Maternity exam #2 questions

A hematoma is the collection of blood beneath the intact skin layer following an injury to a blood vessel. T/F

ANS: True A hematoma is a localized collection of blood in connective or soft tissue under the skin that follows injury of or laceration to a blood vessel without injury to the overlying tissue. At the time of injury, pressure necrosis and inadequate hemostasis occur.

The perinatal nurse includes the following when explaining the physiology of artificial rupture of membranes to the student nurse: rupture of membranes causes a release of arachidonic acid, which converts to prostaglandins, substances known to stimulate oxytocin in the pregnant uterus. T/F

ANS: True At certain points in the labor, an amniotomy, or artificial rupture of the membranes, may be successful in increasing uterine contractility.

The best time to give prophylactic antibiotics to the women undergoing cesarean section is: a. One hour before the surgery b. Two hours before the surgery c. Not indicated unless she has an active infection d. At the time the cord is clamped

ANS: a Administration of narrow-spectrum prophylactic antibiotics should occur within 60 minutes prior to the skin incision.

A postpartum woman has been diagnosed with postpartum psychosis. Which of the following actions should the nurse perform? a. Supervise all infant care. b. Maintain client on strict bed rest. c. Restrict visitation to her partner. d. Carefully monitor toileting.

ANS: a Feedback a. It is essential that a client diagnosed with postpartum (PP) psychosis not be left alone with her infant. b. There is no need for a client with PP psychosis to be on strict bed rest. c. Visitation is not usually restricted to the woman's partner. d. There is no need to monitor the client's toileting.

A nurse is caring for a 2-day-old neonate who was born at 31 weeks' gestation. The neonate has a diagnosis of respiratory distress syndrome (RDS). Which of the following medical treatments would the nurse anticipate for this neonate? (Select all that apply.) a. Exogenous surfactant b. Corticosteroids c. Continuous positive airway pressure (CPAP) d. Bronchodilators

ANS: a, c Feedback a. This is a common medical treatment for RDS. b. Corticosteroids are given to women in preterm labor to decrease the risk of RDS. c. CPAP is used to assist neonates with RDS. d. Bronchodilators are given to neonates with bronchopulmonary dysplasia (BPD).

Contraindications for induction of labor include: a. Abnormal fetal position b. Postdated pregnancy c. Pregnancy-induced hypertension d. Placental abnormalities

ANS: a, d Contraindications for induction of labor include abnormal fetal position because of the risk of fetal injury and placental abnormalities because of the risk of hemorrhage. Pregnancy-induced hypertension and placental abnormalities are two of the common indications for induction of labor.

The perinatal nurse understands that the purpose of combining an opioid with a local anesthetic agent in an epidural is primarily to: a. Increase the total anesthetic volume b. Preserve a greater amount of maternal motor function c. Increase the intensity of the motor and sensory block d. Decrease the number of side effects

ANS: b Combining an opioid with a local anesthetic agent reduces the total amount of anesthetic required and helps to preserve a greater amount of maternal motor function.

The perinatal nurse teaches the postpartum woman about warning signs regarding development of postpartum infection. Signs and symptoms that merit assessment by the health-care provider include the development of a fever and: a. Breast engorgement b. Uterine tenderness c. Diarrhea d. Emotional lability

ANS: b During the immediate postpartum period, the most common site of infection is the uterine endometrium. This infection presents with a temperature elevation over 101°F, often within the first 24 to 48 hours after childbirth, followed by uterine tenderness and foul-smelling lochia.

Which of the following neonatal signs or symptoms would the nurse expect to see in a neonate with an elevated bilirubin level? a. Low glucose b. Poor feeding c. Hyperactivity d. Hyperthermia

ANS: b Feedback a. Hypoglycemia is not a sign that is related to an elevated bilirubin level. b. The baby is likely to feed poorly. An elevated bilirubin level adversely affects the central nervous system. Babies are often sleepy and feed poorly when the bilirubin level is elevated. c. Hyperactivity is the opposite of the behavior one would expect the baby to exhibit. d. Hyperthermia is not directly related to an elevated bilirubin level.

During a cesarean section, which action by the nurse is done to prevent compression of the descending aorta and vena cava? a. Right lateral tilt b. Left lateral tilt c. Elevate head of gurney at 30 degrees d. Administration of IV fluid preload of 500 to 1000 mL

ANS: b Positioning of the patient with a left tilt maintains a left uterine displacement to decrease the risk of aortocaval compression related to compression on the aorta and inferior vena cava due to weight of the gravid uterus.

The perinatal nurse notifies the physician of the findings related to Juanita's assessment. The first step in care will most likely be to: a. Prepare Juanita for surgery b. Administer intravenous fluids c. Apply ice to the perineum d. Insert a urinary catheter

ANS: c If the hematoma is less than 3 to 5 centimeters in diameter, the physician usually orders palliative treatments such as ice to the area for the first 12 hours along with pain medication. After 12 hours, sitz baths are prescribed to replace the application of ice. However, a hematoma larger than 5 centimeters may require incision and drainage with the possible placement of a drain.

A patient, G1 P0, is admitted to the labor and delivery unit for induction of labor. The following assessments were made on admission: Bishop score of 4, fetal heart rate 140s with good variability and no decelerations, TPR 98.6ºF, 88, 20, BP 120/80, negative obstetrical history. A prostaglandin suppository was inserted at that time. Which of the following findings, 6 hours after insertion, would warrant the removal of the Cervidil (dinoprostone)? a. Bishop score of 5 b. Fetal heart of 152 bpm c. Respiratory rate of 24 rpm d. Contraction frequency of every 2 minutes

ANS: d Feedback a. A Bishop score of 9 or higher indicates that the primigravida woman's cervix is ripe. b. A fetal heart rate of 152 is within normal limits for this fetus. c. A respiratory rate of 24 is within normal limits. d. Cervidil should be removed for tachysystole.

A nurse is admitting a woman for a scheduled cesarean section. Which of the following assessment data should be immediately reported to the physician? a. White cell count of 11,000 b. Hemoglobin of 11 g/dL c. Hematocrit of 33% d. Platelet count of 97,000

ANS: d Feedback a. This laboratory value is within normal limits for a pregnant woman. b. This laboratory value is within normal limits for a pregnant woman. c. This laboratory value is within normal limits for a pregnant woman. d. Normal range of platelets is 150,000 to 400,000. A low platelet count places the woman at risk for increased bleeding.

Providing information to parents about jaundice constitutes an important component of the nurse's discharge teaching. Ensuring that parents know when and who to call if their infant develops signs of jaundice will help decrease the risk of __________, or permanent brain damage.

ANS: kernicterus All newborns are screened before discharge for physiological jaundice. The central nervous system can be damaged from unconjugated bilirubin. If bilirubin crosses the blood-brain barrier, it can damage the cerebrum, causing a condition called kernicterus. Kernicterus occurs from brain cell necrosis and can permanently damage a newborn, depending on the amount of time the neurons are exposed to bilirubin, the susceptibility of the nervous system, and the function of the surviving neurons.

Part of the assessment of a preterm infant includes obtaining an abdominal girth measurement. The NICU nurse performs this assessment because the patient is at risk for __________.

ANS: necrotizing enterocolitis (NEC) When caring for a child with necrotizing enterocolitis, the nurse must measure and record frequent abdominal circumferences, auscultate bowel sounds before every feeding, and observe the abdomen for distention (observable loops or shiny skin indicating distention).

Postpartum woman are at an increased risk of thrombus formation immediately following birth due to an increased __________ level.

ANS: plasma fibrinogen Levels of plasma fibrinogen tend to remain elevated during the first few postpartal weeks. Although this alteration exerts a protective effect against hemorrhage, it increases the patient's risk of thrombus formation.

The perinatal nurse recognizes that the laboring multiparous patient who is attempting a vaginal birth following a previous cesarean birth (VBAC) needs frequent assessments to ensure that there is __________ during her labor.

ANS: progress Women with a previous history of cesarean birth may be offered a trial of labor, although a prompt cesarean birth is recommended at the earliest sign of maternal or fetal compromise.

Bonding is bidirectional from parent to infant and infant to parent. T/F

ANS: False Bonding is unidirectional from parent to infant. Attachment is bidirectional.

A nurse is caring for a woman who is 4 hours post-cesarean birth for arrest of labor. The labor and operative records indicate that she had premature rupture of membranes followed by 36 hours of labor. Her IV fluid intake for the past 24 hours is 2500 mL. The estimated blood loss is 1500 mL. Based on this data, the woman is at risk for which of the following? (Select all that apply.) a. Fluid volume deficit b. Infection c. Impaired mother-infant attachment d. Falls

ANS: a, b, c, dThe woman is at risk for fluid volume deficit related to blood loss and risk for postpartum hemorrhage due to risk of uterine atony. She is at risk for infection related to premature and prolonged rupture of membranes. The woman is at risk for impaired mother-infant attachment related to maternal pain and exhaustion. She is at risk for falls related to anesthesia and orthostatic hypotension.

A baby has just been admitted into the neonatal intensive care unit with a diagnosis of intrauterine growth restriction (IUGR). Which of the following maternal problems could have resulted in this complication? (Select all that apply.) a. Cholecystitis b. Hypertension c. Cigarette smoker d. Candidiasis e. Cerebral palsy

ANS: b, c Babies born to women with cholecystitis are not especially high risk for IUGR. Babies born to women with PIH or who smoke are high risk for IUGR. Babies born to women with candidiasis or cerebral palsy are not especially high risk for IUGR.

The perinatal nurse assessing a newborn for jaundice recalls that __________ is a process that converts the yellow lipid-soluble (nonexcretable) bilirubin pigment (present in bile) into a water-soluble (excretable) pigment.

ANS: conjugation Conjugation of bilirubin constitutes a major function of the newborn's liver. Conjugation is a process that converts the yellow lipid-soluble (nonexcretable) bilirubin pigment (present in bile) into a water-soluble (excretable) pigment.

