issues, but these situations are not complicated bereavement.

Prostaglandin gel has been ordered for a pregnant woman at 43 weeks of gestation. What is the primary purpose of prostaglandin administration? a. To enhance uteroplacental perfusion in an aging placenta b. To increase amniotic fluid volume c. To ripen the cervix in preparation for labor induction d. To stimulate the amniotic membranes to rupture

C Preparations of prostaglandin E1and E2are effective when used before labor induction to ripen (i.e., soften and thin) the cervix. Uteroplacental perfusion is not altered by the use of prostaglandins. The insertion of prostaglandin gel has no effect on the level of amniotic fluid. In some cases, women will spontaneously begin laboring after the administration of prostaglandins, thereby eliminating the need for oxytocin. It is not common for a woman's membranes to rupture as a result of prostaglandin use.

In planning for home care of a woman with preterm labor, which concern should the nurse need to address? a. Nursing assessments are different from those performed in the hospital setting b. Restricted activity and medications are necessary to prevent a recurrence of preterm labor c. Prolonged bed rest may cause negative physiologic effects d. Home health care providers are necessary

C Prolonged bed rest may cause adverse effects such as weight loss, loss of appetite, muscle wasting, weakness, bone demineralization, decreased cardiac output, risk for thrombophlebitis, alteration in bowel functions, sleep disturbance, and prolonged postpartum recovery. Nursing assessments differ somewhat from those performed in the acute care setting, but this concern does not need to be addressed. Restricted activity and medications may prevent preterm labor but not in all women. In addition, the plan of care is individualized to meet the needs of each client. Many women receive home health nurse visits, but care is individualized for each woman.

In caring for a mother who has abused (or is abusing) alcohol and for her infant, nurses should be aware that: A. The pattern of growth restriction of the fetus begun in prenatal life is halted after birth, and normal growth takes over B. Two thirds of newborns with fetal alcohol syndrome (FAS) are boys C. Alcohol-related neurodevelopmental disorders (ARNDs) not sufficient to meet FAS criteria (learning disabilities, speech and language problems) are often not detected until the child goes to school D. Both the distinctive facial features of the FAS infant and the diminished mental capacities tend toward normal over time

C Some learning problems do not become evident until the child is in school. The pattern of growth restriction persists after birth. Two thirds of newborns with FAS are girls. Although the distinctive facial features of the FAS infant tend to become less evident with growth, the mental capacities never become normal

An infant is being discharged from the NICU after 70 days of hospitalization. The infant was born at 30 weeks of gestation with several conditions associated with prematurity, including RDS, mild bronchopulmonary dysplasia (BPD), and retinopathy of prematurity (ROP), requiring surgical treatment. During discharge teaching, the infant's mother asks the nurse if her baby will meet developmental milestones on time, as did her son who was born at term. What is the nurse's most appropriate response? a. "Your baby will develop exactly like your first child." b. "Your baby does not appear to have any problems at this time." c. "Your baby will need to be corrected for prematurity." d. "Your baby will need to be followed very closely."

C The age of a preterm newborn is corrected by adding the gestational age and the postnatal age. The infant's responses are accordingly evaluated against the norm expected for the corrected age of the infant. The baby is currently 40 weeks of postconceptional age and can be expected to be doing what a 40-week-old infant would be doing. Although predicting with complete accuracy the growth and development potential of each preterm infant is impossible, certain measurable factors predict normal growth and development. The preterm infant experiences catch-up body growth during the first 2 to 3 years of life. Development needs to be evaluated over time. The growth and developmental milestones are corrected for gestational age until the child is approximately 2.5 years old.

A primigravida at 40 weeks of gestation is having uterine contractions every to 2 minutes and states that they are very painful. Her cervix is dilated 2 cm and has not changed in 3 hours. The woman is crying and wants an epidural. What is the likelystatus of this woman's labor? a. She is exhibiting hypotonic uterine dysfunction b. She is experiencing a normal latent stage c. She is exhibiting hypertonic uterine dysfunction d. She is experiencing precipitous labor

C The contraction pattern observed in this woman signifies hypertonic uterine activity. Typically, uterine activity in this phase occurs at 4-to 5-minute intervals lasting 30 to 45 seconds. Women who experience hypertonic uterine dysfunction, or primary dysfunctional labor, are often anxious first-time mothers who are having painful and frequent contractions that are ineffective at causing cervical dilation or effacement to progress. With hypotonic uterine dysfunction, the woman initially makes normal progress into the active stage of labor; then the contractions become weak and inefficient or stop altogether. Precipitous labor is one that lasts less than 3 hours from the onset of contractions until time of birth.

