Maternity and Women's Health Nursing

A nurse is obtaining the health history of a woman who is visiting the prenatal clinic for the first time. She states that she is 5 months pregnant. For what positive sign of pregnancy should the nurse look in this patient?

Audible fetal heartbeat

A client in preterm labor does not respond to therapy, and birth seems imminent. The client begins to cry and says, "I'm so worried about my baby." What is the nurse's best response?

"All of this must leave you very confused and frightened."

A new mother asks the nurse whether she may wash her baby in a tub after they go home. What is the nurse's best response?

"Babies can be bathed in a tub after the cord has fallen off."

On her first prenatal visit a client says to the nurse, "I guess I'll be having an internal examination today." What is the nurse's best response?

"Have you ever had an internal examination done before?"

A client with active genital herpes has a cesarean birth. The nurse teaches the mother how to limit transmission of the virus to her newborn. The nurse concludes that the instructions have been understood when the mother states:

"I have to wash my hands with soap and water before handling the baby."

A nurse from the pediatric clinic who is strongly opposed to any chemical or mechanical method of birth control is asked to work in the family planning clinic. What is the most professional response that this nurse could give to the requesting supervisor?

"I would prefer another assignment that is not contrary to my beliefs."

After the birth of a neonate, a parent asks, "What is that white substance over the baby's body?" The nurse initially responds:

"It's expected, and it's called vernix caseosa."

A couple arrives at the newborn nursery asking to take their newborn grandson to his mother's room. What is the best response by the nurse?

"Please go on to see your daughter. I'll bring the baby to her room."

A client has just given birth to an infant with Down syndrome. The mother is crying and asks the nurse what she is supposed to do now. What is the nurse's best response?

"Tell me what you know about Down syndrome."

The mother of a newborn son tells the nurse that she is concerned about circumcision because of the pain involved. What is the nurse's best response?

"The health care provider will tell you how your baby's pain will be controlled."

A postpartum client who was receiving an intravenous infusion of oxytocin (Pitocin) to stimulate labor asks the nurse why it is not being discontinued now that the baby is born. The nurse responds:

"The oxytocin causes contraction of the uterine musculature."

A married couple has been using oral contraceptives to delay pregnancy. When the wife misses her regular menstrual period, she decides to find out whether she is pregnant. She tells the nurse that pregnancy may have occurred because she missed her contraceptive pills for 1 week when she had the flu. How should the nurse respond?

"You may be correct. The effect of contraceptive pills depends on their being taken on a regular schedule."

A postpartum client tells the nurse that she wishes to breastfeed. When the nurse brings her newborn to be breastfed, the client asks whether she may drink a small glass of wine to help her relax. How should the nurse respond?

"You seem a little tense. Tell me how you feel about breastfeeding."

A nitrazine test strip that turns deep blue indicates that the fluid being tested has a pH of:

7.5

A pregnant woman who is in the third trimester arrives in the emergency department with vaginal bleeding. She states that she snorted cocaine approximately 2 hours ago. Which complication does the nurse suspect as the cause of the bleeding?

Abruptio placentae

When entering the room of a client in active labor to answer the call light, the nurse sees that she ashen gray, dyspneic, and clutching her chest. What should the nurse do after pressing the emergency light in the client's room?

Administer oxygen by face mask

When working with a client who has spontaneously aborted a pregnancy, it is important for the nurse to first deal with his or her own feelings about abortion, death, and loss so that he or she may :

Allow the clients to express their grief

A newborn has a diagnosis of Erb palsy (Erb-Duchenne paralysis). What does a nurse identify as the cause of this complication?

An injury to the brachial plexus during birth

A nurse is caring for a newborn with a myelomeningocele. What should immediate nursing care for this infant include?

Applying sterile, moist nonadherent dressings to the sac

An infant born at 40 weeks' gestation weighs 6 lb 13 oz (3090 g). What category describes this neonate?

Appropriate for gestational age (AGA) and term

A client at 9 weeks' gestation asks the nurse in the prenatal clinic whether she may have chorionic villi sampling (CVS) performed during this visit. What should the nurse keep in mind as the optimal time for CVS while formulating a response?