The perinatal nurse caring for a laboring woman who is receiving an oxytocin infusion documents the following information: rate of __________, frequency and strength of __________, fetal __________, and cervical __________ and __________.

ANS: infusion; contractions; heart rate; dilatation; effacement Oxytocin protocols in many institutions require that the nurse remain at the patient's bedside at all times for careful surveillance. The following data should be placed on a flow sheet in the patient record: patient's vital signs, fetal heart rate, frequency, duration and strength of contractions, cervical effacement and dilatation, fetal station and lie, rate of oxytocin infusion intake and urine output, and the psychological response of the patient.

A nurse assesses a G2 P1 woman who gave birth to a 4500 gram baby boy 2 hours ago. The nurse notes that the woman's labor was only 2 hours and that the infant was delivered by the labor nurse. The nurse's assessment findings are: Fundus firm and midline at umbilicus Lochia heavy—saturates pad within 15 minutes and bleeding is a steady stream without clots Perineum intact, slight bruising Ice pack on perineum Vital signs are B/P 105/65, P 98, R 20, T 38° Based on this information, the nurse is concerned that the woman has a __________ of the __________ or __________.

ANS: laceration; cervix; vagina Based on the assessment data, the woman is experiencing an early postpartum hemorrhage (PPH). The hemorrhage is most likely not due to uterine atony because the fundus is firm and midline. Laceration of the cervix or vagina is the second most common cause of early PPH. This woman is displaying typical signs and symptoms of laceration of cervix or vagina—firm, midline fundus with steady stream of blood without clots.

The NICU nurse's patient assignment includes an infant who is 25 weeks' gestation. The nurse knows that according to the gestational age, this infant would be described as __________.

ANS: very premature The definition of very premature is a neonate born at less than 32 weeks' gestation. The definition of premature is a neonate born between 32 and 34 weeks' gestation. The definition of late premature is a neonate born between 34 and 37 weeks' gestation.

Augmentation of labor: a. Is part of the active management of labor instituted when the labor process is unsatisfactory and uterine contractions are inadequate b. Relies on more invasive methods when oxytocin and amniotomy have failed c. Is elective induction of labor d. Is an operative vaginal delivery that uses vacuum cups

ANS: a Feedback a. Augmentation stimulates uterine contractions after labor has started but not progressed appropriately. b. Augmentation uses amniotomy and oxytocin. c. Augmentation stimulates labor. d. Vacuum delivery is not part of augmentation of labor.

A multipara, 26 weeks' gestation and accompanied by her husband, has just delivered a fetal demise. Which of the following nursing actions is appropriate at this time? a. Encourage the parents to pray for the baby's soul. b. Advise the parents that it is better for the baby to have died than to have had to live with a defect. c. Encourage the parents to hold the baby. d. Advise the parents to refrain from discussing the baby's death with their other children.

A multipara, 26 weeks' gestation and accompanied by her husband, has just delivered a fetal demise. Which of the following nursing actions is appropriate at this time? a. Encourage the parents to pray for the baby's soul. b. Advise the parents that it is better for the baby to have died than to have had to live with a defect. c. Encourage the parents to hold the baby. d. Advise the parents to refrain from discussing the baby's death with their other children.

A post-cesarean section client has been ordered to receive 500 mL of 5% dextrose in water every 4 hours. The drop factor of the macrodrip tubing is 10 gtt/mL. To what drip rate should the nurse regulate the IV? __________ gtt/min

ANS: 21 Feedback: 21 gtt/min The formula for calculating drip rates is: volume multiplied by drop factor = drip rate time in minutes 500 mL = 10 gtt/cc = 21 gtt/min 4 hours = 60 min/hr

The postpartum nurse is caring for a couple who experienced an unplanned emergency cesarean birth. The nurse observes the following behaviors: Parents are gently touching their newborn. Mother is softly singing to her baby. Father is gazing into his baby's eyes. Based on this data, the correct nursing diagnosis is altered parent-infant bonding related to emergency cesarean birth. Cesarean birth can place the parents at risk for bonding, but based on the observed interaction with their newborn, the parents display positive signs of bonding. T/F

ANS: False

During an emergency cesarean birth the "time-out" procedure may be omitted based on the obstetrical emergency. T/F

ANS: False Joint commission guidelines for patient safety necessitate there always be a time-out to prevent wrong patient, wrong site, wrong procedure, and medical errors.

The perinatal nurse explains to the student nurse that the most frequent fetal risk associated with the use of forceps is cord compression. T/F

ANS: False The most frequent fetal risk associated with the use of forceps is superficial scalp or facial marks that will resolve quickly.

__________ is contraindicated with shoulder dystocia.

ANS: Fundal pressureFundal pressure is contraindicated with shoulder dystocia because it may further impact the shoulder and increases risk of fetal injury.

Eye movements are an example of newborn/infant style of communication. T/F

ANS: True Crying, cooing, facial expressions, eye movements, cuddling, and arm and leg movements are all examples of newborn/infant style of communication.

The perinatal nurse describes asynclitism to students as a presentation that occurs when the fetal head is turned toward the maternal sacrum or symphysis at an oblique angle. T/F

ANS: True Face and brow presentations are examples of asynclitism (the fetal head is presenting at a different angle than expected). Face and brow presentations hyperextend the neck and increase the overall circumference of the presenting part. These presentations are uncommon and are usually associated with fetal anomalies.

Metritis is an infection that usually starts at the placental site. T/F

ANS: True Metritis is an infection of the endometrium that usually starts at the placental site and spreads to encompass the entire endometrium.

Abruptio placenta is a risk factor for amniotic fluid embolism. T/F

ANS: True Risk factors for amniotic fluid embolism include induction of labor, maternal age over 35, operative delivery, placenta previa, abruptio placenta, polyhydramnios, eclampsia, and cervical or uterine lacerations.

Nursing actions that decrease the risk of skin breakdown include which of the following? (Select all that apply.) a. Using gelled mattresses b. Using emollients in groin and thigh areas c. Using transparent dressings d. Drying thoroughly

ANS: a, b, c Feedback a. Use of gelled mattresses decreases the risk of pressure sores. b. Use of emollients reduces the risk of irritation from urine. c. Use of transparent dressings reduces the risk of friction injuries. d. Drying thoroughly is important in maintaining body heat.

Approximately 8 hours ago, Juanita, a 32-year-old G1 P0, gave birth after 2 ½ hours of pushing. She required an episiotomy and an assisted birth (forceps) due to the weight and size of her baby (9 lb. 9 oz.). The perinatal nurse is performing an assessment of Juanita's perineal area. A slight bulge is palpated and the presence of ecchymoses to the right of the episiotomy is noted. The area feels "full" and is approximately 4 cm in diameter. Juanita describes this area as "very tender." The most likely cause of these signs and symptoms is: a. Hematoma formation b. Sepsis in the episiotomy site c. Inadequate repair of the episiotomy d. Postpartum hemorrhage

ANS: a A hematoma is a localized collection of blood in connective or soft tissue under the skin that follows injury of or laceration to a blood vessel without injury to the overlying tissue. The most common sign or symptom of a hematoma is unremitting pain and pressure. Upon examination of the perineal or vulvar areas, the nurse may notice discoloration and bulging of the tissue at the hematoma site. If touched, the patient complains of severe tenderness, and the clinician generally describes the tissue as "full."

A pregnant woman who has a history of cesarean births is requesting to have a vaginal birth after cesarean (VBAC). In which of the following situations should the nurse advise the patient that her request may be declined? a. Transverse fetal lie b. Flexed fetal attitude c. Previous low flap uterine incision d. Positive vaginal candidiasis

ANS: a Feedback a. A baby in the transverse lie is lying sideways in the uterus. This lie is incompatible physiologically with a vaginal delivery. b. A baby in the flexed fetal attitude is in a physiologic position for a vaginal delivery. c. A previous low flap uterine incision is not incompatible physiologically with a vaginal delivery. d. A positive vaginal Candidiasis culture is not an indication for cesarean birth.

Four women are close to delivery on the labor and delivery unit. The nurse knows to be vigilant to the signs of neonatal respiratory distress in which delivery? a. 42-week-gestation pregnancy complicated by intrauterine growth restriction b. 41-week-gestation pregnancy with biophysical profile score of 10 that morning c. 40-week-gestation pregnancy with estimated fetal weight of 3200 grams d. 39-week-gestation pregnancy complicated by maternal cholecystitis

ANS: a Feedback a. A post-term baby with intrauterine growth restriction (IUGR) is high risk for meconium aspiration syndrome, cold stress syndrome, hypoglycemia, and acidosis. In each case, the baby may exhibit signs of respiratory distress. b. A biophysical profile (BPP) of 10 is a normal finding. c. The normal birth weight is between 2500 and 4000 grams. d. Maternal gallbladder disease does not place the baby in danger of developing respiratory distress.

The perinatal nurse is assisting the student nurse with completion of documentation. The laboring woman has just given birth to a 2700 gram infant at 36 weeks' gestation. The most appropriate term for this is: a. Preterm birth b. Term birth c. Small for gestational age infant d. Large for gestational age infant

ANS: a Feedback a. A preterm infant is an infant with gestational age of fewer than 36 completed weeks. b. Term births are infants born between 37 and 40 weeks. c. SAG infants at 36 weeks weigh less than 2000 grams. d. LAG infants at 36 weeks weigh over 3400 grams.

The clinic nurse meets with Rebecca, a 30-year-old woman who is experiencing her first pregnancy. Rebecca's quadruple marker screen result is positive at 17 weeks' gestation. The nurse explains that Rebecca needs a referral to: a. A genetics counselor/specialist b. An obstetrician c. A gynecologist d. A social worker

ANS: a Feedback a. All women should be offered screening with maternal serum markers. The Triple Marker screen and the Quadruple Marker screen test for the presence of alpha-fetoprotein (AFP), estradiol, human chorionic gonadotropin (hCG), and other markers. These tests screen for potential neural tube defects, Down syndrome, and Trisomy 18. If the screen is positive, the woman should be referred to a genetics specialist for counseling, and further testing, such as chorionic villus sampling (CVS) or amniocentesis, should be performed. b. If genetic screening is positive, the woman should be referred to a genetics specialist for counseling, and further testing, such as chorionic villus sampling (CVS) or amniocentesis, should be performed. c. If genetic screening is positive, the woman should be referred to a genetics specialist for counseling, and further testing, such as chorionic villus sampling (CVS) or amniocentesis, should be performed. d. If genetic screening is positive, the woman should be referred to a genetics specialist for counseling, and further testing, such as chorionic villus sampling (CVS) or amniocentesis, should be performed.

