Maternal Infant Exam 4 Practice Questions
The nurse notes that a client's uterus, which was firm after the fundal massage, has become boggy again. Which intervention would the nurse do next?
Check for bladder distention, while encouraging the client to void.
Which feeding position should the nurse recommend for a woman who has just had a cesarean?
Football hold
A newborn's cord begins to bleed 1 day following birth. What measures would the nurse take to address this problem?
Inspect the clamp to insure that it is tightly closed and applied correctly.
Which of the following is an advantage of breastfeeding that directly benefits the mother?
It aids in uterine involution.
The nurse is assisting with the admission of a newborn to the nursery. The nurse notes what appears to be bruising on the left upper outer thigh of this dark-skinned newborn. Which documentation should the nurse provide?
Mongolian spot noted on left upper outer thigh.
The nurse is conducting a prenatal class for a group of pregnant women and their partners. When illustrating the various potential complications that can necessitate a cesarean delivery, which primary reason should the nurse point out?
Nonreassuring fetal status
Eight hours after a cesarean section, a postpartum woman is having heavy lochia. She informs the nurse, who suspects which of the following causes?
Postpartum hemorrhage
According to Brazelton's Neonatal Behavioral Assessment Scale, a newborn would be in what state if the eyes are open and looking at people nearby, and the newborn has minimal activity or body movement?
Quiet alert
Which assessment finding is identified as a sign of increased intracranial pressure in an infant?
Seizures
The nurse is caring for a postpartum woman who is diagnosed with endometritis. Which position should the nurse encourage the client to maintain?
Semi-Fowler
The client has been progressing well through the labor process and the health care provider prepares to deliver the infant and performs an episiotomy. The nurse predicts which situation is the reason for this procedure?
Shoulder dystocia
A preterm newborn has just received synthetic surfactant through an endotracheal tube by a syringe. Which intervention should the nurse implement at this point?
Tip the infant into an upright position.
A pregnant woman at term is in the obstetrics unit for induction in the morning. Her membranes rupture, and the external fetal monitor shows deep variable decelerations. For what should the nurse immediately check the patient?
Umbilical cord prolapse
The parents of a preterm newborn being cared for in the neonatal intensive care unit (NICU) are coming to visit for the first time. The newborn is receiving mechanical ventilation, intravenous fluids and medications and is being monitored electronically by various devices. Which action by the nurse would be most appropriate?
Encourage the parents to touch their preterm newborn.
A neonate has an injury to the brachial plexus. Which of the following conditions is a result of a brachial plexus injury?
Erb palsy
A nurse is caring for a client who requires a cesarean birth because of labor dystocia. The woman's husband signs the consent form. Which of the following individuals is responsible for obtaining the informed consent prior to a cesarean section?
Physician.
The nurse has received the beginning-of-shift report for five clients. With which conditions will the nurse anticipate a cesarean delivery?
Placenta previa Active vaginal or cervical herpes lesions A classical uterine scar
In twin-to-twin transfusion syndrome, the arterial circulation of one twin is in communication with the venous circulation of the other twin. One fetus is considered the donor twin, and one becomes the recipient twin. Observation of the recipient twin would most likely show which condition?
Polycythemia
The nurse would prepare a client for amnioinfusion when which action occurs?
Severe variable decelerations occur and are due to cord compression.
Which recommendation should be given to a client with mastitis who is concerned about breastfeeding her neonate?
She should continue to breastfeed; mastitis will not infect the neonate.
A woman in labor is having very intense contractions with a resting uterine tone >20 mm Hg. The woman is screaming out every time she has a contraction. What is the highest priority fetal assessment the health care provider should focus on at this time?
Look for late decelerations on monitor, which is associated with fetal anoxia.
A 16-year-old client has been in the active phase of labor for 14 hours. An ultrasound reveals that the likely cause of delay in dilation (dilatation) is cephalopelvic disproportion. Which intervention should the nurse most expect in this case?
cesarean birth
A primigravida whose labor was initially progressing normally is now experiencing a decrease in the frequency and intensity of her contractions. The nurse would assess the woman for which condition?
fetopelvic disproportion
What is a consequence of hypothermia in a newborn?
holds breath 25 seconds
When reviewing the medical record of a newborn who is large-for-gestational-age (LGA), which factor would the nurse identify as having increased the newborn's risk of being LGA?
maternal pregravid obesity
A nurse is caring for a client who is nursing her baby boy. The client reports afterpains. Secretion of which substance would the nurse identify as the cause of afterpains?
oxytocin
A student nurse asks the preceptor how breastfeeding protects the infant from getting ill due to viruses and bacteria. Which physiologic concept will the nurse discuss with this student?
properties of immunoglobulin A (IgA)
It is discovered that a new mother has developed a postpartum infection. What is the most likely expected outcome that the nurse will identify for this client related to this condition?
Client's temperature remains below 100.4°F (38.8°C) orally.
How many calories does an ounce of breast milk contain on average?
20
A client has given birth to a small-for-gestation-age (SGA) newborn. Which finding would the nurse expect to assess?
head larger than body
The nurse is caring for a client in the transition stage of labor. In which scenario would the nurse predict the use of forceps may be used to assist with the birth?
Abnormal position of the fetal head
A nurse is providing care to a large for gestational age newborn. The newborn's blood glucose level was 32 mg/dL one hour ago. Breast-feeding was initiated. The nurse checks the newborn's blood glucose level and finds it to be 23 mg/dL. Which action would the nurse do next?
Administer intravenous glucose.
A multipara woman is fully dilated and effaced and has been pushing for over 2 hours. The student nurse observing asks the nurse, "What is causing this to last so long?" Which response by the nurse would be the most accurate?
"The fetal head is in an abnormal position."
A nurse is providing care to a postpartum woman and is completing the assessment. Which finding would indicate to the nurse that a postpartum woman is experiencing bladder distention?
Percussion reveals dullness.
Following delivery, a newborn has a large amount of mucus coming out of his mouth and nose. What would be the nurse's first action?
Using a bulb syringe, suction the mouth then the nose.
Neonatal screening is done before the infant leaves the hospital. Blood is drawn through a heel stick and tested for several disorders that can cause lifelong disabilities. When is the ideal time to collect this specimen?
24 hours after the newborn's first protein feeding
A patient in labor has just been told that she must have an emergency cesarean delivery. The nurse is aware that the surgery is likely to be completed within what time frame? (Fill in the blank with a number of minutes.)
30
A newborn is receiving bag and mask ventilation and cardiac compression. The resuscitation is paused, and the nurse reassesses the infant. The infant's heart rate is 70 bpm with irregular gasping respirations. What is the appropriate action in this situation?
Continue bag and mask ventilation only.
