maternity
Performed a fundal masagge
Ask the client to lie on her back with her knees flexed. Place a hand just above the client's symphysis pubis. Position a hand around the top of the client's fundus. Rotate the upper hand to massage the client's uterus. Use slight downward pressure to compress the client's fundus.
A nurse is caring for a client who is in labor and asks her partner to perform effleurage. The client has on a monitor belt for electronic fetal monitoring. Which of the following instructions should the nurse provide to the client's partner? A. "Lightly stroke the upper thighs." B. "Steadily apply pressure to the sacrum." C. "Gently massage the mid-abdominal area." D. "Firmly squeeze both hips."
Correct Answer: A. "Lightly stroke the upper thighs." Effleurage involves lightly stroking or massaging the abdomen in rhythm with breathing to help relieve labor pain. However, when a monitor belt is in use, the sides of the abdomen, chest, or upper thighs are alternative locations for massage. Incorrect Answers: B. This technique is known as counter-pressure and is used to help decrease lower back pain by relieving occiput pressure on the spinal nerves. C. Gently massaging the abdomen is therapeutic for pain relief; however, massage of the mid-abdominal area is not possible for this client due to the positioning of the monitor belt. D. This is a method of counter-pressure and is used to help relieve lower back pain by placing pressure on the hips.
A nurse is caring for a client who is scheduled to undergo an amniocentesis to assess fetal lung maturity. The client is G2P1 and at 36 weeks of gestation, and she has an O-positive blood type. Which of the following interventions should the nurse perform? A. Apply an external fetal monitor to the client B. Instruct the client to drink fluids and not to void prior to the procedure C. Administer Rho(D) immunoglobin after the procedure D. Instruct the client to take a deep breath and hold it during the entry of the needle
Correct Answer: A. Apply an external fetal monitor to the client The nurse should assess fetal heart tones and uterine tone prior to and throughout the procedure to establish a baseline and monitor for changes. Incorrect Answers: B. Clients should be instructed to void immediately prior to the procedure to decrease the risk of accidentally puncturing the bladder during the amniocentesis. C. Rho(D) immunoglobin would only need to be administered if the client had an Rh-negative blood type to help ensure maternal antibodies do not form against fetal cells. D. The client should stay relaxed and breathe normally during the introduction of the needle. The act of taking a deep breath and holding it will lower the diaphragm and shift the uterine contents. This will increase the risk of inadvertently puncturing the placenta or fetus.
A nurse is discussing contraceptive choices with a client who has a history of thrombophlebitis. Which of the following methods of contraception should the nurse recommend? A. Copper intrauterine device B. Combination pill C. Vaginal ring D. Medroxyprogesterone injection
Correct Answer: A. Copper intrauterine device A history of thrombophlebitis is a contraindication for the use of hormonal contraceptive methods such as oral combinations of estrogen and progesterone in pill form, vaginal inserts that release hormones continuously, and injectable progestins. A copper intrauterine device that does not contain hormones is a safer choice for this client. Other options for this client include barrier methods and spermicides. Incorrect Answers: B. A history of thrombophlebitis is a contraindication for taking oral contraceptives. Safer methods of contraception for this client include barrier methods and spermicides. C. A history of thrombophlebitis is a contraindication for a vaginal insert that releases hormones continuously. Safer methods of contraception for this client include barrier methods and spermicides. D. A history of thrombophlebitis is a contraindication for injectable progestins. Safer methods of contraception for this client include barrier methods and spermicides.
A nurse is admitting a client who is in post-term labor. Which of the following statements should the nurse identify as the priority? A. "I had blood-streaked discharge a few hours ago." B. "When my water broke, it was not clear." C. "I have not felt my baby move as much today." D. "I feel like I cannot breathe when I walk up the stairs."
Correct Answer: B. "When my water broke, it was not clear." The greatest risk to this client is an injury to the newborn from meconium aspiration; therefore, addressing this statement is the nurse's priority. Incorrect Answers: A. The nurse should confirm that there is no active bleeding and reassure the client that this event could have been the bloody show; however, addressing another statement is the nurse's priority. C. The nurse should confirm the heartbeat of the fetus via Doppler to reassure the client or take action if the heartbeat is not identifiable; however, addressing another statement is the nurse's priority. D. The nurse should assess the client's respiratory pattern to confirm that the client's shortness of breath is due to elevation of the diaphragm from the enlarging uterus and not a respiratory infection; however, addressing another statement is the nurse's priority.