A 42-week gestation neonate is admitted to the NICU (neonatal intensive care unit). This neonate is at risk for which complication? a. Meconium aspiration syndrome b. Failure to thrive c. Necrotizing enterocolitis d. Intraventricular hemorrhage

ANS: a Feedback a. Although there is nothing in the scenario that states that the amniotic fluid is green tinged, post-term babies are high risk for meconium aspiration syndrome. b. Post-term babies often gain weight very quickly. c. Preterm, not post-term, babies are high risk for necrotizing enterocolitis. d. Preterm, not post-term, babies are high risk for intraventricular hemorrhages.

A laboratory report indicates the L/S ratio (lecithin/sphingomyelin) results from an amniocentesis of a gravid patient with preeclampsia are 2:1. The nurse interprets the result as which of the following? a. The baby's lung fields are mature. b. The mother is high risk for hemorrhage. c. The baby's kidneys are functioning poorly. d. The mother is high risk for eclampsia.

ANS: a Feedback a. An L/S ratio of 2:1 usually indicates that the fetal lungs are mature. b. L/S ratios are unrelated to maternal blood loss. c. L/S ratios are unrelated to fetal renal function. d. L/S ratios are unrelated to maternal risk for becoming eclamptic.

The laboratory reported that the L/S ratio (lecithin/sphingomyelin) results from an amniocentesis of a gravid client with preeclampsia are 2:1. The nurse interprets the result as which of the following? a. The baby's lung fields are mature. b. The mother is high risk for hemorrhage. c. The baby's kidneys are functioning poorly. d. The mother is high risk for eclampsia.

ANS: a Feedback a. An L/S ratio of 2:1 usually indicates that the fetal lungs are mature. b. L/S ratios are unrelated to maternal blood loss. c. L/S ratios are unrelated to fetal renal function. d. L/S ratios are unrelated to maternal risk for becoming eclamptic.

Which of the following are primary risk factors for subinvolution of the uterus? (Select all that apply.) a. Fibroids b. Retained placental tissue c. Metritis d. Urinary tract infection

ANS: a, b, c Uterine fibroids can interfere with involution. Retained placental tissue does not allow the uterus to remain contracted. Infection in the uterus is a risk factor for subinvolution. UTI does not interfere with involution of the uterus.

A 37-year-old gravid 8 para 7 woman was admitted to the postpartum unit at 2 hours postbirth. On admission to the unit, her fundus was U/U, midline, and firm, and her lochia was moderate rubra. An hour later, her fundus is midline and boggy, and the lochia is heavy with small clots. Based on this assessment data, the first nursing action is: a. Massage the fundus of the uterus. b. Assist the woman to the bathroom and reassess the fundus. c. Notify the physician or midwife. d. Start IV oxytocin therapy as per standing orders.

ANS: a Feedback a. Correct. Based on the assessment data that the uterus is midline and boggy, the woman is experiencing uterine atony. b. Assisting the woman to the bathroom would be a nursing action if the uterus was not midline. c. Oxytocin would be given and the primary health provider would be notified if the uterus did not respond to uterine massage. d. Oxytocin would be given and the primary health provider would be notified if the uterus did not respond to uterine massage.

During the postpartum assessment, the perinatal nurse notes that a patient who has just experienced a forceps-assisted birth now has a large quantity of bright red bleeding. Her uterine fundus is firm. The nurse's most appropriate action is to notify the physician/certified nurse midwife and describe a: a. Need for vaginal assessment and repair b. Requirement for an oxytocin infusion c. Need for further information for the woman/family about forceps d. Requirement for bladder assessment and catheterization

ANS: a Feedback a. In the presence of a firm fundus and bright red bleeding, after a forceps-assisted birth there is a need for vaginal assessment and there may be a need for repair. b. The fundus is firm, and oxytocin is not indicated. c. There is no indication in this scenario that the family needs more information. d. There is no indication in this scenario that the bladder is contributing to the bleeding.

Which of the following is an indication for the administration of methylergonovine? a. Boggy uterus that does not respond to massage and oxytocin therapy b. Woman with a large hematoma c. Woman with a deep vein thrombosis d. Woman with severe postpartum depression

ANS: a Feedback a. Methylergonovine (methergine) is ordered for PPH due to uterine atony or subinvolution. It is used when massage and oxytocin therapy have failed to contract the uterus. b. Hematoma occurs when blood collects within the connective tissues of the vagina or perineal areas related to a vessel that ruptured and continues to bleed. Methylergonovine stimulates contraction of the smooth muscle of the uterus and would not have an effect on the vaginal or perineal areas. c. Heparin is usually prescribed for treatment of thrombosis. d. Methylergonovine is prescribed for treatment of uterine atony.

The nurse is developing a plan of care for a client who is in the "taking-in" phase after delivering a healthy baby boy. Which of the following should the nurse include in the plan? a. Provide the client with a nutritious meal. b. Teach baby care skills like diapering. c. Discuss the pros and cons of circumcision. d. Counsel her regarding future sexual encounters.

ANS: a Feedback a. Mothers are very hungry immediately after delivery. The nurse should provide the client with food. b. Baby care skills should be taught during the "taking-hold" phase. c. Baby care needs should be discussed during the "taking-hold" phase. d. A discussion of sexual issues should be deferred until the "taking-hold" phase or the "letting go" phase.

A neonate is born at 33 weeks' gestation with a birth weight of 2400 grams. This neonate would be classified as: a. Low birth weightb. Very low birth weightc. Extremely low birth weightd. Very premature

ANS: a Feedback a. Neonates with a birth weight of less than 2500 grams but greater than 1500 grams are classified as low birth weight. b. Neonates with birth weight less than 1500 grams but greater than 1000 grams are classified as very low birth weight. c. Neonates with birth weight less than 1000 grams are classified as extremely low birth weight. d. Neonates born less than 32 weeks' gestation are classified as very premature.

The perinatal nurse notes a rapid decrease in the fetal heart rate that does not recover immediately following an amniotomy. The most likely cause of this obstetrical emergency is: a. Prolapsed umbilical cord b. Vasa previa c. Oligohydramnios d. Placental abruption

ANS: a Feedback a. The nurse needs to assess the fetal heart rate immediately before and after the artificial rupture of membranes. Changes such as transient fetal tachycardia may occur and are common. However, other FHR patterns such as bradycardia and variable decelerations may be indicative of cord compression or prolapse. b. Vasa previa is abnormal insertion of the cord into the placenta c. Oligohydramnios is a decreased amount of amniotic fluid. d. Placenta abruption is separation of the placenta from the uterine wall. In this scenario, prolapsed cord is the most likely cause of the abrupt deceleration in the FHR.

The physician has ordered intravenous oxytocin for induction for four gravidas. In which of the following situations should the nurse refuse to comply with the order? a. Primigravida with complete placenta previa b. Multigravida with extrinsic asthma c. Primigravida who is 38 years old d. Multigravida who is colonized with group B streptococci

ANS: a Feedback a. The nurse should refuse to comply with this order because labor is contraindicated for a patient with complete placenta previa. This patient will have to be delivered via cesarean section. b. Induction is not contraindicated for patients with asthma. c. Induction is not contraindicated for patients who are 38 years old. d. Induction is not contraindicated for patients with group B streptococci.

A post-cesarean birth woman has been diagnosed with paralytic ileus. Which of the following symptoms would the nurse expect to see? a. Abdominal distension b. Polyuria c. Diastasis recti d. Dependent edema

ANS: a Feedback a. The nurse would expect to see a distended abdomen in a client with a paralytic ileus. b. Polyuria is unrelated to a paralytic ileus. c. Diastasis recti is unrelated to a paralytic ileus. d. Dependent edema is unrelated to a paralytic ileus.

Which of the following actions can decrease the risk for a postpartum infection? (Select all that apply.) a. Diet high in protein and vitamin C b. Increased fluid intake c. Ambulating within a few hours after delivery d. Washing nipples with soap prior to each breastfeeding session

ANS: a, b, c Protein and vitamin C assist with tissue healing. Rehydrating a woman after delivery can assist with decreasing risk for infections. Early ambulation decreases risk for infection by promoting uterine drainage. The woman should not wash her breasts with soap because soap can dry the tissue and increase the woman's risk for tissue breakdown.

A 16-year-old woman delivers a healthy, full-term male infant. The nurse notes the following behaviors 2 hours after the birth: Woman holds baby away from her body; woman refers to baby as "he"; woman verbalizes she wanted a baby girl; woman requests that baby be placed in the bassinet so she can eat her lunch. The most appropriate nursing diagnosis for this woman is: a. At risk for impaired parenting related to disappointment with baby as evidenced by verbalizing she wanted a girl b. At risk for impaired parenting related to nonnurturing behaviors as evidenced by holding baby away from body c. At risk for impaired mother-infant attachment as evidenced by woman requesting baby being placed in bassinet d. At risk for impaired mother-infant attachment related to disappointment as evidenced by calling baby "he"

ANS: a Feedback a. The potential is for impaired parenting related to disappointment in the gender of the baby. b. Holding baby away from her body during the first few hours is part of the maternal touch process. c. Focusing on eating during the first few hours is a behavior of taking-in and is anticipated during this phase. d. Some parents have not selected a name for their baby and will refer to their baby as "he" or "she." There is concern if the woman calls her baby "it."