A woman is having her first child. She has been in labor for 15 hours. A vaginal examination performed 2 hours earlier revealed the cervix to be dilated to 5 cm and 100% effaced, and the presenting part of the fetus was at station 0; however, another vaginal examination performed 5 minutes ago indicated no changes. What abnormal labor pattern is associated with this description? a. Prolonged latent phase b. Protracted active phase c. Secondary arrest d. Protracted descent

C With a secondary arrest of the active phase, the progress of labor has stopped. This client has not had any anticipated cervical change, indicating an arrest of labor. In the nulliparous woman, a prolonged latent phase typically lasts longer than 20 hours. A protracted active phase, the first or second stage of labor, is prolonged (slow dilation). With a protracted descent, the fetus fails to descend at an anticipated rate during the deceleration phase and second stage of labor.

Which factors predispose an infant to birth injuries? select all that apply A. Multip between the ages of 25 and 30 B. Vertex presentation C. Application of an internal fetal scalp electrode D. Vacuum-assisted birth

C and D The use of an internal fetal scalp electrode could result in a scalp injury, which would be evident upon birth. The use of vacuum extraction could lead to a birth injury. Very young age (less than 16) and older age (more than 35) in a primipara are more likely to predispose an infant to birth injuries. Vertex presentation is a normal finding and as such would not typically lead to a birth injury.

Which of the following processes or findings increase the risk of preterm infants in which hematologic problems are developing? Select all that apply. A. Decrease in size of red blood cells B. Decreased capillary fragility C. Prolonged PT time D. Decreased red blood cell survival time E. Decrease in erythropoiesis

C, D, E Prolonged PT reflects an increased tendency to bleed in preterm infants. Decrease in red blood cell survival time is seen in such infants. So is decreased functional ability of erythropoietin, which limits red blood cell synthesis. One sees an increase in the size of red blood cells in preterm infants, which affects their survival time. Increased capillary fragility also occurs in preterm infants.

The nurse is performing an assessment on a client who thinks she may be experiencing preterm labor. Which information is the most important for the nurse to understand and share with the client? a. Because all women must be considered at risk for preterm labor and prediction is so variable, teaching pregnant women the symptoms of preterm labor probably causes more harm through false alarms b. Braxton Hicks contractions often signal the onset of preterm labor c. Because preterm labor is likely to be the start of an extended labor, a woman with symptoms can wait several hours before contacting the primary caregiver d. Diagnosis of preterm labor is based on gestational age, uterine activity, and progressive cervical change.

D Gestational age of 20 to 37 weeks, uterine contractions, and a cervix that is 80% effaced or dilated 2 cm indicates preterm labor. It is essential that nurses teach women how to detect the early symptoms of preterm labor. Braxton Hicks contractions resemble preterm labor contractions, but they are not true labor. Waiting too long to see a health care provider could result in essential medications failing to be administered. Preterm labor is not necessarily long-term labor.

Which statement related to the induction of labor is most accurate? a. Can be achieved by external and internal version techniques b. Is also known as atrial of labor (TOL) c. Is almost always performed for medical reasons d. Is rated for viability by a Bishop score

D Induction of labor is likely to be more successful with a Bishop score of 9 or higher for first-time mothers or 5 or higher for veterans. Version is the turning of the fetus to a better position by a physician for an easier or safer birth. A TOL is the observance of a woman and her fetus for several hours of active labor to assess the safety of vaginal birth. Two thirds of cases of induced labor are elective and not done for medical reasons.

When would an internal version be indicated to manipulate the fetus into a vertex position? a. Fetus from a breech to a cephalic presentation before labor begins b. Fetus from a transverse lie to a longitudinal lie before a cesarean birth c. Second twin from an oblique lie to a transverse lie before labor begins d. Second twin from a transverse lie to a breech presentation during a vaginal birth

D Internal version is used only during a vaginal birth to manipulate the second twin into a presentation that allows it to be vaginally born. For internal version to occur, the cervix needs to be completely dilated.

A nurse providing care to preterm infants should understand that nasogastric and orogastric tubes are used to: A. Help maintain body temperature B. Provide oxygen and ventilation C. Replace surfactants D. Feed the infants

D Nasogastric and orogastric tubes are used in gavage feeding, providing breast milk or formula directly to an infant unable to nipple feed. To help maintain body temperature, preterm infants should be placed on warmers. Oxygen, continuous positive airway pressure (CPAP), and a ventilator are used for O2 and ventilation. Surfactants are not replaced by using nasogastric or orogastric tubes.