A nurse in a clinic is providing teaching to a client who is at 37 weeks of gestation and is scheduled for an external cephalic version. Which of the following statements should the nurse make? A. "Your provider will insert a hand into your uterus and turn your baby around." B. "You will receive a medication to relax your uterus prior to the procedure." C. "This procedure will be performed in the clinic at your next visit." D. "Your baby's heartbeat will be monitored occasionally throughout the procedure."
Correct Answer: B. "You will receive a medication to relax your uterus prior to the procedure." A client who is scheduled to undergo an external cephalic version often receives a tocolytic prior to the procedure to allow the uterus to relax. A relaxed uterus allows an easier version by the provider. Incorrect Answers: A. This action is appropriate for internal version. With external version, the provider attempts to turn the fetus around externally and not internally. C. External version is a high-risk procedure that is performed in a hospital setting in the event of an emergency. D. During the external version, the fetal heart-rate pattern is monitored continuously because the fetus is at risk of bradycardia and variable decelerations. The nurse also monitors the fetal heart rate for at least 60 minutes following the procedure.
A nurse in a clinic is providing teaching to a client who is at 37 weeks of gestation and is scheduled for an external cephalic version. Which of the following statements should the nurse make? A. "Your provider will insert a hand into your uterus and turn your baby around." B. "You will receive a medication to relax your uterus prior to the procedure." C. "This procedure will be performed in the clinic at your next visit." xIncorrect answer D. "Your baby's heartbeat will be monitored occasionally throughout the procedure."
Correct Answer: B. "You will receive a medication to relax your uterus prior to the procedure." A client who is scheduled to undergo an external cephalic version often receives a tocolytic prior to the procedure to allow the uterus to relax. A relaxed uterus allows an easier version by the provider. Incorrect Answers: A. This action is appropriate for internal version. With external version, the provider attempts to turn the fetus around externally and not internally. C. External version is a high-risk procedure that is performed in a hospital setting in the event of an emergency. D. During the external version, the fetal heart-rate pattern is monitored continuously because the fetus is at risk of bradycardia and variable decelerations. The nurse also monitors the fetal heart rate for at least 60 minutes following the procedure
A nurse is assessing a newborn and notes an axillary temperature of 96.9°F (36°C). Which of the following actions should the nurse perform? A. Obtain a rectal temperature B. Assess the newborn's blood glucose level C. Bathe the newborn with warm water D. Position the infant's bassinet in front of a heater vent
Correct Answer: B. Assess the newborn's blood glucose level Infants who become cold attempt to generate heat through increased muscular and metabolic activity. This process increases glucose consumption and puts the newborn at risk of hypoglycemia. Incorrect Answers: A. The nurse should not obtain a rectal temperature from a newborn due to the risk of rectal perforation. Instead, the nurse should obtain an axillary temperature. C. Bathing a newborn will increase heat loss. The infant should not be bathed until the temperature has stabilized within the normal range. D. Placing the infant in front of a heater vent can incur heat loss through convection. Additionally, there is a potential fire risk from the bassinet linens and the vent.
A nurse administers betamethasone to a client who is at 33 weeks gestation to stimulate fetal lung maturity. When planning care for the newborn, which of the following conditions should the nurse identify as an adverse effect of this medication? A. Hyperthermia B. Decreased blood glucose C. Rapid pulse rate D. Irritability
Correct Answer: B. Decreased blood glucose Betamethasone causes hyperglycemia in the client, which predisposes the newborn to hypoglycemia in the first hours after delivery. The nurse must assess the newborn's blood glucose level within the first hour following birth and frequently thereafter until blood glucose levels are stable. Incorrect Answers: A. Betamethasone does not affect the newborn's ability to maintain body temperature. Hyperthermia is not an adverse effect of betamethasone. C. Betamethasone administered to an antepartum client does not affect the newborn's vital signs. If the newborn has a rapid apical pulse, it is related to another cause like prematurity or respiratory insufficiency. D. Irritability is not an adverse effect of betamethasone.
A nurse in a prenatal clinic is reviewing the laboratory results of a client who is at 33 weeks of gestation. For which of the following results should the nurse notify the provider? A. Hgb 11.3 g/dL B. Platelet count 135,000/mm^3 C. WBC count 10,500/mm^3 D. Hct 38%
Correct Answer: B. Platelet count 135,000/mm^3 The nurse should notify the provider of this result because it is an indication of thrombocytopenia. A low platelet count is a manifestation of preeclampsia or HELLP syndrome and requires further evaluation. Incorrect Answers: A. The nurse should notify the provider if the client's Hgb is below 11 g/dL because this is an indication of anemia. C. The nurse should notify the provider if the client's WBC count is greater than 15,000/mm^3 because this is an indication of infection. D. The nurse should notify the provider if the client's Hct is under 33% because this is an indication of anemia.