At 10 weeks but no later than 12 weeks

The nurse is teaching a client who is scheduling a vasectomy. What information is essential that the nurse explain to the client?

At least 15 ejaculations to clear the tract of sperm must occur before the semen is checked.

While observing a newborn with a diaphragmatic hernia, what does the nurse expect to identify?

Barrel-shaped chest

A client whose membranes have ruptured is admitted to the birthing unit. Her cervix is dilated 3 cm and 50% effaced. The amniotic fluid is clear and the fetal heart rate is stable. What does the nurse anticipate?

Birth of the fetus within a day

After a client gives birth she has the following vital signs: temperature 99.4° F (37.4° C); pulse rate 80 beats/min and regular; respiratory rate of 16 breaths/min, with even respirations; and blood pressure of 148/92 mm Hg. Which vital sign should the nurse continue to monitor?

Blood pressure

What does a nurse expect to find when checking the vital signs of a client in the early postpartum period?

Bradycardia with no change in respirations

On the third postpartum day a mother visits the clinic and asks why her newborn's skin has begun to appear yellow. The nurse explains that the change in her infant's skin tone is the result of:

Breakdown of fetal red blood cells

A nurse is estimating a newborn's gestational age. What parameters should the nurse evaluate? (Select all that apply.)

Breast size Genital development

A woman who was discharged recently from the hospital after undergoing a hysterectomy calls the clinic and states that she has tenderness, redness, and swelling in her right calf. What should the nurse instruct the client to do?

Call an ambulance to go to the emergency department.

During prenatal classes the nurse teaches the difference between true labor and false labor. How does the nurse explain the difference?

Cervix effaces and dilates during true labor.

Shortly after birth the nurse instills erythromycin ophthalmic ointment in the newborn's eyes. The father asks why an antibiotic is needed because the mother does not have an infection. The nurse explains that it protects the newborn from:

Chlamydia and gonorrhea

A client at 35 weeks' gestation who has had no prenatal care arrives in labor and delivery and is found to be 20 percent effaced and 2 cm dilated, with her membranes intact and contractions 3 minutes apart. The nurse notices some ruptured blisterlike vesicles in the genital area. What should the nurse's next action be?

Contacting the health care provider about the need for a cesarean birth

A pregnant client tells the nurse that her husband is a chain smoker. What information should the nurse's teaching include?

Continued exposure to secondhand smoke is related to fetal growth restriction.

A client who recently was told by her practitioner that she has extensive terminal metastatic carcinoma of the breast tells the nurse that she believes an error has been made. She states that she does not have breast cancer, and she is not going to die. The nurse determines that the client is experiencing the stage of death and dying known as:

Denial

A client in labor is receiving an oxytocin (Pitocin) infusion. What should the nurse do first when repetitive late decelerations of the fetal heart rate are observed?

Discontinue the oxytocin infusion

A primigravida asks when she will be able to hear the fetal heartbeat for the first time. The nurse should explain that the heartbeat can be heard with:

Doppler ultrasound at 10 to 12 weeks

A client has a cesarean birth. What is the most important nursing intervention to prevent thromboembolism on the client's first postpartum day?

Encouraging frequent ambulation

A client who is 21 weeks pregnant loses the baby because of an incompetent cervix. Once the client's physical needs have been assessed and met, what is the best way for the nurse to meet the client's psychological needs?

Encouraging the client to see and hold the baby while still possible

Two days after birth a neonate's head circumference is 16 inches (40 cm) and the chest circumference is 13 inches (32.5 cm). What does the nurse infer from these measurements?

Enlarged head

During their first visit to the prenatal clinic a couple asks the nurse whether the woman should have an amniocentesis for genetic studies. Which factor indicates that an amniocentesis should be performed?

Family history of genetic abnormalities

A client is concerned about gaining weight during pregnancy. What should the nurse tell the client is the cause of the greatest weight gain during pregnancy?