On day 3 of life, a newborn continues to require 100% oxygen by nasal cannula. The parents ask if they may hold their infant during his next gavage feeding. Considering that this newborn is physiologically stable, what response should the nurse provide? a. "Parents are not allowed to hold their infants who are dependent on oxygen." b. "You may only hold your baby's hand during the feeding." c. "Feedings cause more physiologic stress; therefore, the baby must be closely monitored. I don't think you should hold the baby." d. "You may hold your baby during the feeding."

D Physical contact with the infant is important to establish early bonding. The nurse as the support person and teacher is responsible for shaping the environment and making the caregiving responsive to the needs of both the parents and the infant. Allowing the parents to hold their baby is the most appropriate response by the nurse. Parental interaction by holding should be encouraged during gavage feedings; nasal cannula oxygen therapy allows for easy feedings and psychosocial interactions. The parent can swaddle the infant or provide kangaroo care while gavage feeding their infant. Both swaddling and kangaroo care during feedings provide positive interactions for the infant and help the infant associate feedings with positive interactions.

Which assessment is least likely to be associated with a breech presentation? a. Meconium-stained amniotic fluid b. Fetal heart tones heard at or above the maternal umbilicus c. Preterm labor and birth d. Postterm gestation

D Postterm gestation is not likely to occur with a breech presentation. The presence of meconium in a breech presentation may be a result of pressure on the fetal wall as it traverses the birth canal. Fetal heart tones heard at the level of the umbilical level of the mother are a typical finding in a breech presentation because the fetal back would be located in the upper abdominal area. Breech presentations often occur in preterm births.

A nurse is assessing a client at 42 weeks of gestation. Which finding, if noted by the nurse requires more assessment? A. Cervix dilated 2 cm and 50% effaced B. Score of 8 on the biophysical profile C. Fetal heart rate of 116 beats/min D. One fetal movement noted in 1 hour of assessment by the mother

D Self-care in a postterm pregnancy should include performing daily fetal kick counts three times per day. The mother should feel four fetal movements per hour. If she feels fewer than four movements, she should count for 1 more hour. Fewer than four movements in that hour warrants evaluation. The findings described in the other choices are normal at 42 weeks of gestation.

The obstetric provider has informed the nurse that she will be performing an amniotomy on the client to induce labor. What is the nurse's highest priority intervention after the amniotomy is performed? a. Applying clean linens under the woman b. Taking the client's vital signs c. Performing a vaginal examination d. Assessing the fetal heart rate (FHR)

D The FHR is assessed before and immediately after the amniotomy to detect any changes that might indicate cord compression or prolapse. Providing comfort measures, such as clean linens, for the client is important but not the priority immediately after an amniotomy. The woman's temperature should be checked every 2 hours after the rupture of membranes but not the priority immediately after an amniotomy. The woman would have had a vaginal examination during the procedure. Unless cord prolapse is suspected, another vaginal examination is not warranted. Additionally, FHR assessment provides clinical cues to a prolapsed cord.

In evaluating the effectiveness of magnesium sulfate for the treatment of preterm labor, which finding alerts the nurse to possible side effects? a. Urine output of 160 ml in 4 hours b. DTRs 2+ and no clonus c. Respiratory rate (RR) of 16 breaths per minute d. Serum magnesium level of 10 mg/dl

D The therapeutic range for magnesium sulfate management is 4 to 7.5 mg/dl. A serum magnesium level of 10 mg/dl could lead to signs and symptoms of magnesium toxicity, including oliguria and respiratory distress. Urine output of 160 ml in 4 hours, DTRs of 2+, and a RR of 16 breaths per minute are all normal findings.

During a follow-up home visit, the nurse plans to evaluate whether parents have progressed to the second stage of grieving (phase of intense grief). Which behavior would the nurse not anticipate finding? a. Guilt, particularly in the mother b. Numbness or lack of response c. Bitterness or irritability d. Fear and anxiety, especially about getting pregnant again

b. Numbness or lack of response. The second phase of grieving encompasses a wide range of intense emotions, including guilt, anger, bitterness, fear, and anxiety. What the nurse would hope not to see is numbness or unresponsiveness, which indicates that the parents are still in denial or shock.