A nurse is reviewing the laboratory values of a client who is pregnant and has a low progesterone level. Which of the following complications should the nurse expect? A. Gestational diabetes B. Preterm labor C. Inadequate milk supply D. Inadequate uterine growth
Correct Answer: B. Preterm labor Progesterone maintains the lining of the uterus, which maintains the pregnancy. It also reduces uterine contractility. A client who has a low progesterone level is at risk for preterm labor. Incorrect Answers: A. Glucose metabolism and lactogenesis are influenced by human placental lactogen (HPL). HPL causes insulin resistance, which may lead to gestational diabetes. C. Lactogenesis is influenced by HPL. D. Estrogen stimulates uterine growth and mammary gland development.
nurse is caring for a preterm newborn who is receiving oxygen therapy. Which of the following findings should the nurse identify as a potential complication of the oxygen therapy? A. Atelectasis B. Retinopathy C. Interstitial emphysema D. Necrotizing enterocolitis
Correct Answer: B. Retinopathy Oxygen therapy can cause retinopathy of prematurity, especially in preterm newborns. It is a disorder of retinal blood vessel development in premature newborns. In newborns who develop retinopathy of prematurity, the vessels grow abnormally from the retina into the clear gel that fills the back of the eye. This condition can reduce vision or result in complete blindness. Incorrect Answers: A. Oxygen therapy does not cause atelectasis but can be used for clients who have atelectasis. C. Oxygen therapy does not cause interstitial emphysema but can be used for clients who have interstitial emphysema. D. Oxygen therapy does not cause necrotizing enterocolitis (NEC), a severe disease of premature newborns. In NEC, the lining of the intestinal wall dies, and the tissue sloughs off. The cause of this disorder is unknown. Decreased blood flow to the bowel may keep the bowel from producing the normal protective mucus. Bacteria in the intestine also may contribute to this condition.
A nurse is monitoring a newborn who is receiving phototherapy. The nurse should identify which of the following findings as requiring intervention? A. Bilirubin level 5 mg/dL B. Weight loss 12% of birth weight C. Loose, green stools D. Axillary temperature of 36.6°C (97.9°F)
Correct Answer: B. Weight loss 12% of birth weight An acceptable weight loss over the first 3 to 5 days is 10%. The nurse should report this finding to the provider. Incorrect Answers: A. This bilirubin level indicates that the newborn no longer needs phototherapy. The provider should discontinue the treatment. C. Loose stools are a common finding in newborns receiving phototherapy. Green stools are also common before they transition to yellow. D. This temperature is within the expected reference range for axillary temperatures of newborns, which is 36.5 to 37.5°C (97.7 to 99.5°F).
A nurse is teaching a parent of a newborn about circumcision care. Which of the following instructions should the nurse include? A. Wash the site with soap and warm water once daily B. Gently remove the yellow exudate that forms around the site C. Avoid using diaper wipes on the site during diaper changes D. Apply the diaper tightly to apply pressure to the site
Correct Answer: C. Avoid using diaper wipes on the site during diaper changes The parent should use plain warm water to clean the penis, as diaper wipes may contain alcohol or other chemicals that can cause pain and irritation. Incorrect Answers: A. The parent should avoid using soap until the site heals, in about 1 week. B. The parent should not attempt to remove the yellow exudate from the circumcision site, as this could cause bleeding. D. The parent should apply the diaper loosely over the penis to avoid creating pressure on the circumcision site.
A nurse is teaching a client who had a vacuum-assisted vaginal delivery. Which of the following statements should the nurse identify as an indication that the client understands the information? A. "My baby's head will be cone-shaped for about 2 months." B. "My doctor performed this procedure because I didn't dilate past 6 centimeters." C. "The doctor performed this procedure because my hemoglobin was low." D. "My baby has a higher risk of developing jaundice." Check Answer Question Feedback Show Explanation Grade Pause Previous
Correct Answer: D. "My baby has a higher risk of developing jaundice." A vacuum-assisted birth increases the risk of jaundice as the bruises caused by the device dissipate. Incorrect Answers: A. The procedure will result in caput succedaneum, which is a swelling on the scalp that generally resolves without treatment in 3 to 4 days. B. Providers choose vacuum-assisted birth when a client has a prolonged second stage of labor or when the fetus is in distress. The client must be fully dilated before undergoing a vaginal birth. C. Providers choose vacuum-assisted birth when a client has a prolonged second stage of labor or when the fetus is in distress, not because of a low Hgb level.