The nurse takes a newborn into the mother's room for feeding following a cesarean delivery. The nurse notes that the mother has large breasts when assisting her to feed the newborn. Which position would the nurse recommend to this mother?
Football hold
In an infant who has hypothermia, what would be an appropriate nursing diagnosis?
Impaired tissue perfusion
A 26-year-old primigravida has brought her doula to the birthing center for support during her labor and birth. The doula has been helping her through the past 16 hours of labor. The laboring woman is now 6 cm dilated. She continues to report severe pain in her back with each contraction. The client finds it comforting when her doula uses the ball of her hand to put counterpressure on her lower back. What is the likely cause of the woman's back pain?
Occiput posterior position
The nurse is conducting a prenatal class on breastfeeding. The nurse determines the class is successful when the young parents correctly choose which time frame is recommended for breastfeeding the infant?
One year
A client with a perineal hematoma undergoes an incision and drainage. Which of the following would be most appropriate after this procedure?
Pack the area to promote hemostasis and drainage
When preparing to resuscitate a preterm newborn, the nurse would perform which action first?
Place the newborn's head in a neutral position.
The nurse is preparing a client for an emergent cesarean delivery. Which action should the nurse prioritize?
Sign informed consent.
What is a typical feature of a small-for-gestational-age (SGA) newborn that differentiates it from a preterm baby with a low-birth-weight?
ability to tolerate early oral feeding
A nurse assesses a client in labor and suspects dysfunctional labor (hypotonic uterine dysfunction). The woman's membranes have ruptured and fetopelvic disproportion is ruled out. Which intervention would the nurse expect to include in the plan of care for this client?
administering oxytocin
A primipara client gave birth vaginally to a healthy newborn girl 12 hours ago. The nurse palpates the client's fundus. Which finding would the nurse identify as expected?
at the level of the umbilicus
Which condition may cause intrauterine asphyxia?
cord compression placental abruption (abruptio placentae) intrauterine growth restriction (IUGR)
How should the nurse counsel a patient who has arrived for a scheduled repeat cesarean delivery?
"An IV catheter will be placed, and we will do some preoperative blood work. Then we will give you some antibiotics."
A client who recently gave birth to her third child expresses a desire to have her older two children come to the hospital for a visit. What should the nurse say in response to this request?
"As long as they are well, absolutely. Why don't we give you a dose of pain medication beforehand so that you will enjoy the visit?"
During a postpartum parenting class, a client reports that she has switched her 6 month old from formula to cow's milk to save money. Which of the following responses from the nurse would be most appropriate?
"Cow's milk should not be used with infants younger than 9 months."
The nurse asks a new mother how she is planning on feeding her newborn. The mother responds that she is planning on formula feeding her baby. Which of the following is the best response for the nurse to give the mother?
"Have you considered breastfeeding? There are some real benefits that it can offer you and your baby."
The primipara tells the nurse, "My baby jumps every time I pick her up. Is she afraid that I will drop her?" Which response by the nurse would be best?
"No, it is the Moro reflex. This reflex simulates the action of warding off an attacker."
A nursing mother calls the nurse and is upset. She states that her newborn son just bit her when he was nursing. Upon examining the newborn's mouth, two precocious teeth are noted on the lower central portion of the gums. What would be the nurse's best response?
"Precocious teeth can occur at birth but we may need to remove them to prevent aspiration."
The nurse is assessing a male neonate in the presence of the parents and notes that the neonate has hypospadias. How should the nurse respond when questioned by the parents as to what this means?
"The opening of his urethra in located on the under surface of the tip of the penis."
A young couple are discussing how long the mother should breast-feed and cannot agree on a time frame. What is the best response from the nurse when they question the nurse about it?
"The recommendation is to use only breast milk for the first 6 months, then add other foods until 12 months."
A nurse is inserting a urinary catheter into a woman about to undergo a cesarean birth. The patient asks why this is necessary. How would the nurse accurately respond?
"This measure will help keep your bladder away from the site of surgery."
A woman gives birth to a newborn at 36 weeks' gestation. She tells the nurse, "I'm so glad that my baby isn't premature." Which response by the nurse would be most appropriate?
"We still need to monitor him closely for problems."
The nurse is assigned to care for a postpartum client with a deep vein thrombosis (DVT) who is prescribed anticoagulation therapy. Which statement will the nurse include when providing education to this client?
"You need to avoid medications which contain acetylsalicylic acid."
The nurse is reviewing discharge instructions with a young couple. The nurse determines they understand how to properly use prepared formula and will discard any leftover refrigerated formula after which time frame?
24 hours
How long is the neonatal period for a newborn?
28 days
The nurse has completed assessing the blood glucose levels of several infants who are 24 hours old. Which result should the nurse prioritize for intervention?
30 mg/dl (1.67 mmol/L)
What is the expected range for respirations in a newborn?
30 to 60 breaths per minute
The nurse is conducting a newborn assessment and notes the head circumference is 35 cm. What is the largest measurement that the nurse will predict for the chest circumference in this infant?
32
A woman is to undergo labor induction. The nurse determines that the woman requires cervical ripening if her Bishop score is:
5.
A newborn is born and, at 1 minute of life, is acrocyanotic, HR is 110, is floppy with some flexion, has a weak cry and grimaces. What Apgar score would the nurse assign this infant?
6
During a childbirth class, the nurse talks to the parents about how to prevent infant abductions in the hospital by recognizing the profile of an abductor. Which person best fits the profile of a typical infant abductor?
A female in her mid-20s who appears pregnant
A nurse places a newborn under a radiant heat warmer. At which location should the temperature probe be placed?
Abdomen, between the umbilicus and the xiphoid process
A newborn with high serum bilirubin is receiving phototherapy. Which is the most appropriate nursing intervention for this client?
Application of eye dressings to the infant
Which action(s) will the nurse take when asked to apply suprapubic pressure during a birth with shoulder dystocia?
Apply downward pressure just above the pubic bone. Apply pressure between contractions. Apply pressure at an angle toward the face of the fetus.
The nurse discharging a newly delivered mother and her newborn infant needs to assess the mother's knowledge about how to take care of herself and her baby. This is her second child. Which approach would be best to verify the client's understanding of these topics?
Ask her questions and observe her caring for the baby.
The nurse identifies a nursing diagnosis of Risk for injury related to possible effects of oxytocin therapy. Which action would the nurse perform to ensure a positive outcome for the client?
Assess contractions by using external monitor.
A client's membranes have just ruptured. Her fetus is presenting breech. Which action should the nurse do immediately to rule out prolapse of the umbilical cord in this client?
Assess fetal heart sounds.
A woman has just entered the recovery room after cesarean birth of a baby weighing 9 lb 14 oz. After connecting the client to the blood pressure monitor, it is noted her HR is 120 and BP is 80/40. What nursing action should be a priority?