During a prenatal examination, a woman reports having two cats at home. The nurse informs her that she should not be cleaning the litter box while she is pregnant. The client questions the nurse as to why. What is the nurse's most appropriate response? a. "Your cats could be carrying toxoplasmosis. This is a zoonotic parasite that can infect you and have severe effects on your unborn child." b. "You and your baby can be exposed to the HIV in your cats' feces." c. "It's just gross. You should make your husband clean the litter boxes." d. "Cat feces are known to carry Escherichia coli, which can cause a severe infection in you and your baby."

a. "Your cats could be carrying toxoplasmosis. This is a zoonotic parasite that can. Toxoplasmosis is a multisystem disease caused by the protozoal Toxoplasma gondii parasite, commonly found in cats, dogs, pigs, sheep, and cattle. Approximately 30% of women who contract toxoplasmosis during gestation transmit the disease to their offspring. Clinical features ascribed to toxoplasmosis include hydrocephalus or microcephaly, chorioretinitis, seizures, or cerebral calcifications. HIV is not transmitted by cats. Although cleaning the litter boxes is "just gross," this statement is not appropriate, fails to answer the client's question, and is not the nurse's best response. E. coli is found in normal human fecal flora and is not transmitted by cats.

Which substance, when abused during pregnancy, is the most significant cause of cognitive impairment and dysfunction in the infant? a. Alcohol b. Tobacco c. Marijuana d. Heroin

a. Alcohol. Alcohol abuse during pregnancy is recognized as one of the leading causes of neurodevelopmental disorders in the United States. Alcohol is a teratogen; maternal ethanol abuse during gestation can lead to identifiable fetal alcohol spectrum disorders that include alcohol-related neurodevelopmental disorders. Cigarette smoking is linked to adverse pregnancy outcomes; the risk for placenta previa, placenta abruption, and premature rupture of membranes is twice that of nonsmokers. Marijuana is the most common illicit drug used by pregnant women. Marijuana crosses the placenta, and its use during pregnancy can result in shortened gestation and a higher incidence of IUGR. Heroin crosses the placenta and often results in IUGR, stillbirth, and congenital anomalies.

A pregnant woman arrives at the birth unit in labor at term, having had no prenatal care. After birth, her infant is noted to be small for gestational age with small eyes and a thin upper lip. The infant also is microcephalic. Based on her infant's physical findings, this woman should be questioned about her use of which substance during pregnancy? a. Alcohol b. Cocaine c. Heroin d. Marijuana

a. Alcohol. The description of the infant suggests fetal alcohol syndrome, which is consistent with maternal alcohol consumption during pregnancy. Fetal brain, kidney, and urogenital system malformations have been associated with maternal cocaine ingestions. Heroin use in pregnancy frequently results in intrauterine growth restriction (IUGR). The infant may have a shrill cry and sleep-cycle disturbances and may exhibit with poor feeding, tachypnea, vomiting, diarrhea, hypothermia or hyperthermia, and sweating. Studies have found a higher incidence of meconium staining in infants born of mothers who used marijuana during pregnancy.

A 3.8-kg infant was vaginally delivered at 39 weeks after a 30-minute second stage. A nuchal cord was found at delivery. After birth, the infant is noted to have petechiae over the face and upper back. Which information regarding petechiae is most accurate and should be provided to the parents? a. Are benign if they disappear within 48 hours of birth b. Result from increased blood volume c. Should always be further investigated d. Usually occur with a forceps-assisted delivery

a. Are benign if they disappear within 48 hours of birth. Petechiae, or pinpoint hemorrhagic areas, acquired during childbirth may extend over the upper portion of the trunk and face. These lesions are benign if they disappear within 2 days of childbirth and no new lesions appear. Petechiae may result from decreased platelet formation. In this situation, the presence of petechiae is most likely a soft-tissue injury resulting from the nuchal cord at birth. Unless the lesions do not dissipate in 2 days, alarming the family is not necessary. Petechiae usually occur with a breech presentation vaginal birth.

A newborn in the neonatal intensive care unit (NICU) is dying of a massive infection. The parents speak to the neonatologist, who informs them of their son's prognosis. When the father sees his son, he says, "He looks just fine to me. I can't understand what all this is about." What is the most appropriate response or reaction by the nurse at this time? a. "Didn't the physician tell you about your son's problems?" b. "This must be a difficult time for you. Tell me how you're doing." c. Quietly stand beside the infant's father. d. "You'll have to face up to the fact that he is going to die sooner or later."

b. "This must be a difficult time for you. Tell me how you're doing." The phase of intense grief can be very difficult, especially for fathers. Parents should be encouraged to share their feelings during the initial steps in the grieving process. This father is in a phase of acute distress and is reaching out to the nurse as a source of direction in his grieving process. Shifting the focus is not in the best interest of the parent. Nursing actions may help the parents actualize the loss of their infant through a sharing and verbalization of their feelings of grief. Telling the father that his son is going to die sooner or later is dispassionate and an inappropriate statement on the part of the nurse.