Fetal growth

After being transported to the hospital by the ambulance, a pregnant woman is brought into the emergency department on a stretcher. The nurse notes that the fetus' head has emerged. How should the nurse assist the mother in the birth of the fetus' anterior shoulder?

Gently guiding the head downward

In the second hour after the client gives birth her uterus is firm, above the level of the umbilicus, and to the right of midline. What is the most appropriate nursing action?

Having the client empty her bladder

A client who is at 12 weeks' gestation tells a nurse at the prenatal clinic that she is experiencing severe nausea and frequent vomiting. The nurse suspects that the client has hyperemesis gravidarum. What factor is frequently associated with this disorder?

High level of chorionic gonadotropin

A woman who had a home birth brings the infant to the well-baby clinic on the third day after the birth, and the infant weighs 5% less than at birth. What does the nurse suspect as the cause of this weight loss?

Imbalance between nutrient intake and fluid loss

A nurse elicits the Babinski reflex on a newborn. The nurse concludes that this finding indicates:

Immaturity of the central nervous system (CNS)

After treatment for a bladder Infection; a client asks whether there is anything she can do to prevent cystitis in the future. What is the best response by the nurse?

Increase daily fluid consumption.

The nurse is caring for a client in her third trimester who is to undergo amniocentesis. What should the nurse do to prepare the client for this test?

Instruct her to void immediately before the test

A couple, married for 5 years, want to start a family. When talking with the nurse the husband says, "Well, I guess we're going to have to jump into bed three or four times a day, every day, until it works." What is the nurse's best response?

Instructing them in the frequency and timing of intercourse to promote conception

What is a common problem that affects the client in labor when an external fetal monitor has been applied to her abdomen?

Intrusion on movement

A newborn who has remained in the hospital because the mother had a cesarean birth is to be tested for phenylketonuria (PKU) on the morning of discharge. What should the nurse explain to the mother about the purpose of PKU testing?

It is used to measure protein metabolism.

A 23-year-old woman arrives at the prenatal clinic because she thinks that she is pregnant. Her last menstrual period began on March 31, and her pregnancy test reveals a positive result. According to Nägele's rule, what is this client's expected date of birth (EDB)?

January 7

What must the LPN observe first when planning to promote mother-infant attachment?

Mother-infant interaction

A 42-year-old client undergoes amniocentesis during the 16th week of gestation because of concern about Down syndrome. What additional information about the fetus will examination of the amniotic fluid reveal at this time?

Neural tube defect

A client who has had a cesarean birth seems upset. She has been having difficulty breastfeeding for 2 days and now asks the nurse to bring her a bottle of formula. What is the nurse's initial action?

Observing the client's breastfeeding technique

In specific situations gloves are used to handle newborns whether or not they are HIV positive. When is it unnecessary for the nurse to wear gloves while caring for a newborn?

Offering a feeding

At 32 weeks' gestation a client undergoes ultrasound, which reveals a low-lying placenta. What complication should the nurse anticipate as the client's pregnancy approaches term?

Painless vaginal bleeding

The practice of separating parents from their newborn immediately after birth and limiting their time with the infant during the first few days after delivery contradicts studies of:

Parent-child attachment

A primigravida in the first trimester tells a nurse that she has heard that hormones play an important role in pregnancy. Which hormone should the nurse tell the client maintains pregnancy?

Progesterone

A client at 36 weeks' gestation is admitted to the high-risk unit because she gained 5 lb in the previous week and there is a pronounced increase in blood pressure. What is the initial intervention in the client's plan of care?

Providing a dark, quiet room with minimal stimuli

A pregnant woman tells a nurse, "I think I can feel the baby move now. It feels like butterflies in my stomach. My friend calls it feeling life." What term should the nurse include when discussing fetal movement with the woman?

Quickening

A nurse is counseling a pregnant woman with type 1 diabetes. What is the most important nursing consideration in the planning of care for this client?

Requirement of intensive prenatal care

A young sexually active client at the family planning clinic is advised to have a Papanicolaou (Pap) smear. She has never had a Pap smear before. What should the nurse include in the explanation of this procedure?

The Pap smear can detect cancer of the cervix.