Assess for bleeding
A newborn's condition is not improving after intubation. What assessment by the nurse would identify a possible problem?
Auscultate breath sounds.
The nurse is caring for an infant. Which nursing action will facilitate psychosocial growth of the infant?
Be consistently attentive to the infant's basic needs.
A nurse is caring for an infant with an elevated bilirubin level who is under phototherapy. What evaluation data would best indicate that the newborn's jaundice is improving?
Bilirubin level went from 15 to 11.
The nurse is monitoring the woman who is 1 hour postpartum and notes on assessment the uterine fundus is boggy, to the right, and approximately 2 cm above the umbilicus. The nurse would conclude this is most likely related to which potential complication?
Bladder distention
The nurse is performing an assessment on a 2-day postpartum client and discovers a boggy fundus at the umbilicus and slightly to the right. The nurse determines that this is most likely related to which situation?
Bladder distention
The neonate's respirations are gasping and irregular with a rate of 24 bpm. Which circulatory alteration will the nurse assess for in this infant?
Blood flows from the aorta to the pulmonary artery.
The nurse is caring for a postpartum woman who exhibits a large amount of bleeding. Which areas would the nurse need to assess before the woman ambulates?
Blood pressure, pulse, reports of dizziness
A client who is 3 days postpartum calls the office and complains of excessive night sweats. Which explanation should the nurse provide for the client?
Body secreting the excess fluids from pregnancy
A shoulder dystocia situation is called in room 4. The nurse enters the room to help and the health care provider says to the nurse, "McRoberts maneuver." What does the nurse do next?
Bring the client's knees back toward the shoulders, causing hyperflexion of the hips and rotation of the pubic symphysis
A 21-year-old has been in labor for 4 hours; her examination 2 hours ago revealed 6 cm/100%/-3. During a contraction, she spontaneously ruptures her membranes. The doctor checks the patient, finds her to be 9 cm/100%/-3, and states that the cord is palpable. What should the nurse do?
Call for help and prepare the patient for an emergency cesarean delivery.
The nurse notices that there is no vitamin K administration recorded on a newborn's medical record upon arrival to the newborn nursery. What would be the nurse's first action?
Call the Labor and Delivery nurse who cared for the newborn to inquire about why the medication was not documented.
A nurse is called into the room of one of the clients where the grandparents are visiting. The grandmother is visibly upset, and says "Just look at my grandson! His head is all soft and swollen here and it shouldn't be. The doctor injured him when he was born." The nurse assesses the newborn and finds an area of swelling about the size of a half-dollar at the center of the upper scalp. The nurse determines this finding is most likely which condition?
Caput succedaneum
A 30-minute-old newborn starts crying in a high-pitched manner and cannot be consoled by the mother. Which action should the nurse prioritize if jitteriness is also noted and the infant is unable to breastfeed?
Check blood glucose.
A patient is 3 hours post-cesarean delivery. The nurse notes the Foley catheter bag has 30 mL of urine and it has been 2 hours since it was last checked. What is the appropriate nursing intervention?
Check the Foley tubing
The nurse is teaching a prenatal class illustrating the steps that are used to keep families safe. The nurse determines the session is successful when the parents correctly choose which precaution to follow after the birth of their infant?
Check the identification badge of any health care worker before releasing baby from room.
What is priority for the nurse to do when transporting a newborn back to the mother after completing the hearing test?
Compare the identification bracelets prior to leaving the newborn with the mother.
The nurse is weighing an infant and is ensuring that the scale is warmed and the procedure is performed as quickly as possible. Doing so allows the nurse to minimize the effects of heat loss by what method?
Conduction
One of the primary assessments a nurse makes every day is for postpartum hemorrhage. What does the nurse assess the fundus for?
Consistency, shape, and location
The nurse is preparing a care plan for a new mother who desires to breast-feed. Which action should the nurse prioritize if the mother has a history of breast implants?
Consult a lactation specialist for assistance.
The new mother is surprised to learn that oxytocin is helping her breast-feed her baby, especially after her health care provider used oxytocin to induce her labor. Which additional function of oxytocin should the nurse point out to the mother?
Contracts breast cells to move the milk out of ducts
The nurse walks into a client's room and notes a small fan blowing on the mother as she holds her infant. The nurse should explain this can result in the infant losing body heat based on which mechanism?
Convection
A client is undergoing an amniotomy during labor. Which of the following complications associated with this intervention should the nurse be most prepared to address?
Cord prolapse
All of the following are maternal benefits of breastfeeding except: -Decreased incidence of breast and ovarian cancer -Decreased risk of adult-onset asthma -Uterine involution -Weight loss
Decreased risk of adult-onset asthma
The nurse notices while holding him upright that a 1-day-old newborn has a significantly indented anterior fontanelle. She immediately brings it to the attention of the physician. What does this finding most likely indicate?
Dehydration
A 33-week-gestation infant has just been born. The child's heartbeat is not audible. What is the priority nursing intervention?
Depression of the sternum with both thumbs 1 to 2 cm at a rate of 100 times per minute
The nurse is monitoring a woman who is receiving IV oxytocin to assist with uterine irritability. Which action should the nurse prioritize if the woman's contractions are determined to be 80 seconds in length after 1 hour of administration of the oxytocin?
Discontinue the oxytocin infusion.
A laboring woman is receiving oxytocin IV to augment her labor and 2 hours later begins having contractions every 2 minutes lasting 60 to 90 seconds each with little, if any, rest time in between the contractions. At this time, which interventions would be the priority for the nurse caring for this client?
Discontinue the oxytocin infusion. Administer an IV bolus of fluids. Apply oxygen to the woman via mask at 8 to 10 L/min.
A postpartum woman is developing thrombophlebitis in her right leg. Which assessment should the nurse no longer use to assess for thrombophlebitis?
Dorsiflex her right foot and ask if she has pain in her calf.
The nurse in the NICU is caring for preterm newborns. Which guidelines are recommended for care of these newborns? Select all that apply.
Dress the newborn in ways to preserve warmth. Take the newborn's temperature often. Supply oxygen for the newborn, if necessary.
The nurse is preparing discharge instructions for a new mother who has been learning to breast-feed. Which response should the nurse prioritize when the mother questions her ability to produce enough milk for her infant?
Drink a lot of fluids.
What is the correct sequence of events in a neonatal resuscitation?
Dry the infant, establish an airway, expand the lungs, and initiate ventilation.
Which action would be priority for the nurse to complete immediately after the delivery of a 40-week gestation newborn?
Dry the newborn and place it skin-to-skin on mother.
The nurse is leading a group discussion of new mothers about breast-feeding. Which instruction should the nurse prioritize as the best method to increase their milk supply?
Empty the breast as completely as possible.