13. A client gives birth to a stillborn infant. At first, she appears stunned by the news, cries a little, and then asks the nurse to call her mother. What is the proper term for the phase of bereavement that this client is experiencing? a. Anticipatory grief b. Acute distress c. Intense grief d. Reorganization

b. Acute distress. The immediate reaction to news of a perinatal loss or infant death encompasses a period of acute distress. Disbelief and denial can occur. However, parents also feel very sad and depressed. Intense outbursts of emotion and crying are normal. However, a lack of affect, euphoria, and calmness may occur and may reflect numbness, denial, or personal ways of coping with stress. Anticipatory grief applies to the grief related to a potential loss of an infant. The parent grieves in preparation of the infant's possible death, although he or she clings to the hope that the child will survive. Intense grief occurs in the first few months after the death of the infant. This phase encompasses many different emotions, including loneliness, emptiness, yearning, guilt, anger, and fear. Reorganization occurs after a long and intense search for meaning. Parents are better able to function at work and home, experience a return of self-esteem and confidence, can cope with new challenges, and have placed the loss in perspective.

Parents have asked the nurse about organ donation after that infant's death. Which information regarding organ donation is important for the nurse to understand? a. Federal law requires the medical staff to ask the parents about organ donation and then to contact their state's organ procurement organization (OPO) to handle the procedure if the parents agree. b. Organ donation can aid grieving by giving the family an opportunity to see something positive about the experience. c. Most common donation is the infant's kidneys. d. Corneas can be donated if the infant was either stillborn or alive as long as the pregnancy went full term.

b. Organ donation can aid grieving by giving the family an opportunity to see something positive about the experience. Evidence indicates that organ donation can promote healing among the surviving family members. The federal Gift of Life Act made state OPOs responsible for deciding whether to request a donation and for making that request. The most common donation is the cornea. For cornea donation, the infant must have been born alive at 36 weeks of gestation or later.

Which finding would indicate to the nurse that the grieving parents have progressed to the reorganization phase of grieving? a. The parents say that they "feel no pain." b. The parents are discussing sex and a future pregnancy c. The parents have abandoned those moments of "bittersweet grief." d. The parents' questions have progressed from "Why?" to "Why us?"

b. The parents are discussing sex and a future pregnancy. Many couples have conflicting feelings about sexuality and future pregnancies. A little painis always present, certainly beyond the first year when recovery begins to peak. Bittersweet grief describes the brief grief response that occurs with reminders of a loss, such as anniversary dates. Most couples never abandon these reminders. Recovery is ongoing. Typically, a couple's search for meaning progresses from "Why?" in the acute phase to "Why me?" in the intense phase to "What does this loss mean to my life?" in the reorganizational phase.

The nurse should be cognizant of which condition related to skeletal injuries sustained by a neonate during labor or childbirth? a. Newborn's skull is still forming and fractures easily. b. Unless a blood vessel is involved, linear skull fractures heal without special treatment. c. Clavicle fractures often need to be set with an inserted pin for stability. d. Other than the skull, the most common skeletal injuries are to leg bones.

b. Unless a blood vessel is involved, linear skull fractures heal without special treatment. Approximately 70% of neonatal skull fractures are linear. Because the newborn skull is flexible, considerable force is required to fracture it. Clavicle fractures need no special treatment. The clavicle is the bone most often fractured during birth.

A primigravida has just delivered a healthy infant girl. The nurse is about to administer erythromycin ointment in the infant's eyes when the mother asks, "What is that medicine for?" How should the nurse respond? a. "It is an eye ointment to help your baby see you better." b. "It is to protect your baby from contracting herpes from your vaginal tract." c. "Erythromycin is prophylactically given to prevent a gonorrheal infection." d. "This medicine will protect your baby's eyes from drying out over the next few days."

c. "Erythromycin is prophylactically given to prevent a gonorrheal infection." With the prophylactic use of erythromycin, the incidence of gonococcal conjunctivitis has declined to less than 0.5%. Eye prophylaxis is administered at or shortly after birth to prevent ophthalmia neonatorum. Erythromycin has no bearing on enhancing vision, is used to prevent an infection caused by gonorrhea, not herpes, and is given to prevent infection, not for lubrication.