The nurse is assisting a physician in the delivery of a baby via vacuum extraction. Which of the following nursing diagnoses for the gravida is appropriate at this time? a. Risk for injury b. Colonic constipation c. Risk for impaired parenting d. Ineffective individual coping

ANS: a Feedback a. There is a risk for injury. For example, the patient could suffer a cervical, vaginal, or perineal laceration. b. A diagnosis of colonic constipation is unrelated to the fact that the baby was delivered by forceps. c. There is nothing in the scenario that implies that the patient is at risk for impaired parenting. d. There is nothing in the scenario that implies that the patient is at risk for ineffective individual coping.

A baby boy was just born to a mother who had positive vaginal cultures for group B streptococci. The mother was admitted to the labor room 30 minutes before the birth. For which of the following should the nursery nurse closely observe this baby? a. Grunting b. Acrocyanosis c. Pseudostrabismus d. Hydrocele

ANS: a Feedback a. This infant is high risk for respiratory distress. The nurse should observe this baby carefully for grunting. b. Acrocyanosis is a normal finding. c. Pseudostrabismus is a normal finding. d. Hydrocele should be reported to the neonatologist. It is not, however, an emergent problem, and it is not related to group B streptococci colonization in the mother.

Tanya, a 30-year-old woman, is being prepared for an elective cesarean birth. The perinatal nurse assists the anesthesiologist with the spinal block and then positions Tanya in a supine position. Tanya's blood pressure drops to 90/52, and there is a decrease in the fetal heart rate to 110 bpm. The perinatal nurse's best response is to: a. Place a wedge under Tanya's left hip. b. Discontinue Tanya's intravenous administration. c. Have naloxone (Narcan) ready for administration. d. Have epinephrine ready for administration.

ANS: a In the event of severe maternal hypotension, the nurse should place the patient in a lateral position or use a wedge under the hip to displace the uterus, elevate the legs, maintain or increase the IV infusion rate, and administer oxygen by face mask at 10 to 12 L/min, or according to institution protocol.

The perinatal nurse recognizes that a risk factor for postpartum depression is: a. Inadequate social support b. Age >35 years c. Gestational hypertension d. Regular schedule of prenatal care

ANS: a Recognized risk factors for postpartum depression include an undesired or unplanned pregnancy, a history of depression, recent major life changes such as the death of a family member, moving to a new community, lack of family or social support, financial stress, marital discord, adolescent age, and homelessness.

The postpartum nurse caring for a 20-year-old G1 P0 woman who 3 hours ago delivered a healthy full-term infant, observes the woman who is lightly touching her baby girl with her fingertips but who seems to be uncomfortable holding her baby close to her body. Which of the following is an accurate interpretation of these observed behaviors? a. The woman is in the initial stage of maternal touch. b. The woman is in the taking-in phase. c. The woman is having difficulty in bonding with her baby. d. The woman needs to be medicated for pain.

ANS: a These are classical signs of the initial stage of Rubin's maternal touch.

The perinatal nurse teaches the student nurse that deep breathing exercises following a cesarean birth are critical to the prevention of (select all that apply): a. Pneumonia b. Atelectasis c. Abdominal distension d. Increased tidal volume

ANS: a, b Incisional pain and abdominal distension often cause patients to adopt shallow breathing patterns that can lead to decreased gas exchange and a reduced tidal volume. To facilitate adequate lung functions, patients should be taught how to perform pulmonary exercises. Expectoration of secretions and deep breathing help prevent common complications including atelectasis and pneumonia. Abdominal distension and gas pains are common after abdominal surgery and result from delayed peristalsis

Documentation related to vacuum delivery includes which of the following: a. Fetal heart rate b. Timing and number of applications c. Position and station of fetal head d. Maternal position

ANS: a, b, c Assessment of fetal heart rate is part of second-stage management, timing and number of applications are part of standard of care related to safe vacuum deliveries, and position and station of fetal head are noted for safe vacuum extraction. Maternal position is not critical to the documentation related to vacuum deliveries.

Hyperstimulation is defined as: a. Contractions lasting more than 2 minutes b. Five or more contractions in 10 minutes c. Contractions occurring within 1 minute of each other d. Uterine resting tone below 20 mm/Hg

ANS: a, b, c Contractions lasting more than 2 minutes, five or more contractions in 10 minutes, and contractions occurring within 1 minute of each other describe the criteria for hyperstimulation. Uterine resting tone below 20 mm/Hg reflects normal uterine resting tone.

A G2 P1 woman who experienced a prolonged labor and prolonged rupture of membranes is at risk for metritis. Which of the following nursing actions are directed at decreasing this risk? (Select all that apply.) a. Instruct woman to increase her fluid intake b. Instruct woman to change her peri-pads after each voiding c. Instruct woman to ambulate in the halls four times a day d. Instruct woman to apply ice packs to the perineum

ANS: a, b, c Feedback a. Maintaining adequate hydration can decrease a person's risk for infection. b. Lochia is a media for bacterial growth, so it is important to frequently change the peri-pads. c. Ambulation can decrease the risk of infection by promoting uterine drainage. d. Ice pack therapy is directed at decreasing edema of the perineum and promoting comfort. It has no effect on metriosis.

Which of the following nursing actions can assist a man in his transition to fatherhood? (Select all that apply.) a. Ask the man to share his ideas of what it means to be a father. b. Demonstrate infant care such as diapering and feeding. c. Engage couple in a discussion regarding each other's expectations of the fathering role. d. Provide the man with information on infant care.

ANS: a, b, c, d Each of these actions can assist the father in his transition. It is important for the man to be able to learn and practice infant care skills in a nonthreatening environment. It is also important for the man to be able to openly talk about his feelings regarding fatherhood and for the couple to identify mutual expectations of the fathering role.

A nurse is completing the initial assessment on a neonate of a mother with type I diabetes. Important assessment areas for this neonate include which of the following? (Select all that apply.) a. Assessment of cardiovascular system b. Assessment of respiratory system c. Assessment of musculoskeletal system d. Assessment of neurological system

ANS: a, b, c, d Feedback a. Neonates of mothers with type I diabetes are at higher risk for cardiac anomalies. b. Neonates of mothers with type I diabetes are at higher risk for RDS due to a delay in surfactant production related to high maternal glucose levels. c. Neonates of mothers with type I diabetes are usually large and are at risk for a fractured clavicle. d. Neonates of mothers with type I diabetes are at higher risk for neurological damage and seizures due to neonatal hyperinsulinism.

Which of the following are common assessment findings of postmature neonates? (Select all that apply.) a. Dry and peeling skin b. Abundant vernix caseosa c. Hypoglycemia d. Thin, wasted appearance

ANS: a, b, c, d Feedback a. Vernix caseosa covers the fetus's body around 17 to 20 weeks' gestation; as pregnancy advances, the amount of vernix decreases. Vernix prevents water loss from the skin to the amniotic fluid; as the amount of vernix decreases, an increasing amount of water is lost from the skin. This contributes to the dry and peeling skin seen in postmature neonates. b. Vernix caseosa covers the fetus's body around 17 to 20 weeks' gestation; as pregnancy advances, the amount of vernix decreases. c. Placental insufficiency related to the aging of the placenta may result in postmaturity syndrome, in which the fetus begins to use its subcutaneous fat stores and glycemic stores. This results in the thin and wasted appearance of the neonate and risk for hypoglycemia during the first few hours post-birth. d. Placental insufficiency related to the aging of the placenta may result in postmaturity syndrome, in which the fetus begins to use its subcutaneous fat stores and glycemic stores. This results in the thin and wasted appearance of the neonate and risk for hypoglycemia during the first few hours post-birth.

Which of the following factors place a new mother at risk for parenting? (Select all that apply.) a. She is 17 years old. b. Family income is below the average income. c. Her parents live in the same city and are perceived as helpful. d. She dropped out of school at age 13.

ANS: a, b, d Adolescent parents may have a more difficult transition to parenthood because they have not made the transition to adulthood. Financial concerns can hamper the transition to parenthood because the focus of attention may be on where to get money to pay for daily living expenses versus on the care of their newborn. Decreased ability to read and comprehend information regarding child care may hamper the ability to gain knowledge about the care of their child.

A nurse is caring for a 40 weeks' gestation neonate. The neonate is 12 hours post-birth and has been admitted to the NICU for meconium aspiration. The nurse recalls that the following are potential complications related to meconium aspiration (select all that apply): a. Obstructed airway b. Hyperinflation of the alveoli c. Hypoinflation of the alveoli d. Decreased surfactant proteins

ANS: a, b, d Feedback a. The presence of meconium in the neonate's lungs can cause a partial obstruction of the lower airway that leads to a trapping of air and a hyperinflation of the alveoli. b. The presence of meconium in the neonate's lungs can cause a partial obstruction of the lower airway that leads to a trapping of air and a hyperinflation of the alveoli. c. The presence of meconium in the neonate's lungs can cause a partial obstruction of the lower airway that leads to a trapping of air and a hyperinflation of the alveoli. d. The presence of meconium in the lungs can also cause a chemical pneumonitis and inhibit surfactant production.

Which of the following nursing actions are directed at promoting bonding? (Select all that apply.) a. Providing opportunity for parents to hold their newborn as soon as possible following the birth. b. Providing opportunities for the couple to talk about their birth experience and about becoming parents. c. Promoting rest and comfort by keeping the newborn in the nursery at night. d. Providing positive comments to parents regarding their interactions with their newborn.

ANS: a, b, d Parent bonding can be delayed by prolonged periods of separation from their child. The other three actions support parent bonding with their newborn.

Nursing actions focused at reducing a postpartum woman's risk for cystitis include which of the following? (Select all that apply.) a. Voiding within a few hours post-birth b. Oral intake of a minimum of 1000 mL per day c. Changing peri-pads every 3 to 4 hours or more frequently as indicated d. Reminding the woman to void every 3 to 4 hours while awake

ANS: a, c, d Early voiding helps flush bacteria from the urethra. Voiding every 3 to 4 hours will decrease the risk of bacterial growth in the bladder. Soiled peri-pads are a media for bacterial growth. It is recommend that a postpartum woman drink a minimum of 3000 mL/day to help dilute urine and promote frequent voiding.