An LGA newborn has a blood glucose level of 30 mg/dL and is exhibiting symptoms of hypoglycemia. Which action would the nurse do next?
Encourage frequent feedings
The newborn has been placed in skin-to-skin contact with his mother. A blanket covers all of his body except his head. His hair is still wet with amniotic fluid, etc. What is the most likely type of heat loss this baby may experience?
Evaporative
The nurse assesses that a fetus is in an occiput posterior position. The nurse predicts the client will experience which situation related to this assessment?
Experience of additional back pain
A nurse is caring for a breastfeeding client who reports engorgement. The nurse identifies that the client's condition is due to not fully emptying her breasts at each feeding. Which suggestion should the nurse make to help her prevent engorgement?
Feed the baby at least every two or three hours.
Which of the following instructions should a nurse give to a client whose infant has galactosemia?
Feed the infant a lactose-free formula
What condition that would be a contraindication for the infant to continue breast-feeding?
Galactosemia
A nurse is performing an assessment on a female client who gave birth 24 hours ago. On assessment, the nurse finds that the fundus is 2 cm above the umbilicus and boggy. Which intervention is a priority?
Have the client void, and then massage the fundus until it is firm.
The nurse is caring for a newborn with a mother who has a positive hepatitis B surface antigen (HBsAg) test. Which of the following can the nurse expect the newborn to receive? Select all that apply. Hepatitis B vaccination Hepatitis A vaccination Intravenous immune globulin G Hepatitis B immune globulin
Hepatitis B vaccination Hepatitis B immune globulin
A breast-fed infant has been diagnosed with non-physiologic jaundice. Which of the following would the nurse most likely attribute this to?
Inadequate intake of breast milk
A woman who gave birth 10 hours ago is ambulating to the bathroom and calls for assistance with perineal care. When the nurse touches her skin, the nurse notices that she is excessively warm. After reinforcing the woman's self-care, the nurse encourages increased oral intake. Why was this the appropriate instruction to give to this client?
Increased intake will rehydrate the client and decrease her skin temperature.
A nurse correctly recognizes which of the following as a current trend within the population of birthing women?
Increased rates of cesarean sections.
The nurse is preparing the nursing care plan for a newborn who was born via a cesarean delivery. Which diagnosis should the nurse prioritize?
Ineffective airway clearance related to mucus and secretions
Which is true regarding mineral requirements in the newborn? -Infants who are breastfed need supplemental iron. -Tetany from inadequate calcium intake is likely to occur in a breastfed infant, not in a formula-fed infant. -Mothers who are breastfeeding should drink spring water only. -Infants who are formula-fed should drink an iron-enriched formula for at least 12 months.
Infants who are formula-fed should drink an iron-enriched formula for at least 12 months.
The nursing instructor is conducting a class presenting the various aspects of a cesarean delivery. The instructor determines the class is successful after the students correctly choose which complication as the most common postoperative complication?
Infection
A newborn infant at 36 hours of age is jaundiced. The mother is breast-feeding. What intervention is appropriate to increase the excretion of bilirubin?
Instruct the mom to feed every two to three hours.
A client with a high-risk pregnancy has recently begun labor. Which procedure will help the nurse assess contraction strength in the client?
Internal electronic monitoring
The nursing instructor is leading a discussion on the physical changes to a woman's body after the birth of the baby. The instructor determines the session is successful after the students correctly point out which process results in the return of nonpregnant size and function of the female organs?
Involution
A nurse does an initial assessment on a newborn and notes a pulsation over the anterior fontanel (fontanelle) that corresponds with the newborn's heart rate. How would the nurse interpret this finding?
It is normal to feel pulsations that correlate with the newborn's heart rate over the anterior fontanel.
When using the LATCH assessment tool, the nurse will evaluate breastfeeding using which factors?
Latch, audible swallowing, type of nipple, nipple comfort, and hold/positioning
The nurse is screening a woman during a home visit following birth. The nurse identifies which risk factors for developing postpartum depression?
Low self-esteem Feeling overwhelmed and out of control Low socioeconomic status Lack of social support
At the birth of a high-risk newborn, what is the nurse's priority action to prevent cerebral hypoxia?
Maintain adequate respirations.
A woman presents to the clinic at 1-month postpartum and reports her left breast has a painful, reddened area. On assessment, the nurse discovers a localized red and warm area. The nurse predicts the client has developed which disorder?
Mastitis
While caring for a new mother on her second day postpartum, the nurse notes the new mother handles her newborn tentatively, not kissing her child but appears afraid to interact with her baby. Which situation would the nurse suspect as the probable reason for this?
Normal reaction to accepting a new child.
The nurse is assessing a 3-day-old infant. The infant's sclerae have a yellow tinge as does the infant's forehead and nose. What would the nurse do next?
Obtain a transcutaneous bilirubin level.
The pregnant client and her partner have arrived for a scheduled cesarean delivery. Which action should the nurse prioritize?
Obtain laboratory specimens.
The nurse is monitoring several postpartum women for potential complications related to the birthing process. Which assessment should a nurse prioritize on an hourly basis?
Pad count
Which manifestation would alert the nurse to suspect that a postpartum client has septic pelvic thrombophlebitis (SPT)?
Pain in lower abdomen
The fetus of a woman in labor is determined to be in a persistent occiput posterior position. Which intervention would the nurse prioritize?
Pain relief measures
The nurse is caring for a woman undergoing cervical dilation. Which assessment finding would alert the nurse to the complication of vasa previa?
Painless bleeding at the beginning of cervical dilation
A client in labor has just learned that she will have to undergo a cesarean birth due to failure to progress. The woman looks frightened and stressed. Which of the following is a physiological stress response that the nurse would expect to see in such a patient?
Peripheral vasoconstriction
A 3-hour old newborn is assessed and is tachypneic with a respiratory rate of 44. Heart rate is 168, temperature is 97.3°F (36.3°C) and blood glucose is 90. What is the first action the nurse should take?
Place the newborn away from drafts and under a blanket.
The nurse cared for a client who gave birth. The duration of labor from the onset of contractions until the birth of the baby was 2 hours. How will the nurse document the client's labor in the health record?
Precipitous labor
Nurses know that which factor most influences whether women decide to initiate breastfeeding?
Prenatal education.
The nurse is monitoring a client in labor who has had a previous cesarean section and is trying a vaginal birth with an epidural. The nurse observes a sudden drop in blood pressure, increased heart rate, and deep variable deceleration on the fetal monitor. The client reports severe pain in her abdomen and shoulder. What should the nurse prepare to do?
Prepare the client for a cesarean birth.
The nurse is caring for a client who has developed a paralytic ileus following a cesarean birth. Which element of the procedure results in this condition?