Which options for saying "good-bye" would the nurse want to discuss with a woman who is diagnosed with having a stillborn girl? a. The nurse should not discuss any options at this time; plenty of time will be available after the baby is born. b. "Would you like a picture taken of your baby after birth?" c. "When your baby is born, would you like to see and hold her?" d. "What funeral home do you want notified after the baby is born?"

c. "When your baby is born, would you like to see and hold her?" Mothers and fathers may find it helpful to see their infant after delivery. The parents' wishes should be respected. Interventions and support from the nursing and medical staff after a prenatal loss are extremely important in the healing of the parents. The initial intervention should be directly related to the parents' wishes concerning seeing or holding their dead infant. Although information about funeral home notification may be relevant, this information is not the most appropriate option at this time. Burial arrangements can be discussed after the infant is born.

The nurse is evaluating a neonate who was delivered 3 hours ago by vacuum-assisted delivery. The infant has developed a cephalhematoma. Which statement is most applicable to the care of this neonate? a. Intracranial hemorrhage (ICH) as a result of birth trauma is more likely to occur in the preterm, low-birth-weight infant. b. Subarachnoid hemorrhage (the most common form of ICH) occurs in term infants as a result of hypoxia. c. In many infants, signs of hemorrhage in a full-term infant are absent and diagnosed only through laboratory tests. d. Spinal cord injuries almost always result from vacuum-assisted deliveries.

c. In many infants, signs of hemorrhage in a full-term infant are absent and diagnosed only through laboratory tests. Abnormalities in lumbar punctures or red blood cell counts, for instance, or in visuals on computed tomographic (CT) scans might reveal a hemorrhage. ICH as a result of birth trauma is more likely to occur in the full-term, large infant. Subarachnoid hemorrhage in term infants is a result of trauma; in preterm infants, it is a result of hypoxia. Spinal cord injuries are almost always from breech births; however, spinal cord injuries are rare today because cesarean birth is used for breech presentation.

Which statement most accurately describes complicated grief? a. Occurs when, in multiple births, one child dies and the other or others live b. Is a state during which the parents are ambivalent, as with an abortion c. Is an extremely intense grief reaction that persists for a long time. d. Is felt by the family of adolescent mothers who lose their babies

c. Is an extremely intense grief reaction that persists for a long time. Parents showing signs of complicated grief should be referred for counseling. Multiple births, in which not all of the babies survive, create a complicated parenting situation but not complicated bereavement. Abortion can generate complicated emotional responses, but these responses do not constitute complicated bereavement. Families of lost adolescent pregnancies may have to deal with complicated issues, but these issues are not complicated bereavement.

Providing care for the neonate born to a mother who abuses substances can present a challenge for the health care team. Nursing care for this infant requires a multi system approach. What is the first step in the provision of care for the infant? a. Pharmacologic treatment b. Reduction of environmental stimuli c. Neonatal abstinence syndrome (NAS) scoring d. Adequate nutrition and maintenance of fluid and electrolyte balance

c. Neonatal abstinence syndrome (NAS) scoring. NAS describes the cohort of symptoms associated with drug withdrawal in the neonate. The NAS system evaluates CNS, metabolic, vasomotor, respiratory, and gastrointestinal (GI) disturbances. This evaluation tool enables the health care team to develop an appropriate plan of care. The infant is scored throughout his or her length of stay, and the treatment plan is adjusted accordingly. Pharmacologic treatment is based on the severity of the withdrawal symptoms, which are determined by using a standard assessment tool. Medications of choice are morphine, phenobarbital, diazepam, or diluted tincture of opium. Swaddling, holding, and reducing environmental stimuli are essential in providing care to the infant who is experiencing withdrawal. These nursing interventions are appropriate for the infant who displays CNS disturbances. Poor feeding is one of the GI symptoms common to this client population. Fluid and electrolyte balance must be maintained, and adequate nutrition provided. These infants often have a poor suck reflex and may need to be fed via gavage.

Which conditions are infants of diabetic mothers (IDMs) at a higher risk for developing? a. Iron deficiency anemia b. Hyponatremia c. Respiratory distress syndrome d. Sepsis

c. Respiratory distress syndrome. IDMs are at risk for macrosomia, birth trauma, perinatal asphyxia, respiratory distress syndrome, hypoglycemia, hypocalcemia, hypomagnesemia, cardiomyopathy, hyperbilirubinemia, and polycythemia. IDMs are not at risk for anemia, hyponatremia, or sepsis.