A female client with Hodgkin disease is to start total nodal irradiation. She and her partner, who are planning a family, become concerned when they learn that the radiation therapy includes the pelvic area. Before responding what must the nurse consider?

The eggs in the ovaries can be removed and frozen for future use.

The parents of a newborn ask the nurse about several areas of deep-blue coloring on their baby's lower back and buttocks. The nurse's response is based on the information that:

These areas usually are normal and will fade within the first year.

The mother of a neonate with Down syndrome visits the clinic 1 week after delivery. She explains to the nurse that she is having problems feeding her baby. What is the probable cause of these feeding difficulties?

Tongue thrust

A client is admitted with a marginal placenta previa. What should the nurse have available?

Two units of typed and screened blood

For what complication should the nurse specifically monitor a grand multipara who has just given birth?

Uterine atony

What is the nurse's initial action immediately after assisting with a precipitous birth in the triage area of the emergency department?

Warming the newborn

A client in labor is receiving an oxytocin (Pitocin) infusion. For which adverse reaction resulting from prolonged administration should the nurse monitor the client?

Water intoxication

The health care provider has prescribed 500 mg of cephalexin (Keflex) by mouth every 6 hours for 10 days for a client with mastitis. The health care provider has given the client 24 sample tablets of 250 mg apiece. How many days should this supply last? Record your answer using a whole number. _____ days

3

A nurse is caring for several pregnant clients in the prenatal clinic. Which client causes the most concern because of her predisposition to placenta previa?

30 years old, gravida 6, para 5

Which client is at risk for a postpartum infection?

A woman who required catheterization after voiding less than 75 mL

A primipara gives birth to an infant weighing 9 lb 15 oz (4508 g). During labor a midline episiotomy is performed and the client sustains a third-degree laceration. The client tells the nurse that her perineal area is very painful. What should the nurse consider before explaining the reason for the pain?

The anal sphincter muscle has been injured.

A client who is visiting the prenatal clinic for the first time has a serology test for toxoplasmosis. What information about the client's activities in the history indicates to the nurse that there is a need for this test?

The client takes care of a cat.

The nurse is helping a mother breastfeed her newborn. What is the best indication that the newborn has achieved an effective attachment to the breast?

The mouth covers most of the areolar surface.

A client gives birth vaginally, with a midline episiotomy, to an infant who weighs 8 lb 13 oz (4000 g). An ice pack is applied to the perineum to ease the swelling and pain. The client complains, "This pain in my vaginal and rectum is excruciating, and my vagina feels so full and heavy." What does the nurse suspect as the cause of the pain?

Vaginal hematoma

The nurse is conducting teaching for a client being discharged after an abdominal hysterectomy. Which statement by the client indicates a need for further teaching?

"I'm glad I'll be able to get back into my jogging routine next week."

A woman at 22 weeks' gestation is admitted with heavy bleeding and severe abdominal cramping. When told that no fetal heart sounds can be detected, the client says to the nurse, "We wanted this baby so badly." How should the nurse respond?

"It must be difficult to lose this baby that was important to you both."

A client with mild preeclampsia is told that she must remain on bedrest at home. The client starts to cry and tells the nurse that she has two small children at home who need her. How should the nurse respond?

"Let's explore your available current support and opportunities for child care."

A client who is pregnant for the first time and is carrying twins is scheduled for a cesarean birth. What should the nurse tell the client to expect?

"We'll be encouraging you to walk early after surgery."

A client visiting the prenatal clinic for the first time tells the nurse that she has heard conflicting stories about sex during pregnancy and asks about continuing sexual activity. How should the nurse respond?

"With an uncomplicated pregnancy, there are no limitations on sexual activity."

A nurse assesses a newborn 1 minute after birth. The body is pink with blue extremities; the heart rate is 122 beats/min; the legs are withdrawn when the soles are flicked, respiration is easy, with no evidence of distress; and the arms and legs are flexed and moving vigorously. What Apgar score should the nurse document in the newborn's medical record?

9

What should be included in the plan of care for a client with class I cardiac disease during the last weeks of pregnancy?