A nurse is caring for a 10-day-old neonate who was born at 33 weeks' gestation. Which of the following actions assist the nurse in assessing for signs of feeding tolerance? (Select all that apply.) a. Check for presence of bowel sounds b. Assess temperature c. Check gastric residual by aspirating stomach contents d. Assess stools

ANS: a, c, d Feedback a. Feedings should be held and physician notified if bowel sounds are absent. b. The neonate's temperature has no direct effect on feeding tolerance. c. Aspirated stomach contents are assessed for amount, color, and consistency. This assists in the evaluation of the degree of digestion and absorption. d. Stools are assessed for consistency, amount, and frequency. This assists in the evaluation of the degree of digestion and absorption.

The nurse is caring for a postpartum woman who gave birth to a healthy, full-term baby girl. She has a 2-year-old son. She voices concern about her older child's adjustment to the new baby. Nursing actions that will facilitate the older son's adjustment to having a new baby in the house would include which of the following? (Select all that apply.) a. Explain to the mother that she can have her son lie in bed with her when he is visiting her in the hospital. b. Teach her son how to change the baby's diapers. c. Assist her son in holding his new baby sister. d. Recommend that she spend time reading to her older son while he sits in her lap.

ANS: a, c, d Two-year-olds enjoy being close to their mothers, including lying next to their mothers or being held. Changing diapers is not viewed as a pleasurable experience and is not developmentally appropriate for a 2-year-old. Children enjoy being able to hold their sibling and feeling "grown up."

Which of the following factors increases the risk of necrotizing enterocolitis (NEC) in very premature neonates? (Select all that apply.) a. Early oral feedings with formula b. Prolonged use of mechanical ventilation c. Hyperbilirubinemia d. Nasogastic feedings

ANS: a, d Feedback a. Preterm neonates have a decreased ability to digest and absorb formula. Undigested formula can cause a blockage in the intestines leading to necrosis of the bowel. b. Preterm neonates are predisposed to NEC due to alteration in blood flow to the intestines, impaired gastrointestinal host defense, and alteration in inflammatory response. c. Preterm neonates are predisposed to NEC due to alteration in blood flow to the intestines, impaired gastrointestinal host defense, and alteration in inflammatory response. d. Bacterial colonization in the intestines can occur from contaminated feeding tubes causing an inflammatory response in the bowel.

The perinatal nurse observes the new mother watching her baby daughter closely, touching her face, and asking many questions about infant feeding. This stage of mothering is best described as: a. Taking in b. Taking hold c. Taking charge d. Taking time

ANS: b As the mother's physical condition improves, she begins to take charge and enters the taking-hold phase where she assumes care for herself and her infant. At this time, the mother eagerly wants information about infant care and shows signs of bonding with her infant. During this phase, the nurse should closely observe mother-infant interactions for signs of poor bonding, and if present, implement actions to facilitate attachment.

Karen, a G2, P1, experienced a precipitous birth 90 minutes ago. Her infant is 4200 grams and a repair of a second-degree laceration was needed following the birth. As part of the nursing assessment, the nurse discovers that Karen's uterus is boggy. Furthermore, it is noted that Karen's vaginal bleeding has increased. The nurse's most appropriate first action is to: a. Assess vital signs including blood pressure and pulse. b. Massage the uterine fundus with continual lower segment support. c. Measure and document each perineal pad changed in order to assess blood loss. d. Ensure appropriate lighting for a perineal repair if it is needed.

ANS: b As the primary caregiver, the registered nurse may be the first person to identify excessive blood loss and initiate immediate actions. The nurse should first locate the uterine fundus and initiate fundal massage. Nursing actions performed after the massage are frequent vital sign measurements with an automatic device, measuring the length of time it takes for blood loss to saturate a pad, and assessing for bladder distention.

The perinatal nurse is preparing a woman for a scheduled cesarean birth. The woman will be receiving spinal anesthesia for the birth. In order to prevent maternal hypotension, the nurse: a. Assists the woman to lie down in a supine position. b. Administers a rapid intravenous infusion of 500 mL of normal saline. c. Assesses blood pressure and pulse every 5 minutes, three times, before the spinal insertion. d. Encourages frequent cleansing breaths after the patient has been placed in the correct position for the anesthesia administration.

ANS: b Complications that may occur with spinal anesthesia block include maternal hypotension, decreased placental perfusion, and an ineffective breathing pattern. Prior to administration, the patient's fluid balance is assessed, and IV fluids are administered to reduce the potential for sympathetic blockade (decreased cardiac output that results from vasodilation with pooling of blood in the lower extremities). Following administration of the anesthetic, the patient's blood pressure, pulse, and respirations and fetal heart rate must be taken and documented every 5 to 10 minutes.

The nurse notes that a new father gazes at his baby for prolonged periods of time and comments that his baby is beautiful and he is very happy having a baby. These behaviors are commonly associated with: a. Bonding b. Engrossment c. Couvade syndrome d. Attachment

ANS: b Feedback a. Bonding is defined as the emotional feelings that begin during pregnancy or shortly after birth between the parent and the newborn. Bonding is unidirectional from parent to newborn. b. Correct. Characteristics of engrossment are visual awareness of baby, tactile awareness of baby, perception that baby is perfect, strong attraction to baby, feeling of strong elation, and increased self-esteem. c. Couvade syndrome relates to a set of pregnancy symptoms the father experiences during pregnancy of the woman. d. Attachment is a connection that forms from parent to infant and infant to parent. Attachment has a lifelong impact on the developing individual.

You are caring for a primiparous woman admitted to labor and delivery for induction of labor at 42 weeks' gestation. She asks you to explain the factors that contribute to prolonged labor. The best response would be to state the following: a. Primiparous women are not at risk for dystocia because they usually have small babies. b. Dystocia is related to uterine contractions, the pelvis, the fetus, the position of the mother, and psychosocial response. c. Labor is primarily associated with pelvic abnormalities. d. Dystocia is typically diagnosed prior to labor based on pelvimetry.

ANS: b Feedback a. Dystocia is not exclusively related to fetal size and being primiparous. b. This is the only correct definition of prolonged labor and dystocia. The success of any labor depends on the complex interrelationship of several factors: fetal size, presentation, position, size and shape of the pelvis, and quality of uterine contractions. c. Pelvic abnormality is the least important contributor to dystocia. d. Dystocia is diagnosed during, not prior to, labor.

Your pregnant patient is in her first trimester and is scheduled for an abdominal ultrasound. When explaining the rationale for early pregnancy ultrasound, the best response is: a. "The test will help to determine the baby's position." b. "The test will help to determine how many weeks you are pregnant." c. "The test will help to determine if your baby is growing appropriately." d. "The test will help to determine if you have a boy or girl."

ANS: b Feedback a. Fetal position during pregnancy changes, and position in the first trimester is not indicative of position later in pregnancy. b. Fetal growth and size are fairly consistent during the first trimester and are a reliable indicator of the weeks of gestation. c. Fetal growth is best assessed later in pregnancy. d. The primary rationale for ultrasounds is not to determine gender.

Which of the following sites is priority for the nurse to assess when caring for a breastfeeding client, G8 P5, who is 1 hour postdelivery? a. Nipples b. Fundus c. Lungs d. Rectum

ANS: b Feedback a. Her nipples should be assessed, but this is not the priority assessment. b. This client is a grand multipara. She is high risk for uterine atony and postpartum hemorrhage. The nurse should monitor her fundus very carefully. c. Her lungs should be assessed bilaterally, but this is not the priority assessment. d. Her rectum should be assessed for hemorrhoids, but this is not the priority assessment.

A full-term neonate who is 30 hours old has a bilirubin level of 10 mg/dL. The neonate has a yellowish tint to the skin of the face. The mother is breastfeeding her newborn. The nurse caring for this neonate would anticipate which of the following interventions? a. Phototherapy b. Feeding neonate every 2 to 3 hours c. Switch from breastfeeding to bottle feeding d. Assess red blood cell count

ANS: b Feedback a. Phototherapy is considered when the levels are 12 mg/dL or higher when the neonate is 25 to 48 hours old. Neonates re-absorb increased amounts of unconjugated bilirubin in the intestines due to lack of intestinal bacteria and decreased gastrointestinal motility. b. Adequate hydration promotes excretion of bilirubin in the urine. c. Colostrum acts as a laxative and assists in the passage of meconium. d. Assessing RBC is not a treatment for hyperbilirubinemia.

Your patient is a 28-year-old gravida 2 para 1 in active labor. She has been in labor for 12 hours. Upon further assessment, the nurse determines that she is experiencing a hypotonic labor pattern. Possible maternal and fetal implications from hypotonic labor patterns are: a. Intrauterine infection and maternal exhaustion with fetal distress usually occurring early in labor. b. Intrauterine infection and maternal exhaustion with fetal distress usually occurring late in labor. c. Intrauterine infection and postpartum hemorrhage with fetal distress early in labor. d. Intrauterine infection and ruptured uterus and fetal death.

ANS: b Feedback a. The risk of hypotonic labor occurs later in labor. b. Hypotonic labor patterns increase risk for infection and maternal exhaustion, with fetal distress occurring late in labor as hypotonic patterns prolong labor. c. There is not an increased risk of postpartum hemorrhage or fetal distress in early labor. d. Hypotonic patterns do not result in rupture of the uterus.

A primigravida woman at 42 weeks' gestation received Prepidil (dinoprostone) for induction 12 hours ago. The Bishop score is now 3. Which of the following actions by the nurse is appropriate? a. Perform Nitrazine analysis of the amniotic fluid. b. Report the lack of progress to the obstetrician. c. Place the woman on her left side. d. Ask the doctor for an order for oxytocin.

ANS: b Feedback a. There is nothing in the scenario that implies that the membranes may have ruptured. b. Little progress has taken place. The Bishop score of a primigravida will need to be 9 or higher before oxytocin will be effective. c. There is nothing in the scenario that implies that the patient needs to be placed on her side. d. The Bishop score of a primigravida will need to be 9 or higher before oxytocin will be effective.