For an infant experiencing symptoms of drug withdrawal, which intervention should be included in the plan of care? a. Administering chloral hydrate for sedation b. Feeding every 4 to 6 hours to allow extra rest between feedings c. Snugly swaddling the infant and tightly holding the baby d. Playing soft music during feeding

c. Snugly swaddling the infant and tightly holding the baby. The infant should be snugly wrapped to reduce self-stimulation behaviors and to protect the skin from abrasions. Phenobarbital or diazepam may be administered to decrease central nervous system (CNS) irritability. The infant should be fed in small, frequent amounts and burped well to diminish aspiration and maintain hydration. The infant should not be stimulated (such as with music), because stimulation will increase activity and potentially increase CNS irritability.

During the initial acute distress phase of grieving, parents still must make unexpected and unwanted decisions about funeral arrangements and even naming the baby. What is the nurse's role at this time? a. To take over as much as possible to relieve the pressure b. To encourage the grandparents to take over c. To ensure that the parents, themselves, approve the final decisions d. To leave them alone to work things out

c. To ensure that the parents, themselves, approve the final decisions. The nurse is always the client's advocate. Nurses can offer support and guidance and yet leave room for the same from grandparents. In the end, however, nurses should let the parents make the final decisions. For the nurse to be able to present options regarding burial and autopsy, among other issues, in a sensitive and respectful manner is essential. The nurse should assist the parents in any way possible; however, taking over all arrangements is not the nurse's role. Grandparents are often called on to help make the difficult decisions regarding funeral arrangements or the disposition of the body because they have more life experiences with taking care of these painful yet required arrangements. Some well-meaning relatives may try to take over all decision-making responsibilities. The nurse must remember that the parents, themselves, should approve all of the final decisions. During this time of acute distress, the nurse should be present to provide quiet support, answer questions, obtain information, and act as a client advocate.

After giving birth to a stillborn infant, the woman turns to the nurse and says, "I just finished painting the baby's room. Do you think that caused my baby to die?" What is the nurse's most appropriate response? a. "That's an old wives' tale; lots of women are around paint during pregnancy, and this doesn't happen to them." b. "That's not likely. Paint is associated with elevated pediatric lead levels." c. Silence. d. "I can understand your need to find an answer to what caused this. What else are you thinking about?"

d. "I can understand your need to find an answer to what caused this. What else are you thinking about?" The statement "I can understand your need to find an answer to what caused this. What else are you thinking about?" is very appropriate for the nurse. It demonstrates caring and compassion and allows the mother to vent her thoughts and feelings, which is therapeutic in the process of grieving. The nurse should resist the temptation to give advice or to use clichés in offering support to the bereaved. In addition, trying to give bereaved parents answers when no clear answers exist or trying to squelch their guilt feeling does not help the process of grieving. Silence would probably increase the mother's feelings of guilt. One of the most important goals of the nurse is to validate the experience and feelings of the parents by encouraging them to tell their stories and then listening with care. The nurse should encourage the mother to express her thoughts.

Which statement is the most appropriate for the nurse to make when caring for bereaved parents? a. "This happened for the best." b. "You have an angel in heaven." c. "I know how you feel." d. "What can I do for you?"

d. "What can I do for you?" Acknowledging the loss and being open to listening is the best action that the nurse can do. No bereaved parent would find the statement "This has happened for the best" to be comforting in any way, and it may sound judgmental. Nurses must resist the impulse to speak about the afterlife to people in pain. They should also resist the temptation to give advice or to use clichés. Unless the nurse has lost a child, he or she does not understand how the parents feel.

A macrosomic infant is born after a difficult forceps-assisted delivery. After stabilization, the infant is weighed, and the birth weight is 4550 g (9 lb, 6 oz). What is the nurse's first priority? a. Leave the infant in the room with the mother. b. Immediately take the infant to the nursery. c. Perform a gestational age assessment to determine whether the infant is large for gestational age. d. Frequently monitor blood glucose levels, and closely observe the infant for signs of hypoglycemia.

d. Frequently monitor blood glucose levels, and closely observe the infant for signs of hypoglycemia. Regardless of gestational age, this infant is macrosomic (defined as fetal weight more than 4000 g) and is at high risk for hypoglycemia, which affects many macrosomic infants. Blood glucose levels should be frequently monitored, and the infant should be closely observed for signs of hypoglycemia. Close observation can be achieved in the mother's room with nursing interventions. However, depending on the condition of the infant, observation may be more appropriate in the nursery.