Pressure on the intestine
Which considerations are addressed in the plan of care for a mother healing from a cesarean section?
Problems with self-image Interference with organ function Circulatory complications Stress responses
A nurse is caring for a pregnant client who inquires about the benefits of breast feeding. The nurse explains that secretory immunoglobulin A found in breast milk helps the infant by:
Protecting the gastrointestinal tract from foreign proteins
A nurse assisting in a birth notices that the amniotic fluid is stained greenish black as the neonate is being born. Which intervention should the nurse implement as a result of this finding?
Provide supplemental oxygen and monitor respiratory status
A nurse is explaining to a group of new parents about the changes that occur in the neonate to sustain extrauterine life, describing the cardiac and respiratory systems as undergoing the most changes. Which information would the nurse integrate into the explanation to support this description?
Pulmonary vascular resistance (PVR) is decreased as lungs begin to function.
An 18-year-old client has given birth at 28 weeks' gestation and her newborn is showing signs of respiratory distress syndrome (RDS). Which statement is true for a newborn with RDS?
RDS is caused by a lack of alveolar surfactant.
A nurse is caring for a client with peritonitis. Which nursing intervention is a priority?
Regulate client's body temperature
The nurse is assessing a neonate after a cesarean delivery. Which most common complication should the nurse be prepared for?
Respiratory distress
When providing discharge instructions to a client who has had a cesarean birth, which of the following points should the nurse include in the discharge plan?
Restrictions about lifting
Which action will the nurse avoid when performing basic care for a newborn male?
Retracting the foreskin over the glans to assess for secretions
The nurse will assess the newborn for which potential cause of excess sleepiness?
Review bilirubin level for elevation. Check glucose level for possible hypoglycemia.
A nurse assisting in a cesarean birth should essentially demonstrate understanding of which of the following?
Skill in either a scrubbing or circulating role
A nurse is caring for a client in labor who has been diagnosed with placental problems. Which of the following is indicative of placenta succenturiata?
Small accessory lobes develop in the membranes at a distance from the main placenta.
The nurse is teaching a client with newly diagnosed mastitis about her condition. The nurse would inform the client that she most likely contracted the disorder from which organism?
Staphylococcus aureus
A nurse is caring for a preterm newborn who has developed rapid, irregular respirations with periods of apnea. Which additional assessment finding should the nurse identify as an indication of respiratory distress syndrome (RDS)?
Sternal retraction
The nurse is monitoring a client at 41 weeks' gestation receiving IV oxytocin. Which action should the nurse prioritize if noticeable contractions are occurring every 2 minutes, lasting 60 to 90 seconds on the fetal monitor?
Stop the IV oxytocin infusion
A woman receiving an oxytocin infusion for labor induction develops contractions that occur every minute and last 75 seconds. Uterine resting tone remains at 20 mm Hg. Which action would be most appropriate?
Stop the infusion immediately.
At 0500 hrs, a client was started on oxytocin. The nurse notes on assessment the client is dilated to 4 cm with contractions every 1 minute and increased signs of fetal distress. What action should the nurse prioritize after noting the time is now 1200 hrs?
Stop the oxytocin infusion.
The nurse is assessing a 1-month-old male infant during a routine examination at a family health center. Which method does the nurse use to test for Babinski's sign?
Stroke the bottom of the foot to determine if there's fanning and dorsiflexion of the big toe
The nurse is caring for a client in active labor. Which assessment finding should the nurse prioritize and report to the team?
Sudden shortness of breath
A nurse is assisting with preparations for a cesarean birth. Who is responsible for obtaining informed consent?
Surgeon
A new mother tells the postpartum nurse that she thinks her baby does not like her since it cries often when she holds it. How should the nurse respond to this statement?
Tell the mother that it is natural to have feelings of uncertainty when adjusting to a new baby.
Dietary needs change from pregnancy to lactation. What should breastfeeding mothers be advised?
That even if a mother has adequate fat stores, calorie intake should increase
The nurse palpates a postpartum woman's fundus 2 hours after birth and finds it located to the right of midline and somewhat soft. What is the correct interpretation of this finding?
The bladder is distended.
A 1-day-old newborn is being examined by the nurse practitioner, who makes the following notation: face and sclera appear mildly jaundiced. What causes this finding?
The breakdown of RBCs release bilirubin, which the liver cannot excrete.
A client is 2 weeks past her due date, and her health care provider is considering whether to induce labor. Which conditions must be present before induction can take place?
The fetus is in a longitudinal lie. The cervix is ripe. A presenting part is engaged.
The nurse is looking at the latest lab work for her postpartum client. The client's predelivery hemoglobin and hematocrit (H & H) was 12.8 and 39, respectively. This morning, the client's values are 8.9 and 30. How would the nurse interpret these lab values?
The health care provider needs to be notified of the latest lab values.
The nurse is conducting prenatal counseling with pregnant women in the community. An 18-year-old G1 P0 in her 36th week states, "I don't know if I should breast-feed or not. Isn't formula just as good for the baby?" What is the nurse's best response?
The immunologic properties in breast milk cannot be duplicated in formula.
A breast-feeding mother calls the clinic, asking how much water she should be giving her 2-month-old infant. What would the nurse recommend to this mother?
The infant does not need any water supplement if nursing well.
A neonate has been administered a prescribed dose of vitamin K. What outcome would most clearly indicate to the nurse that the medication has had the intended effect?
The infant remains free of bleeding
At birth, the newborn was at the 8th percentile with a weight of 2350 g and born at 36 weeks' gestation. Which documentation is most accurate?
The infant was a preterm, low-birth-weight and small-for-gestational-age
Annie, a new mother, is talking with the nurse about breast-feeding. She asks, "How does lactation work?" The best answer by the nurse is:
The newborn sucking on the breast stimulates the pituitary gland causing the release of prolactin and oxytocin. Prolactin causes synthesis and release of breast milk and oxytocin causes contraction of the smooth muscle around the alveoli of the breast.
The nurse observes a neonate born at 28 weeks' gestation. Which finding would the nurse expect to see?
The pinna of the ear is soft and flat and stays folded.
The nurse is preparing new parents and their infant for discharge by answering questions and presenting basic discharge instruction. Which explanation should the nurse provide when questioned about the infant's yellow hue?
The tint is due to jaundice.
What should the nurse expect for a full-term newborn's weight during the first few days of life?
There is a loss of 5% to 10% of birth weight in formula-fed and breastfed newborns.
A client is being prepared for a scheduled cesarean delivery by the medical team. Which intervention will be most critical for the team to monitor in the first 24 hours post cesarean delivery?
Urinary output
A woman arrives at labor and delivery with contractions every 2-3 minutes lasting 30-45 seconds reporting that she "thinks my water broke." On exam, the RN notes the presenting part is difficult to determine. What intervention should the LPN anticipate?