A nurse is providing teaching to a client who is planning to breastfeed her newborn. Which of the following statements by the client indicates an understanding of the teaching? A. "I must drink milk every day in order to assure good-quality breast milk." B. "Drinking lots of fluids will increase my breast milk production." C. "After the first few weeks, my nipples will toughen, and breastfeeding won't hurt anymore." D. "My baby may sometimes feed every hour for several hours in a row."
Correct Answer: D. "My baby may sometimes feed every hour for several hours in a row." Cluster feeding is an expected finding for newborns who are breastfeeding. The mother should follow her newborn's cues and feed her 8-12 times per day. Incorrect Answers: A. The client should eat a healthy, well-balanced diet of nutrient-dense foods with adequate amounts of calcium, minerals, and fat-soluble vitamins. The client is not required to eat specific foods. B. The newborn's demand for milk will influence the mother's milk production. As the newborn removes milk from the breast, the mother will produce more milk. Mothers who are breastfeeding should drink only to satisfy thirst. C. If the mother is experiencing pain during breastfeeding soon after the newborn starts sucking, she might not be holding the newborn correctly, or the newborn may not be latching on correctly. The nurse should teach the client appropriate breastfeeding techniques.
A nurse is providing teaching to a client who is planning to breastfeed her newborn. Which of the following statements by the client indicates an understanding of the teaching? A. "I must drink milk every day in order to assure good-quality breast milk." B. "Drinking lots of fluids will increase my breast milk production." C. "After the first few weeks, my nipples will toughen, and breastfeeding won't hurt anymore." D. "My baby may sometimes feed every hour for several hours in a row."
Correct Answer: D. "My baby may sometimes feed every hour for several hours in a row." Cluster feeding is an expected finding for newborns who are breastfeeding. The mother should follow her newborn's cues and feed her 8-12 times per day. Incorrect Answers: A. The client should eat a healthy, well-balanced diet of nutrient-dense foods with adequate amounts of calcium, minerals, and fat-soluble vitamins. The client is not required to eat specific foods. B. The newborn's demand for milk will influence the mother's milk production. As the newborn removes milk from the breast, the mother will produce more milk. Mothers who are breastfeeding should drink only to satisfy thirst. C. If the mother is experiencing pain during breastfeeding soon after the newborn starts sucking, she might not be holding the newborn correctly, or the newborn may not be latching on correctly. The nurse should teach the client appropriate breastfeeding techniques.
A nurse in a newborn nursery has received reports on 4 newborns. Which of the following newborns should the nurse identify as requiring intervention? A newborn who has acrocyanosis B. A newborn who has a macular, papular, vesicular rash on the torso C. A newborn who has a blood glucose level of 54 mg/dL D. A newborn whose axillary temperature is 36.1°C (96.9°F)
Correct Answer: D. A newborn whose axillary temperature is 36.1°C (96.9°F) This temperature places the newborn at risk for cold stress, which can diminish pulmonary perfusion. The nurse should place the newborn under a radiant heat warmer, monitor the temperature of the newborn, and continue to assess the newborn's respiratory and cardiovascular status. Incorrect Answers: A. Acrocyanosis, which is a bluish discoloration of the hands and feet, is a common finding during the first 24 to 48 hours after birth and does not require intervention. B. This finding describes erythema toxicum, a common, transient rash that appears on the skin of many newborns during the first 24 to 72 hours after birth and does not require intervention. C. The nurse should continue to check this newborn's glucose levels in case they decrease to a level that would put the newborn at risk for a neurological injury. However, no intervention is necessary until the newborn's glucose level drops below 40 mg/dL.
Respiratory distress syndrome asphyxia and meconium aspiration
Surfactant deficiency in lungs causing poor gas exchange and ventilatory failure Surfactant is a phospholipid that assist in alveoli expansion this keeps alveoli from collapsing Atelectasis collapse portion of lung increase work of breathing causing respiratory acids and hypoxemia complications are oxygen therapy and mechanical ventilation pneumothorax pneumomediastinum retinopathy of prematurity bronchopulmonary dysplasia infection intraventricular hemorrhage
Hypoglycemia
glucose stops when umbilical cord is clamped causing hypoglycemia Untreated hypoglycemia result in seizure brain damage or death Monitor glucose and feed the baby every 2 to 3 hr at least Blood glucose 40 too 45 its considered hypoglycemia on a newborn
Preterm newborn
newborn after 20 weeks of gestation and before 37 weeks risk variety due to immature organs systems