A nurse caring for a family during a loss might notice that a family member is experiencing survivor guilt. Which family member is most likely to exhibit this guilt? a. Siblings b. Mother c. Father d. Grandparents

d. Grandparents. Survivor guilt is sometimes felt by grandparents because they feel that the death is out of order; they are still alive, while their grandchild has died. They may express anger that theyare alive and their grandchild is not. The siblings of the expired infant may also experience a profound loss. A young child will respond to the reactions of the parents and may act out. Older children have a more complete understanding of the loss. School-age children are likely to be frightened, whereas teenagers are at a loss on how to react. The mother of the infant is experiencing intense grief at this time. She may be dealing with questions such as, "Why me?" or "Why my baby?" and is unlikely to be experiencing survival guilt. Realizing that fathers can be experiencing deep pain beneath their calm and quiet appearance and may need help acknowledging these feelings is important. This need, however, is not the same as survivor guilt.

What bacterial infection is decreasing because of effective drug treatment? a. Escherichia coli infection b. Tuberculosis c. Candidiasis d. Group B streptococci (GBS) infection

d. Group B streptococci (GBS) infection. Penicillin has significantly decreased the incidence of GBS infection. E. coli may be increasing, perhaps because of the increasing use of ampicillin (resulting in a more virulent E. coli resistant to the drug). Tuberculosis is increasing in the United States and in Canada. Candidiasis is a fairly benign fungal infection.

A pregnant woman at 37 weeks of gestation has had ruptured membranes for 26 hours. A cesarean section is performed for failure to progress. The fetal heart rate (FHR) before birth is 180 beats per minute with limited variability. At birth the newborn has Apgar scores of 6 and 7 at 1 and 5 minutes and is noted to be pale and tachypneic. Based on the maternal history, what is the most likely cause of this newborn's distress? a. Hypoglycemia b. Phrenic nerve injury c. Respiratory distress syndrome d. Sepsis

d. Sepsis The prolonged rupture of membranes and the tachypnea (before and after birth) suggest sepsis. A differential diagnosis can be difficult because signs of sepsis are similar to noninfectious problems such as anemia and hypoglycemia. Phrenic nerve injury is usually the result of traction on the neck and arm during childbirth and is not applicable to this situation. The earliest signs of sepsis are characterized by lack of specificity (e.g., lethargy, poor feeding, irritability), not respiratory distress syndrome.

Parents are often asked if they would like to have an autopsy performed on their infant. Nurses who are assisting parents with this decision should be aware of which information? a. Autopsies are usually covered by insurance. b. Autopsies must be performed within a few hours after the infant's death. c. In the current litigious society, more autopsies are performed than in the past. d. Some religions prohibit autopsy.

d. Some religions prohibit autopsy. Some religions prohibit autopsies or limit the choice to the times when it may help prevent further loss. The cost of the autopsy must be considered; it is not covered by insurance and can be very expensive. There is no rush to perform an autopsy unless evidence of a contagious disease or maternal infection is present at the time of death. The rate of autopsies is declining, in part because of a fear by medical facilities that errors by the staff might be revealed, resulting in litigation.

Human immunodeficiency virus (HIV) may be transmitted perinatally or during the postpartum period. Which statement regarding the method of transmission is most accurate? a. Only in the third trimester from the maternal circulation b. From the use of unsterile instruments c. Only through the ingestion of amniotic fluid d. Through the ingestion of breast milk from an infected mother

d. Through the ingestion of breast milk from an infected mother. Postnatal transmission of the HIV through breastfeeding and breast milk may occur. Transmission of the HIV from the mother to the fetus may occur through the placenta at various gestational ages. Transmission of the HIV from the use of unsterile instruments is highly unlikely; most health care facilities must meet sterility standards for all instrumentation.

A family is visiting two surviving triplets. The third triplet died 2 days ago. What action indicates that the family has begun to grieve for the dead infant? a. Refers to the two live infants as twins b. Asks about the dead triplet's current status c. Brings in play clothes for all three infants d. Refers to the dead infant in the past tense

d. refers to the dead infant in the past tense. Accepting that the infant is dead (in the past tense of the word) demonstrates an acceptance of the reality and that the family has begun to grieve. Parents of multiples are challenged with the task of parenting and grieving at the same time. Referring to the two live infants as twins does not acknowledge an acceptance of the existence of their third child. Bringing in play clothes for all three infants indicates that the parents are still in denial regarding the death of the third triplet. The death of the third infant has imposed a confusing and ambivalent induction into parenthood for this couple. If the two live infants are referred to as twins and/or if play clothes for all three infants are still considered, then the family is clearly still in denial regarding the death of one of the triplets.