Use of an ultrasound to determine position
A postpartum client is recovering from the birth and emergent repair of a cervical laceration. Which sign on assessment should the nurse prioritize and report to the health care provider?
Weak and rapid pulse
There is much discussion in the medical community about vaginal birth after a cesarean delivery (VBAC). When a woman has had a previous emergency cesarean delivery, she is at high risk for a ruptured uterus. When is VBAC contraindicated?
When a classical uterine incision has been made previously
During a woman's repeat cesarean delivery, estimated blood loss of 850 mL is recorded. When reviewing the woman's laboratory test results 24 hours after delivery, which finding would the nurse expect? White blood cell count going from 13,000/mm³ predelivery to 45,000/mm³ Hemoglobin going from 11.5 g predelivery to 7.6 g Hematocrit of 37% predelivery going to 26% Platelets of 230 predelivery going to 75,000/mcL
White blood cell count going from 13,000/mm³ predelivery to 45,000/mm³ Hemoglobin going from 11.5 g predelivery to 7.6 g Hematocrit of 37% predelivery going to 26%
A new mother asks the nurse what she is allowed to do when she goes home from the hospital. Which statement by the nurse would be correct? You should be able to resume normal activities after 2 weeks. You should not lift anything heavier than your infant in its carrier. Only clean half of the house per day to allow yourself more rest. You need to hire a maid for the first month after delivery to help out around the house.
You should not lift anything heavier than your infant in its carrier.
A postpartum mother is experiencing sore nipples. The woman asks the nurse what she is doing wrong that is causing this problem. The nurse identifies which breastfeeding technique or condition may result in sore nipples? Select all that apply. -Positioning the newborn so that the head is level or in the sniffing position -Placing a finger in the newborn's cheeks to break seal prior to removing the newborn from the breast -Allowing the newborn to stay latched on to the breast for a prolonged period after feeding -Not assessing that the newborn has a highly arched palate that interferes with proper latching -Setting the breast pump on a higher pressure setting to empty milk faster
allowing the newborn to stay latched on to the breast for a prolonged period after feeding not assessing that the newborn has a highly arched palate that interferes with proper latching setting the breast pump on a higher pressure setting to empty milk faster
Immediately after giving birth to a full-term infant, a client develops dyspnea and cyanosis. Her blood pressure decreases to 60/40 mm Hg, and she becomes unresponsive. What does the nurse suspect is happening with this client?
amniotic fluid embolism
The nurse examines a 26-week-old premature neonate. The skin temperature is lowered. What could be a consequence of the infant being cold?
apnea
Which intervention would be helpful to a bottle-feeding client who's experiencing hard or engorged breasts?
applying ice
Which intervention would be helpful to a client who is bottle feeding her infant and experiencing hard, engorged breasts?
applying ice
What action by the nurse provides the neonate with sensory stimulation of a human face?
assisting the mother to position the infant in an en face position
Which finding would alert the nurse to suspect that a newborn is experiencing respiratory distress?
asymmetrical chest movement
Which measurement best describes delayed postpartum hemorrhage?
blood loss in excess of 500 ml, occurring at least 24 hours and up to 12 weeks after birth
When the nurse is assessing a postpartum client approximately 6 hours after birth, which finding would warrant further investigation? deep red, fleshy-smelling lochia voiding of 350 cc blood pressure 90/50 mm Hg profuse sweating
blood pressure 90/50 mm Hg
The nurse is admitting a 10-pound (4.5-kg) newborn to the nursery. What is important for the nurse to monitor during the transition period?
blood sugar
A new mother has been reluctant to hold her newborn. Which action by the nurse would help promote this mother's attachment to her newborn?
bringing the newborn into the room
Which intervention would be most important when caring for the client with breech presentation confirmed by ultrasound?
continuing to monitor maternal and fetal status
Which finding would lead the nurse to suspect that the fetus of a woman in labor is in hypertonic uterine dysfuction?
contractions most forceful in the middle of uterus rather than the fundus
The nurse frequently assesses the respiratory status of a preterm newborn based on the understanding that the newborn is at increased risk for respiratory distress syndrome because of which factor?
deficiency of surfactant
A postpartum client has a fourth-degree perineal laceration. The nurse would expect which medication to be prescribed?
docusate
A client who gave birth by cesarean delivery 3 days ago is bottle-feeding her neonate. While collecting data the nurse notes that vital signs are stable, the fundus is four fingerbreadths below the umbilicus, lochia are small and red, and the client complains of discomfort in her breasts, which are hard and warm to touch. The best nursing intervention based on this data would be:
encouraging the client to wear a supportive bra
The nurse is monitoring the uterine contractions of a woman in labor. The nurse determines the woman is experiencing hypertonic uterine dysfunction based on which contraction finding?
erratic
When describing the hormonal changes that occur after birth of a newborn, the nurse would identify a decrease in which hormone as being associated with breast engorgement?
estrogen
What is a classic sign of neonatal respiratory distress syndrome?
expiratory grunting nasal flaring retractions tachypnea
A client at 38 weeks' gestation has an ultrasound performed at a routine office visit and learns that her fetus has not moved out of a breech position. Which intervention does the nurse anticipate for this client?
external cephalic version
After a normal labor and birth, a client is discharged from the hospital 12 hours later. When the community health nurse makes a home visit 2 days later, which finding would alert the nurse to the need for further intervention?
frequent scant voidings
The nurse is teaching a group of parents who have preterm newborns about the differences between a full-term newborn and a preterm newborn. Which characteristic would the nurse describe as associated with a preterm newborn but not a term newborn?
greater body surface area in proportion to weight
An infant has a grade 3 intraventricular hemorrhage (IVH). The nurse monitors the infant for which complication?
hydrocephalus
An obese woman with diabetes has just given birth to a term, large-for-gestational-age (LGA) newborn. Which condition should the nurse most expect to find in this infant?
hypoglycemia
The nurse begins frequent oral feedings for a small-for-gestational-age newborn to prevent which occurrence?
hypoglycemia
A nurse is observing the interaction between a new father and his newborn. The nurse determines that engrossment has yet to occur based on which behavior?
identifies imperfections in the newborn's appearance
A nurse is teaching a postpartum client how to do muscle-clenching exercises for the perineum. The client asks the nurse, "Why do I need to do these exercises?" Which reason would the nurse most likely incorporate into the response?
improves pelvic floor tone
The nurse is assessing a postpartum woman and is concerned the client may be hemorrhaging. Which assessment finding is the nurse finding most concerning?
increased heart rate
A nursing instructor is teaching students about fetal presentations during birth. The mostcommon cause for increased incidence of shoulder dystocia is:
increasing birth weight.