Advising the client to limit stress, promoting rest after meals, and educating the client about the analgesia and anesthesia used during labor

A nurse is caring for a client with preeclampsia who is receiving intravenous magnesium sulfate therapy. What antidote should the nurse have readily available?

Calcium gluconate

A client in labor is admitted to the birthing unit. Assessment reveals that the fetus is in a footling breech presentation. What should the nurse consider about breech presentations when caring for this client?

Cesarean birth probably will be necessary

A client who is in labor is admitted 30 hours after her membranes ruptured. For what condition does the nurse anticipate that the client is most at risk?

Chorioamnionitis

A primigravida who is at 38 weeks' gestation is undergoing a nonstress test. The nurse determines that the baseline fetal heart rate is 130 to 140 beats/min. It rises to 160 on two occasions and 157 once during a 20-minute period. Each of the episodes in which the heart rate is increased lasts 20 seconds. What action should the nurse take?

Discontinuing the test because the pattern is reassuring

A 28-year-old woman comes into the clinic and tells the nurse that she fears that she is infertile because she has been trying to become pregnant for 2 years. While collecting the health history the nurse learns that the client experiences irregular and infrequent menstrual periods. The client is overweight and has severe acne and alopecia. The health care provider diagnoses polycystic ovarian syndrome (PCOS). Which of the following interventions is the most important?

Discussing weight loss, exercise, and a balanced low-fat diet

While reviewing laboratory results of clients seen at a maternity clinic, the nurse notes that one client's maternal serum α-fetoprotein level is lower than is typical. The nurse recognizes that this may be associated with:

Down syndrome

The health care provider hands a neonate to a nurse immediately after birth. What should the nurse do next for the newborn?

Dry and provide skin-to-skin contact with the mother

A nurse is preparing to counsel a client whose two previous pregnancies were uneventful, ending in term vaginal births of healthy children. What should the nurse consider about multiparas with previous uneventful pregnancies before beginning prenatal counseling?

Each pregnancy is a unique experience that is stressful despite multiparity.

A primigravida is admitted with a ruptured fallopian tube resulting from a tubal pregnancy and surgery is performed to remove the fallopian tube. What should postoperative nursing care include?

Explaining that the client may still be capable of becoming pregnant

A pregnant client with cardiac disease asks a nurse to clarify what she was told about making the birth easier for her. What should the nurse remind her is an option to facilitate birth?

Facilitating the birth with vacuum extraction

The nurse explains to a pregnant client undergoing a nonstress test that the test is a way of evaluating the condition of the fetus by comparing the fetal heart rate with:

Fetal movement

The four essential components of labor are powers, passageway, passenger, and psyche. Passageway refers to the bony pelvis. What type of pelvis is considered the most favorable for a vaginal delivery?

Gynecoid A gynecoid pelvis is considered most favorable for a vaginal birth because the inlet allows the fetus room to pass. The gynecoid pelvis is considered the typical female pelvis. An android pelvis, which has a heart shape, is considered a male pelvis. The fetus often gets stuck. The anthropoid pelvis is elongated, with a roomy anterior posterior dimension and a narrower transverse diameter than the gynecoid pelvis. Although delivery is possible with this type of pelvis, it is less likely to be successful. The platypelloid pelvis is flat, with a compressed oval shape as the middle opening, instead of an open circle like the gynecoid pelvis. This is a rare type of pelvis.

How should a nurse direct care for a client in the transition phase of the first stage of labor?

Helping the client maintain control

A nurse is caring for a client who has had a spontaneous abortion. For what complication should the nurse monitor this client?

Hemorrhage

A nurse in the prenatal clinic reviews second-trimester physiological changes in the hematological system before explaining them to a client. What change should the nurse identify?

Increased blood volume

Two days after delivery, a client has a temperature of 101° F (38.3), general malaise, anorexia, and chills. What does the nurse expect to identify on the client's laboratory report?