Your pregnant patient is having maternal alpha-fetoprotein (AFP) screening. She does not understand how a test on her blood can indicate a birth defect in the fetus. The best reply by the nurse is :a. "We have done this test for a long time." b. "If babies have a neural tube defect, alpha-fetoprotein leaks out of the fetus and is absorbed into your blood, causing your level to rise. This serum blood test detects that rise." c. "Neural tube defects are a genetic anomaly, and we examine the amount of alpha-fetoprotein in your DNA." d. "If babies have a neural tube defect, this results in a decrease in your level of alpha-fetoprotein."

ANS: b Feedback a. This response does not explain AFP screening. b. When a neural tube defect is present, AFP is absorbed in the maternal circulation, resulting in a rise in the maternal AFP level. c. AFP testing is not related to DNA. d. Fetal neural tube defects result in an increase in maternal AFP.

The perinatal nurse caring for Emily, a 24-year-old mother of an infant born at 26 weeks' gestation, is providing discharge teaching. Emily is going to travel to the specialty center approximately 200 miles away where her daughter is receiving care. The nurse tells Emily that it is normal for Emily to feel (select all that apply): a. In control b. Anxious c. Guilty d. Overwhelmed

ANS: b, c, d Feedback a. Parents usually feel out of control. b. Correct answer. c. Correct answer. d. Correct answer.

The nurse is caring for a recently immigrated Chinese woman in the postpartum unit. Based on cultural beliefs and practices of the woman, the nurse would anticipate which of the following? (Select all that apply.) a. The woman prefers cold water for drinking. b. The woman prefers not to shower. c. The woman prefers to have her female relatives care for her baby. d. The woman prefers to have her family bring her food to eat.

ANS: b, c, d In traditional Chinese beliefs and practices, the woman is to rest and female family members take care of the woman and her infant. During the first month, the woman is to avoid yin energy by eating specific foods and avoiding drinking or touching cold water.

A 1-day-old neonate in the well-baby nursery is suspected of suffering from drug withdrawal because he is markedly hyperreflexic and is exhibiting which of the following additional sign or symptom? a. Prolonged periods of sleep b. Hypovolemic anemia c. Repeated bouts of diarrhea d. Pronounced pustular rash

ANS: c Feedback a. Babies who are withdrawing from drugs have disorganized behavioral states and sleep very poorly. b. There is nothing in the scenario that indicates that this child is hypovolemic or anemic. c. Babies who are experiencing withdrawal often experience bouts of diarrhea. d. A pustular rash is characteristic of an infectious problem, not of neonatal abstinence syndrome.

A woman on the day of discharge from the postpartum unit requests clean towels so she can take a shower, asks a number of questions regarding breastfeeding, and shares that she is nervous about taking her baby home and not being able to remember everything she has been taught. These are behaviors associated with: a. Bonding b. Taking in c. Taking hold d. Attachment

ANS: c Feedback a. Bonding is defined as the emotional feelings that begin during pregnancy or shortly after birth between the parent and the newborn. Bonding is unidirectional from parent to newborn. b. In the taking-in phase, women are dependent and need assistance with self-care and care of the infant. c. Correct. These are common behaviors of women in the taking-hold phase. Women during this phase have moved to being more independent and able to initiate self-care. They are highly interested in learning about the care of their baby but can easily become frustrated and discouraged when they do not immediately master a new skill. d. Attachment is a connection that forms from parent to infant and infant to parent. Attachment has a lifelong impact on the developing individual.

A NICU nurse is caring for a full-term neonate being treated for group B streptococcus. The mother of the neonate is crying and shares that she cannot understand how her baby became infected. The best response by the nurse is: a. "Newborns are more susceptible to infections due to an immature immune system. Would you like additional information on the newborn immune system?" b. "The infection was transmitted to your baby during the birthing process. Do you have a history of sexual transmitted infections?" c. "Approximately 10% to 30% of women are asymptomatic carries of group B streptococcus which is found in the vaginal area. What other questions do you have regarding your baby's health?" d. "I see that this is very upsetting for you. I will come back later and answer your questions."

ANS: c Feedback a. Correct information, but does not fully address the woman's concern. b. Correct, but GBS is not a sexually transmitted disease. c. Correct. This response answers her questions and allows her to ask additional questions about her baby's health. d. Acknowledges that she is upset but does not provide immediate information.

A nurse is preparing a woman in early labor for an urgent cesarean birth related to breech presentation. Select the best nursing action for reducing the couple's anxiety levels. a. Explain the reason for the need for a cesarean section .b. Inform parents that their baby is in distress. c. Ask the couple to share their concerns. d. Reassure the couple that both the woman and baby are in no danger.

ANS: c Feedback a. Explaining the reason she is having a cesarean birth is helpful but may not address their concerns. b. It is important to acknowledge that the baby is stable, but this response does not allow the couple to share their concerns that may be causing an increase in anxiety. c. By asking the couple to share their concerns, the nurse can address these concerns. d. Reassuring the couple that the woman and baby are in no danger is correct, but it is not the best answer because it does not allow the couple to verbalize their concerns.

The perinatal nurse is providing care to Carol, a 28-year-old multiparous woman in labor. Upon arrival to the birthing suite, Carol was 7 cm dilated and experiencing contractions every 1 to 2 minutes which she describes as "strong." Carol states she labored for 1 hour at home. As the nurse assists Carol from the assessment area to her labor and birth room, Carol states that she is feeling some rectal pressure. Carol is most likely experiencing: a. Hypertonic contractions b. Hypotonic contractions c. Precipitous labor d. Uterine hyperstimulation

ANS: c Feedback a. Hypertonic contractions result in little cervical change. b. Hypotonic contractions result in little cervical change. c. Contrary to both hypertonic and hypotonic labor, precipitate labor contractions produce very rapid, intense contractions. A precipitous labor lasts less than 3 hours from the beginning of contractions to birth. Patients often progress through the first stage of labor with little or no pain and may present to the birth setting already advanced into the second stage of labor. d. Patients with precipitous labor often progress through the first stage of labor with little or no pain and may present to the birth setting already advanced into the second stage of labor. Precipitous labor contractions produce very rapid, intense contractions.

During labor induction with oxytocin, the fetal heart rate baseline is in the 140s with moderate variability. Contraction frequency is assessed to be every 2 minutes with duration of 60 seconds, of moderate strength to palpation. Based on this assessment, the nurse should take which action? a. Increase oxytocin infusion rate per physician's protocol. b. Stop oxytocin infusion immediately. c. Maintain present oxytocin infusion rate and continue to assess. d. Decrease oxytocin infusion rate by 2 mU/min and report to physician.

ANS: c Feedback a. Increasing the oxytocin infusion could result in uterine hyperstimulation. b. The uterine contraction pattern is normal, and oxytocin infusion should be maintained, not stopped. c. Correct. Maintain present oxytocin infusion rate and continue to assess is the correct response, as this question describes a normal uterine contraction pattern. d. The uterine contraction pattern is normal, and oxytocin infusion should be maintained, not stopped or decreased.

A woman who is 12 weeks postpartum presents with the following behavior: she reports severe mood swings and hearing voices, believes her infant is going to die, she has to be reminded to shower and put on clean clothes, and she feels she is unable to care for her baby. These behaviors are associated with which of the following? a. Postpartum blues b. Postpartum depression c. Postpartum psychosis d. Maladaptive mother-infant attachment

ANS: c Feedback a. Postpartum blues usually occurs within the first few weeks of the postpartum period. Women experiencing postpartum blues will have mild mood swings, and they can take care of themselves as well as their baby. b. Women with PPD are predominately depressed and do not have mood swings. c. Postpartum psychosis is associated with a break from reality reflected in the woman hearing voices. d. The symptoms reported are reflective of a psychiatric disorder beyond maladaptive attachment.

The nurse is assessing a baby girl on admission to the newborn nursery. Which of the following findings should the nurse report to the neonatologist? a. Intermittent strabismus b. Startling c. Grunting d. Vaginal bleeding

ANS: c Feedback a. Pseudostrabismus is a normal finding. b. Startling is a normal finding. c. Grunting is a sign of respiratory distress. The neonatologist should be notified. d. Vaginal bleeding is a normal finding.

A postpartum nurse has received an exchange report on the four following mother-baby couplets. Based on the provided information, which couplet should the nurse first assess? a. A 25-year-old G2P1 woman who is 36 hours postbirth and is having difficulty breastfeeding her baby girl. Her fundus is firm at the umbilicus, and lochia is moderate to scant. b. A 16-year-old G1P0 who will be discharged in the afternoon. It was reported that she refers to her baby boy as "it" and that she requested to have her baby stay in the nursery so she could sleep. c. A 32-year-old G5P4 woman who delivered a 4500 gram baby boy 2 hours ago after a 20 hour labor that was augmented. It was reported that her fundus is 2 cm above umbilicus with moderate lochia. d. A 28-year-old G2P1 woman who delivered a 3800 gram baby girl by elective cesarean birth. She had spinal anesthesia and was given intrathecal preservative-free morphine for postoperative pain management. Her vital signs are B/P 115/75, P 80, R 18 T 98.

ANS: c Feedback a. The priority need for this woman is breastfeeding assistance which does not require immediate attention. b. The data indicate that the woman is experiencing a delay in bonding and that social services should become involved. This needs to be done prior to discharge but does not require immediate attention. c. This woman is at risk for hemorrhage (large baby, prolonged labor, augmented labor, high parity, and immediate postpartum). This woman needs to be assessed first to determine whether the fundus is firm and if lochia is within normal limits. d. Based on data provided, this woman is stable, but should be assessed second.

The NICU nurse recognizes that respiratory distress syndrome results from a developmental lack of: a. Lecithin b. Calcium c. Surfactant d. Magnesium

ANS: c Feedback a. The ratio of lecithin to sphingomyelin in the amniotic fluid is used to assess maturity of fetal lungs. b. Calcium is needed to prevent undermineralization of bones. c. Respiratory distress syndrome (RDS) is a developmental respiratory disorder that affects preterm newborns due to lack of lung surfactant. The pathology of RDS is that there is diffuse atelectasis with congestion and edema in the lung spaces. On deflation, the alveoli collapse, and there is decreased lung compliance. d. Magnesium is needed to prevent undermineralization of bones.