A client experienced prolonged labor with prolonged premature rupture of membranes. The nurse would be alert for which condition in the mother and the newborn?
infection
The nurse is developing a teaching plan for a client who has decided to bottle-feed her newborn. Which information would the nurse include in the teaching plan to facilitate suppression of lactation?
instructing her to apply ice packs to both breasts every other hour
An infant who is diagnosed with meconium aspiration displays which symptom?
intercostal and substernal retractions
After spontaneous rupture of membranes, the nurse notices a prolapsed cord. The nurse immediately places the woman in which position?
knee-chest
A nursing student has learned that precipitous labor is when the uterus contracts so frequently and with such intensity that a very rapid birth will take place. This means the labor will be completed in which span of time?
less than 3 hours
When monitoring a postpartum client 2 hours after birth, the nurse notices heavy bleeding with large clots. Which response is most appropriate initially?
massaging the fundus firmly
A 35-year-old client has just given birth to a healthy newborn during her 43rd week of gestation. What should the nurse expect when assessing the condition of the newborn?
meconium aspiration in utero or at birth
A nursing instructor teaching about growth and development informs the students that the period when growth is the most rapid is which of the following?
neonatal
How does the nurse position the infant experiencing respiratory difficulty?
on the back with the head elevated 15 degrees
Which findings would lead the nurse to suspect that a postpartum woman has developed endometritis?
pain on both sides of the abdomen foul-smelling lochia leukocytosis
The Ballard scoring system evaluates newborns on which two factors?
physical maturity and neuromuscular maturity
A new mother of twins asks the nurse if there is any way she can feed them both at the same time. Which piece of equipment would the nurse recommend for this situation?
pillow supports designed with wider sides to allow the twins to feed at the same time
The nurse is assessing a client at a postpartum visit and notes the client is emotionally sensitive, complains about being a failure, and appears extremely sad. The nurse concludes the client is presenting with which potential condition?
postpartum depression
A nurse is caring for a client on the second day postpartum. The client informs the nurse that she is voiding a large volume of urine frequently. Which factor should the nurse identify as a potential cause for urinary frequency?
postpartum diuresis
When caring for a client requiring a forceps-assisted birth, the nurse would be alert for:
potential lacerations and bleeding.
A pregnant client presents to the emergency department reporting back-to-back contractions. Within 2 hours, the client is completely effaced and 9 cm dilated, and the fetal head is showing. Within minutes the client gives birth with only the nurse in attendance. This is an example of which occurrence?
precipitate labor
When examining a newborn female, the nurse notices a small pinkish discharge from the vaginal area. What should the nurse suspect?
pseudomenstruation, a normal finding
Which finding would lead the nurse to suspect that a postpartum client is developing thrombophlebitis?
redness in lower legs
A newborn is being monitored for retinopathy of prematurity. Which condition predisposes an infant to this condition?
respiratory distress syndrome
While caring for a preterm newborn receiving oxygen therapy, the nurse monitors the oxygen therapy duration closely based on the understanding that the newborn is at risk for which condition?
retinopathy of prematurity
A nurse is discussing breastfeeding with a new mother and demonstrates that when she strokes the baby's cheek, the baby turns his head in that direction. This movement is known as which reflex?
rooting reflex
The nurse is reviewing the physical examination findings for a client who is to undergo labor induction. Which finding would indicate to the nurse that a woman's cervix is ripe in preparation for labor induction?
shortened
A new mother gave birth to her baby 24 hours ago and today has been content to rest in her hospital bed, hold her baby, allow the nurse to care for her, and to discuss her labor and birth experience with visitors. Which phase of the postpartum restorative period is this client in?
taking-in phase
Rubin identified a series of changes that a new mother makes during the postpartum period. The correct sequence of these changes is:
taking-in, taking-hold, letting-go.
An episiotomy or a cesarean incision requires assessment. Which assessment criterion for skin integrity is not initially noted?
temperature
A newborn girl who was born at 38 weeks' gestation weighs 2000 g and is below the 10th percentile in weight. The nurse recognizes that this girl will be placed in which classification?
term, small-for-gestational-age, and low-birth-weight infant
Which is the best place to perform a heel stick on a newborn?
the fat pads on the lateral aspects of the foot
A nurse initiates bag and mask ventilation with an anesthesia bag on a newborn with no spontaneous respiratory effort. What controls the pressure of breaths delivered by an anesthesia bag?
the pressure the nurse uses when the hand squeezes against the bag
When assessing the postpartum woman, the nurse uses indicators other than pulse rate and blood pressure for postpartum hemorrhage because:
these measurements may not change until after the blood loss is large.
Review of a primiparous woman's labor and birth record reveals a prolonged second stage of labor and extended time in the stirrups. Based on an interpretation of these findings, the nurse would be especially alert for which condition?
thrombophlebitis
The nurse encourages the mother of a healthy newborn to put the newborn to the breast immediately after birth for which reason?
to facilitate maternal-infant bonding
A client with a pendulous abdomen and uterine fibroid tumors has just begun labor and arrived at the hospital. After examining the client, the primary care provider informs the nurse that the fetus appears to be malpositioned in the uterus. Which fetal position or presentation should the nurse most expect in this woman?
transverse lie
A fundal massage is sometimes performed on a postpartum woman. The nurse would perform this procedure to address which condition?
uterine atony
Which factor puts a multiparous client on her first postpartum day at risk for developing hemorrhage?
uterine atony
A woman with a history of crack cocaine use disorder is admitted to the labor and birth area. While caring for the client, the nurse notes a sudden onset of fetal bradycardia. Inspection of the abdomen reveals an irregular wall contour. The client also reports acute abdominal pain that is continuous. Which condition would the nurse suspect?
uterine rupture
A postpartum client who had a cesarean birth reports right calf pain to the nurse. The nurse observes that the client has nonpitting edema from her right knee to her foot. The nurse knows to prepare the client for which test first?
venous duplex ultrasound of the right leg
At what point should the nurse expect a healthy newborn to pass meconium?
within 24 hours after birth
When instructing a new mom on providing skin care to her newborn, which statement, made by the mother, indicates additional teaching is needed?
"I can use talc powders to prevent diaper rash."
A newly delivered mother asks the nurse "What can I do to help my womb to get back to a normal size more quickly?" The nurse's best response would be:
"If you are breast-feeding, that will help make your uterus contract and get smaller."
A new mother is concerned because it is 24 hours after birth and her breasts have still not become engorged with breast milk. How should the nurse respond to this concern?
"It takes about 3 days after birth for milk to begin forming."
A client who gave birth vaginally 16 hours ago states she does not need to void at this time. The nurse reviews the documentation and finds that the client has not voided for 7 hours. Which response by the nurse is indicated?
"It's not uncommon after birth for you to have a full bladder even though you can't sense the fullness."