Increased white blood cell (WBC) count

At a client's first prenatal visit, the healthcare provider performs a pelvic examination, stating that the client's cervix is bluish purple, which is known as the Chadwick sign. The client becomes concerned and asks whether something is wrong. The best response is "This is expected; it:

Is caused by increased blood flow to the uterus during pregnancy"

A nurse performs Leopold's maneuvers on a newly admitted client in labor. Palpation reveals a soft, firm mass in the fundus; a firm, smooth mass on the mother's left side; several knobs and protrusions on the mother's right side; and a hard, round, movable mass in the pubic area with the brow on the right. On the basis of these findings, the nurse determines that the fetal position is:

LOA

A client is admitted to the high-risk prenatal unit with the diagnosis of placenta previa. What should the nurse instruct the client to do?

Lie on her side to avoid putting pressure on the vena cava

A 28-year-old woman is scheduled to undergo a laparoscopic bilateral salpingo-oophorectomy. What does a nurse expect to be the client's priority concern?

Loss of childbearing potential

A multipara is admitted to the birthing room in active labor. Her temperature is 98° F (36.7° C), pulse 70 beats/min, respirations 18 breaths/min, and blood pressure 126/76 mm Hg. A vaginal examination reveals a cervix that is 90% effaced and 7 cm dilated with the vertex presenting at 2+ station. The client is complaining of pain and asks for medication. Which medication should be avoided because it may cause respiratory depression in the newborn?

Meperidine (Demerol)

A nurse understands the stages of parental adjustment that follow the birth of an at-risk infant who is in the neonatal intensive care unit. To better plan nursing care, the nurse bases observations and assessments on the recognition that the:

Mother should be reunited with her infant as soon as possible to enhance adjustment

A 36-year-old primagravida is receiving treatment for preeclampsia at 29 weeks' gestation. In light of the latest information on the client's record, what does the nurse identify as the priority of care?

Notifying the primary health care provider about the epigastric pain, headache, and blurred vision

A client who has breast cancer had postlumpectomy chemotherapy and is now scheduled for radiation on an outpatient basis. What is an important nursing intervention while the client is receiving radiation?

Observing the irradiated site daily for redness or irritation

A client at 24 weeks' gestation arrives at the clinic for a routine examination. She tells the nurse, "I feel puffy all over." In light of this statement, what is most important?

Obtaining her blood pressure

While mopping the kitchen floor, a client at 37 weeks' gestation experiences a sudden sharp pain in her abdomen with a period of fetal hyperactivity. When the client arrives at the prenatal clinic, the nurse examines her and detects fundal tenderness and a small amount of dark-red bleeding. What does the nurse conclude is the probable cause of these clinical manifestations?

Partial abruptio placentae

Examination of a client in active labor reveals fetal heart sounds in the right lower quadrant. The head is in the anterior position, is well flexed, and is at the level of the ischial spines. What fetal position should the nurse document?

ROA, 0 station

A nurse administers the prescribed intravenous dose of magnesium sulfate to a client with severe preeclampsia. What adverse effect should the nurse address when evaluating the client's response to the medication?

Respiratory depression

A nurse is planning to administer Rhogam (Rh immune globulin). Which situation requires the administration of this medication?

Rh-negative woman who has had an amniocentesis

A 16-year-old primigravida at 32 weeks' gestation is admitted to the high-risk unit. Her blood pressure is 170/110 mm Hg and she has 4+ proteinuria. She gained 50 lb during the pregnancy, and her face and extremities are edematous. What complication, which occurs in the latter part of pregnancy, does the nurse identify?

Severe preeclampsia With severe preeclampsia, arteriolar spasms cause hypertension and decreased arterial perfusion of the kidneys, which in turn cause an alteration in the glomeruli, resulting in oliguria and proteinuria, as well as retention of sodium and water, resulting in edema. Eclampsia is characterized by seizures; there are no data to indicate that the client is having or has had seizures. Chronic hypertension is hypertension diagnosed before pregnancy or before 20 weeks' gestation. If hypertension diagnosed during pregnancy for the first time persists beyond the postpartum period, it is also considered chronic hypertension. Gestational hypertension is hypertension that occurs during midpregnancy for the first time and without proteinuria; it is definitively diagnosed when the hypertension resolves 12 weeks after delivery.