It is noted that the amniotic fluid of a 42-week gestation baby, born 30 seconds ago, is thick and green. Which of the following actions by the nurse is critical at this time? a. Perform a gavage feeding immediately. b. Assess the brachial pulse. c. Assist a physician with intubation. d. Stimulate the baby to cry.

ANS: c Feedback a. This action is not appropriate. The baby needs tracheal suctioning. b. The baby needs to have tracheal suctioning. The most important action to promote health for the baby is for the health-care team to establish an airway that is free of meconium. c. This action is appropriate. The baby needs to be intubated in order for deep suctioning to be performed by the physician. A nurse would not intubate and suction but rather would assist with the procedures. d. It is strictly contraindicated to stimulate the baby to cry until the trachea has been suctioned. The baby would aspirate the meconium-stained fluid, which could result in meconium-aspiration syndrome.

The perinatal nurse accurately defines postpartum hemorrhage by including a decrease in hematocrit levels from pre- to postbirth by: a. 5% b. 8% c. 10% d. 15%

ANS: c Historically, practitioners have defined postpartum hemorrhage as a blood loss greater than 500 mL following a vaginal birth and 1000 mL or more following a cesarean birth. Hematocrit levels that decrease 10% from pre- to postbirth measurements are also included in the definition.

Nursing actions that minimize oxygen demands in the neonate include which of the following? (Select all that apply.) a. Providing frequent rest breaks when feeding b. Placing neonate on back for sleeping c. Maintaining a neutral thermal environment (NTE) d. Clustering nursing care

ANS: c, d Feedback a. A prolonged feeding session increases energy consumption that increases oxygen consumption. b. Placing the neonate on the back for sleeping has no effect on oxygen consumption. c. A decrease in environmental temperature leads to a decrease in the neonate's body temperature which leads to an increase in respiratory and heart rate that leads to an increase in oxygen consumption. d. Clustering of nursing care decreases stress which decreases oxygen requirements.

Which of the following nursing actions are directed at assisting men in their transition to fatherhood? (Select all that apply.) a. Encourage the woman to take on the major responsibility for infant care. b. Talk to the man, away from his partner, about his expectations of the fathering role. c. Praise the father for his interactions with his infant. d. Provide information on infant care and behavior to both parents.

ANS: c, d It is important to first have the couple discuss with each other their expectations of the fathering role. Once this has occurred, then the woman and nurse need to support the man in his role of infant care. Both parents need to receive information about infant care and infant behaviors, and both parents need to be praised for their interactions with their baby.

A baby was born 4 days ago at 34 weeks' gestation. She is receiving phototherapy as ordered by the physician for physiological jaundice. She has symptoms of temperature instability, dry skin, poor feeding, lethargy, and irritability. The nurse's priority nursing action(s) is (are) to (select all that apply): a. Verify laboratory results to check for hypomagnesia. b. Verify laboratory results to check for hypoglycemia. c. Monitor the baby's temperature to check for hypothermia. d. Calculate 24-hour intake and output to check for dehydration.

ANS: c, d There are two priority nursing interventions for hyperbilirubinemia. Hydration status is important if the newborn shows signs of dehydration such as dry skin and mucus membranes, poor intake, concentrated urine or limited urine output, and irritability. The newborn should also be kept warm while receiving phototherapy. When an infant is under phototherapy, the temperature needs to be monitored closely because the lights give off extra heat, but if the newborn is in an open crib and undressed, hypothermia may occur. Hypomagnesia and hypoglycemia are not related to phototherapy.

Which of the following is a medical indication for a cesarean birth? (Select all that apply.) a. Maternal blood pressure of 130/90 b. Cervical dilation of 1.5 cm per hour during the active phase of labor c. Late deceleration of the fetal heart rate with minimal variability d. Complete placenta previae. Arrest of fetal descent

ANS: c, d, eA maternal blood pressure of 130/90 may be an indication of mild PHI which is not a medical indication for cesarean birth. Cervical dilation of 1.5 cm/minutes is within normal limits for cervical changes during the active phase. Late decelerations combined with minimal variability in the fetal heart rate reflect fetal intolerance of labor and are an indication for cesarean birth. A complete placenta previa covers the internal os necessitating a cesarean birth. Arrest of fetal descent indicates cephalopelvic disproportion.

A woman is 3 hours post-early-postpartum hemorrhage of 800 mL at delivery. Select the nursing actions for care of this patient. (Select all that apply.) a. Limit fluid intake to prevent nausea and vomiting. b. Assess fundus every 4 hours during the first 8 hours. c. Explain the importance of preventing an overdistended bladder. d. Provide assistance with ambulation.

ANS: c, dFluid intake should be increased following a postpartum hemorrhage to decrease the risk of hypovolemia. The fundus should be assessed a minimum of every hour for the first 4 hours following a PPH. The woman needs to know the importance of preventing an overdistended bladder to decrease the risk of further hemorrhage. After postpartum hemorrhage, a woman is at risk for orthostatic hypotension.

The perinatal nurse listens as Chantal describes her labor and emergency cesarean birth. Providing an opportunity to review this experience may assist Chantal in: a. Her role development in the "letting go" stage b. Decreasing her ambivalence about her labor and birth c. Understanding her guilt involved in her labor and birth d. Developing more positive feelings about her labor and birth

ANS: d After a cesarean birth, especially when unplanned, nurses must be aware of the myriad of potential psychological issues that may arise. Research suggests that women may perceive cesarean birth to be a less positive experience than a vaginal birth. Unplanned or emergent cesarean deliveries and the experience of cesarean birth may be associated with more negative perceptions of the birthing experience. Allowing Chantal to talk about the experience can help her develop a more positive attitude about her own experience.

The following four babies are in the neonatal nursery. Which of the babies should be seen by the neonatologist as soon as possible? a. 1-day-old, HR 170 bpm, crying b. 2-day-old, T 98.9°F, slightly jaundice c. 3-day-old, breastfeeding q 2 h, rooting d. 4-day-old, RR 70 rpm, dusky coloring

ANS: d Feedback a. A slight tachycardia—170 bpm—is normal when a baby is crying. b. Slight jaundice on day 2 is within normal limits. c. It is normal for a breastfed baby to feed every 2 hours. d. A dusky skin color is abnormal in any neonate, whether or not the respiration rate is normal, although this baby is also slightly tachypneic.

A client is 1 hour postpartum from a vacuum delivery over a midline episiotomy of a 4500-gram neonate. Which of the following nursing diagnoses is appropriate for this mother? a. Risk for altered parenting b. Risk for imbalanced nutrition: less than body requirements c. Risk for ineffective individual coping d. Risk for fluid volume deficit

ANS: d Feedback a. Although the baby is macrosomic, there is no evidence that this mother is high risk for altered parenting. b. This woman's baby is macrosomic—there is no indication that this woman is consuming a diet that is less than body requirements. c. There is no evidence that this mother is high risk for altered coping. d. This client is high risk for fluid volume deficit. Women who deliver macrosomic babies are high risk for uterine atony, which can lead to heavy flow of lochia.

The primary complications of amniocentesis are: a. Damage to fetal organs b. Puncture of umbilical cord c. Maternal pain d. Infection

ANS: d Feedback a. Amniocentesis is done under ultrasound guidance, and damage to fetal organs is very rare. b. Amniocentesis is done under ultrasound guidance, and damage to the umbilical cord is very rare. c. Amniocentesis is done under local anesthesia, and maternal pain is generally minimal. d. Amniocentesis involves insertion of a needle into the amniotic sac, and infection is the primary complication.

Your patient is a 37-year-old pregnant woman who is 5 weeks pregnant and is considering genetic testing. During your discussion, the woman asks the nurse what the advantages of chorionic villus sampling (CVS) are over amniocentesis. The best response is: a. "You will need anesthesia for amniocentesis, but not for CVS." b. "CVS is a faster procedure." c. "CVS provides more detailed information than amniocentesis." d. "CVS can be done earlier in your pregnancy, and the results are available more quickly."

ANS: d Feedback a. Anesthesia is not done for either procedure. b. The length of time for either procedure is similar. c. Both amniocentesis and CVS provide the same information. d. CVS can be done earlier in gestation.

A nurse assesses that a 3-day-old neonate who was born at 34 weeks' gestation has abdominal distention and vomiting. These assessment findings are most likely related to: a. Respiratory Distress Syndrome (RDS) b. Bronchopulmonary Dysplasia (BPD) c. Periventricular Hemorrhage (PVH) d. Necrotizing Enterocolitis (NEC)

ANS: d Feedback a. Assessment findings for RDS include tachypnea, intercostal retractions, respiratory grunting, and nasal flaring. b. Assessment findings for BPD include chest retractions; audible wheezing, rales, and rhonchi; hypoxia; and bronchospasm. c. Assessment findings for PVH include bradycardia, hypotonia, full and/or tense anterior fontanel, and hyperglycemia. d. Assessment findings related to NEC include abdominal distention, bloody stools, abdominal distention, vomiting, and increased gastric residual. These signs and symptoms are related to the premature neonate's inability to fully digest stomach contents and limitation in absorptive function.

A 37-year-old woman who is 17 weeks pregnant has had an amniocentesis. Before discharge, the nurse teaches the woman to call her doctor if she experiences which of the following side effects? a. Pain at the puncture site b. Macular rash on the abdomen c. Decrease in urinary output d. Cramping of the uterus

ANS: d Feedback a. It is normal for the patient to experience pain at the puncture site. b. A rash is not an expected complication. c. Oliguria is not an expected complication. d. The woman should report any uterine cramping. Although rare, amniocentesis could stimulate preterm labor.