The nurse observes an ambulating postpartum woman limping and avoiding putting pressure on her right leg. Which assessments should the nurse prioritize in this client?
Assess for warmth, erythema, and pedal edema.
The nurse is monitoring a client who is 5 hours postpartum and notes her perineal pad has become saturated in approximately 15 minutes. Which action should the nurse prioritize?
Assess the woman's fundus.
During a prenatal ultrasound, the client is discovered to have a placenta succenturiata. Following delivery of the fetus and placenta, which nursing assessment is most important?
Assessment for hemorrhage
A woman is bottle-feeding her baby. When the nurse comes into the room the woman says that her breasts are painful and engorged. Which nursing intervention is appropriate?
Assist the woman in placing ice packs on her breasts.
A nurse is working with a client who has just begun labor and who has given birth vaginally five previous times. Which of the following interventions will the nurse most likely need to implement to meet the needs of this particular client?
Convert the birthing room to birth readiness before full dilatation is obtained
The nurse is assessing a newborn who appears healthy and at term. Which assessment finding of the feet does the nurse predict to observe to confirm the status of at-term birth?
Creases on two-thirds of the foot
The nurse is concerned that the nares of a newborn are not patent bilaterally. What can the nurse do to address this concern?
Occlude the nares one at a time by applying pressure to each side to see if the newborn can breath comfortably.
A woman presents at Labor and Delivery very upset. She reports that she has not felt her baby moving for the last 6 hours. The nurse listens for a fetal heart rate and cannot find a heartbeat. An ultrasound confirms fetal death and labor induction is started. What intervention by the nurse would be appropriate for this mother at this time?
Offer to take pictures and footprints of the infant once it is delivered.
Within three days of birth, a newborn has developed a yellowish tinge that extends from face to mid-chest, is lethargic, and has to be awoken to feed. Which condition does the nurse suspect this infant is manifesting?
Physiologic jaundice.
The nurse is conducting a postpartum examination on a client who reports pain and is unable to sit comfortably. The perineal exam reveals an episiotomy without signs of a hematoma. Which action should the nurse prioritize?
Place an ice pack.
A 20-year-old client gave birth to a baby boy at 43 weeks' gestation. What might the nurse observe in the newborn during routine assessment?
The newborn may look wrinkled and old at birth.
Seven hours ago, a multigravida woman gave birth to a male infant weighing 4,133 g. She has voided once and calls for a nurse to check because she states that she feels "really wet" now. Upon examination, her perineal pad is saturated. The immediate nursing action is to:
assess and massage the fundus.
The nurse encourages a mother to rock, sing, and talk to her premature newborn. What is the purpose of these activities with the infant?
to develop trust in people
A client who is 3 weeks postpartum calls the nurse to report that her breastfed infant is not gaining weight as rapidly as her friend's formula-fed newborn of the same age. Which response by the nurse would be most appropriate?
"Bottle-fed babies generally gain weight faster than breastfed babies."
The nurse is caring for the following five clients in the labor and delivery unit. When providing shift hand-off, which clients are identified as likely to need a cesarean birth?
A client with cephalopelvic disproportion A client diagnosed with AIDS A client with a fetal transverse lie A client with a complete placenta previa A client with cord prolapse
A mother who is breastfeeding asks the nurse when she should start weaning her infant. Which time factor should the nurse point out is the recommended time?
1 year
The nurse is caring for a mother within the first four hours after a cesarean birth. Which nursing intervention would be most appropriate to prevent thrombophlebitis in the mother?
Ambulate the client as soon as her vital signs are stable.
What is the most effective way to stimulate circulation after cesarean birth?
Ambulation within 4 hours of birth
A laboring client is experiencing dysfunctional labor or dystocia due to the malfunction of one or more of the "four Ps" of labor. Which scenario best illustrates a power problem?
Uterine contractions are weak and ineffective.
A G2P1 woman is in labor attempting a VBAC, when she suddenly complains of light-headedness and dizziness. An increase in pulse and decrease in blood pressure is noted as a change from the vital signs obtained 15 minutes prior. The nurse should investigate further for additional signs or symptoms of which complication?
Uterine rupture
A primipara client gave birth vaginally to a healthy newborn girl 48 hours ago. The nurse palpates the client's fundus and documents which finding as normal?
two fingerbreadths below the umbilicus
The nurse is caring for a client suspected to have a uterine rupture. The nurse predicts the fetal monitor will exhibit which pattern if this is true?
Late decelerations
A client's membranes rupture. The nurse observes the fetal heart rate drop from 156 to 110. The nurse inspects the client's perineum and sees a loop of umbilical cord. What is the nurse's priority concern in this situation?
Decreased fetal oxygenation
The nursing instructor is teaching a class on the physiologic prosperities involved with the birthing process. The instructor determines the session is successful when the students correctly match surfactant with which function?
It keeps alveoli from collapsing with breaths.
A client is exhibiting signs of engorgement, but her milk is still flowing easily. Which suggestion should the nurse prioritize?
Ensure the baby empties the breasts at each feeding
A gravida 4 para 4 mother calls the nurse's station reporting uterine pain following delivery. When the nurse responds to the call, the mother reports that she is having what feels like labor pains again off and on. What would be the nurse's response?
Explain to her that women who have had several babies prior to this delivery often experience afterpains, which is where the uterus is contracting and relaxing at intervals.
The nurse is explaining the discharge instructions to a client who has developed postpartum cystitis. The client indicates she is not drinking a glass of fluid every hour because it hurts too much when she urinates. What is the best response from the nurse?
Teach that adequate hydration helps clear the infection quicker.
The nurse is assisting with a G2P1, 24-year-old client who has experienced an uneventful pregnancy and is now progressing well through labor. Which action should be prioritized after noting the fetal head has retracted into the vagina after emerging?
Use McRoberts maneuver.
The nurse is making a follow-up home visit to a woman who is 12 days postpartum. Which finding would the nurse expect when assessing the client's fundus?
cannot be palpated
The nurse is assessing a woman who had a forceps-assisted birth for complications. Which condition would the nurse assess in the fetus?
caput succedaneum
While performing a physical assessment of a newborn boy, the nurse notes diffuse edema of the soft tissues of his scalp that crosses suture lines. The nurse documents this finding as:
caput succedaneum.
When discussing heat loss in newborns, placing a newborn on a cold scale would be an example of what type of heat loss?
conduction
A G1 P1 new mother asks what position she should place the newborn in while feeding formula? Which response by the nurse is best?
holding infant with head slightly elevated
As part of an in-service program to a group of home health care nurses who care for postpartum women, a nurse is describing postpartum depression. The nurse determines that the teaching was successful when the group identifies that this condition becomes evident at which time after birth of the newborn?
within the first 6 weeks