A nurse determines that the husband of a client in the early phase of labor understands the teaching from childbirth classes when he helps his wife use the breathing pattern of:

Slow-chest Slow-chest breathing pattern is used during the early phase of labor, when mild contractions dilate the cervix to 3 cm. The pant-blow breathing pattern is used during the transition phase of labor. The shallow-chest breathing pattern is used in combination with other breathing patterns; it is a part of the accelerated-decelerated pattern. The accelerated-decelerated breathing pattern is used during the active phase of the first stage of labor.

The transmission of which microorganism that causes maternal mastitis is minimized by frequent handwashing by nursing staff members?

Staphylococcus aureus

A breastfeeding mother asks the nurse what she can do to ease the discomfort caused by a cracked nipple. What should the nurse instruct the client to do?

Start feedings on the unaffected breast until the affected breast heals

A nurse observes a laboring client's amniotic fluid and decides that it is the expected color. What finding supports this conclusion?

Straw-colored, clear, and containing little white specks

How does the nurse perform tactile stimulation to initiate respiration in a newborn? Select all that apply.

Stroke the extremities Flick the soles of the feet

The gravida 1 now para 1 woman delivered a 7-lb 6 oz female infant at 11 pm yesterday after a labor of 14 hours. After breakfast the nursery staff brings the baby to the new mother. The mother smiles at the baby, then asks that the nurse take the baby back to the nursery because she has not had a shower yet. One hour later the nurse returns with the infant. Again the mother smiles at the baby; then she holds her, kisses her, and feeds her a bottle. Immediately after feeding the baby, the mother calls the nursery and asks that the baby be picked up so she can take a nap. What behavior is the new mother demonstrating?

Taking-in

A client is admitted to the birthing unit because fluid is leaking from her vagina. She is unsure whether her "bag of water" has broken. What should the nurse do to help determine whether the fluid is amniotic fluid?

Test the fluid with nitrazine paper

A nurse caring for a client who gave birth to a healthy neonate evaluates the client's uterine tone 8 hours later. How does the nurse determine that the uterus is demonstrating appropriate involution?

The amount of lochia rubra is moderate.

A mother is seeing her newborn, who has visible birth defects, for the first time. When she sees her baby, she becomes disturbed, pushes away, and tells a nurse, "Oh, take the baby away; I never want to see it again." What does the nurse conclude from this behavior?

The response is a common one in a new mother who is finding it difficult to accept that her newborn is less than perfect.

A nurse is providing nutritional counseling to a low-income pregnant client who has iron-deficiency anemia. What food should the nurse encourage the client to include in her diet each day to best address this problem?

½ cup of red kidney beans

A pregnant woman at 34 weeks' gestation is being seen at the clinic. The client's blood pressure is 166/100 mm Hg and her urine is +3 for protein. She states that she has a severe headache and occasional blurred vision. Her baseline blood pressure was 100/62 mm Hg. What is the priority nursing action?

Arranging transportation to the hospital

A woman has just received the news that she is pregnant. She is ambivalent about the pregnancy because she had planned to go back to work when her youngest child started school next year. What developmental task of pregnancy must the woman accomplish in the first trimester of pregnancy?

Accept that she is pregnant

A client who is pregnant for the first time expels the products of conception at 12 weeks' gestation. The client's blood type is Rh negative. What should the nurse anticipate concerning the administration of Rho(D) immune globulin (RhoGAM)?

Administer RhoGAM within 72 hours of the miscarriage.

A woman in active labor arrives at the birthing unit. She tells the nurse that she was found to have a chlamydial infection the last time she visited the clinic but that she stopped taking the antibiotic after 3 days because she "felt better." What would the nurse anticipate as part of the plan of care, in light of this history?

Administration of antibiotics before delivery

A client at 39 weeks' gestation arrives in the birthing suite reporting that she is having regular contractions. A vaginal examination reveals that the presentation is a double-footling breech. The practitioner decides to proceed to a cesarean birth under regional anesthesia. What is an important intervention to help prevent postoperative maternal complications?

Maintaining adequate hydration