Your patient is 34 weeks pregnant and during a regular prenatal visit tells you she does not understand how to do "kick counts." The best response by the nurse would be to explain: a. "Here is an information sheet on how to do kick counts." b. "It is not important to do kick counts because you have a low-risk pregnancy." c. "Fetal kick counts are not a reliable indicator of fetal well-being in the third trimester." d. "Fetal movements are an indicator of fetal well-being. You should count twice a day, and you should feel 10 fetal movements in 2 hours."

ANS: d Feedback a. Providing written information may not be enough, and the patient may need a verbal explanation. b. Kick counts are indicated for all pregnancies. c. Kick counts are a reliable indicator of fetal well-being after 32 to 34 weeks' gestation. d. This response provides the patient with information on how to do kick counts and the rationale for doing kick counts and criteria for normal fetal movement.

A nursery nurse observes that a full-term AGA neonate has nasal congestion, hypertonia, and tremors and is extremely irritable. Based on these observations, the nurse suspects which of the following? a. Hypoglycemia b. Hypercalcemia c. Cold stress d. Neonatal withdrawal

ANS: d Feedback a. Signs and symptoms of hypoglycemia are jitteriness, hypotonia, irritability, apnea, lethargy, and temperature instability, but not nasal congestion. b. Signs and symptoms of hypercalcemia are vomiting, constipation, and cardiac arrhythmias. c. Signs and symptoms of cold stress are decreased temperature, cool skin, lethargy, pallor, tachypnea, hypotonia, jitteriness, weak cry, and grunting. d. These are common signs and symptoms of neonatal withdrawal.

A client delivered a 2800-gram neonate 4 hours ago by cesarean section with epidural anesthesia. Which of the following interventions should the nurse perform on the mother at this time? a. Maintain the client flat in bed. b. Assess the client's patellar reflexes. c. Monitor hourly urinary outputs. d. Assess the client's respiratory rate.

ANS: d Feedback a. The client should be assisted to a position of comfort. b. There is no indication in the scenario that the client must have her reflexes assessed. c. The client's hydration should be monitored postsurgery, but hourly assessments are unnecessary. d. The client has undergone major abdominal surgery. Her respiratory function should be assessed regularly.

A nurse is caring for a woman 10 hours post-cesarean birth. She received a dose of intrathecal morphine at the time of the birth. Which of the following assessment data would require immediate intervention? a. Itching of the palms and feet b. Nausea c. Urinary output of 300 mL in the past 4 hours d. Respiratory rate of 10 breaths/minute

ANS: d Feedback a. This is a side effect of intrathecal morphine which is not life threatening. b. This is a side effect of intrathecal morphine which is not life threatening. c. A urinary output of 300 mL in 4 hours is within normal limits. d. Correct. An adverse effect of intrathecal morphine that requires immediate intervention is respiratory distress.

The NICU nurse is providing care to a 35-week-old infant who has been in the neonatal intensive care unit for the past 3 weeks. His mother wants to breastfeed her son naturally but is currently pumping her breasts to obtain milk. His mother is concerned that she is only producing about 1 ounce of milk every 3 hours. The nurse's best response to the patient's mother would be: a. "Pumping is hard work and you are doing very well. It is good to get about 1 ounce of milk every 3 hours." b. "Natural breastfeeding will be a challenging goal for your baby. Beginning today, you will need to begin to pump your breasts more often." c. "Your baby will not be ready to go home for at least another week. You can begin to pump more often in the next few days in preparation for taking your child home." d. "You have been working hard to give your son your breast milk. We can map out a schedule to help you begin today to pump more often to prepare to take your baby home."

ANS: d Feedback a. This is correct information but does not assist the women in producing more milk. b. This does not provide her with a plan to increase her milk. c. This does not provide her with a plan. d. The mother should be praised for her efforts to breastfeed and encouraged to continue to pump her milk. A determined schedule for pumping the milk will help the mother keep her milk flow steady and provide enough nutrients for the infant after discharge.

If the umbilical cord prolapses during labor, the nurse should immediately: a. Type and cross-match blood for an emergency transfusion. b. Await MD order for preparation for an emergency cesarean section. c. Attempt to reposition the cord above the presenting part. d. Apply manual pressure to the presenting part to relieve pressure on the cord.

ANS: d Feedback a. Type and cross-match is one of the interventions with cord prolapse but not a priority. b. Awaiting MD intervention is not appropriate as umbilical cord prolapse is an obstetrical emergency requiring immediate intervention. c. Once the cord has prolapsed, it cannot be repositioned. d. Apply manual pressure to the presenting part to relieve pressure on the cord represents the first nursing intervention to attempt to improve circulation to the fetus.

The nurse is massaging a boggy uterus. The uterus does not respond to the massage. Which medication would the nurse expect would be given first: a. Methergine b. Ergotrate c. Carboprost d. Oxytocin or pitocin

ANS: d If the cause of the hemorrhage is uterine atony, continual fundal massage with lower uterine segment support is mandatory. While one member of the team massages the fundus, another nurse establishes intravenous access with a large bore needle and administers oxytocic drugs in the following order: oxytocin (Pitocin), followed by methylergonovine (Methergine) or ergonovine (Ergotrate), and carboprost (Hemabate).

The clinic nurse sees Xiao and her infant in the clinic for their 2-week follow-up visit. Xiao appears to be tired, her clothes and hair appear unwashed, and she does not make eye contact with her infant. She is carrying her son in the infant carrier and when asked to put him on the examining table, she holds him away from her body. The clinic nurse's most appropriate question to ask would be: a. "What has happened to you?" b. "Do you have help at home?" c. "Is there anything wrong with your son?" d. "Would you tell me about the first few days at home?"

ANS: d The well-baby checkup that generally takes place 1 to 2 weeks following the hospital discharge may offer the first opportunity to assess the mother-baby dyad. In this setting, the nurse needs to be alert for subtle cues from the new mother, such as making negative comments about the baby or herself, ignoring the baby's or other children's needs, as well as the mother's physical appearance. In a private area, the nurse should take time to explore the new mother's feelings. A nonthreatening way to open the dialogue might be to say: "Tell me how the first few days at home have gone." This statement provides the new mother with an opportunity to share both positive and negative impressions.

The perinatal nurse knows that the presence of abdominal distension and gas in the post-cesarean birth mother is due to __________.

ANS: delayed peristalsis Delayed peristalsis and constipation commonly occur because of slowed peristalsis associated with pregnancy hormones and childbirth anesthesia. In addition, incisional pain may contribute to a decrease in ambulation which contributes to delayed peristalsis.

The perinatal nurse understands that the most appropriate nursing action following an amniotomy is an assessment of the __________ as well as the __________ and __________ of the amniotic fluid.

ANS: fetal heart rate; color; odor The nurse carefully monitors the patient who will undergo an amniotomy. Vital signs, cervical effacement and dilation, station of the presenting part, fetal heart rate, and color and amount of amniotic fluid are assessed.

The perinatal nurse prepares for two potential complications that may accompany a precipitous labor and birth: postpartum __________ and a need for neonatal __________.

ANS: hemorrhage; resuscitation Feedback 1: Complications from a precipitate labor pattern result from trauma to maternal tissue and to the fetus because of the rapid descent. Hemorrhage may occur from uterine rupture and vaginal lacerations. The fetus may suffer from hypoxia related to the decreased periods of uterine relaxation between the contractions and intracranial hemorrhage related to the rapid birth. Feedback 2: Complications from a precipitate labor pattern result from trauma to maternal tissue and to the fetus because of the rapid descent. Hemorrhage may occur from uterine rupture and vaginal lacerations. The fetus may suffer from hypoxia related to the decreased periods of uterine relaxation between the contractions and intracranial hemorrhage related to the rapid birth.

The perinatal nurse provides information about postpartum depression to all families members because of the potential danger not only to the mother but also to the __________.

ANS: infant The earlier that postpartum depression is recognized and treatment begun, the better is the prognosis for a full recovery. The nurse should involve the family in helping the patient cope with her feelings and assisting with infant care.

During labor, oxytocin is always administered __________.

ANS: intravenously with an infusion pumpDuring labor, oxytocin can only be administered intravenously via an infusion pump to titrate and regulate the dose for safe administration.

The NICU nurse recognizes that the infant who requires ventilation for meconium aspiration syndrome is most often __________.

ANS: post-term Meconium aspiration pneumonia occurs in 10% to 26% of all deliveries, and the incidence increases directly with gestational age. (Before 37 weeks' gestation there is a 2% incidence, and at 42 weeks' gestation there is a 44% incidence.)

A postpartum woman who describes symptoms of hallucinations and suicidal thoughts is most likely experiencing postpartum __________.

ANS: psychosis Postpartum psychosis is a rare but severe form of mental illness that severely affects not only the new mother, but the entire family. Postpartum psychosis may present with symptoms of postpartum depression. However, the distinguishing signs of psychosis are hallucinations, delusions, agitation, confusion, disorientation, sleep disturbances, suicidal and homicidal thoughts, and a loss of touch with reality.

The development of a large hematoma can place the postpartum woman at risk for __________.

ANS: shock Upon examination of the perineal or vulvar areas, the nurse may notice discoloration and bulging of the tissue at the hematoma site. If touched, the patient complains of severe tenderness, and the clinician generally describes the tissue as "full." If the hematoma is large, signs of shock may be evident, and the patient may exhibit an absence of lochia and an inability to void.

The Joint Commission Standard states that the __________, __________, and __________ are accurately identified and clearly communicated during the final verification process before the start of any surgical or invasive procedure.

ANS: site; procedure; patient To decrease the risk of surgery or invasive procedure being done on the wrong patient or in the wrong site, a "time-out" is called, and active communication to verify correct procedure, site, and patient is done just prior to the beginning of surgery or invasive procedure.

The perinatal nurse explains to a new mother that the first sign of a postpartum infection will most likely be an increased __________.

ANS: temperature During the immediate postpartum period, the most common site of infection is the uterine endometrium. This infection presents with a temperature elevation over 101°F (38.4°C), often within the first 24 to 48 hours after childbirth, followed by uterine tenderness and foul-smelling lochia.