MATERNITY - HESI : PN
Maslow's Hierarchy of Needs
(level 1) Physiological Needs, (level 2) Safety and Security, (level 3) Relationships, Love and Affection, (level 4) Self Esteem, (level 5) Self Actualization
Risk factors for Postpartum Hemorrhage (PPH)
- Multiparity - Induction of labor - Chorioamnionitis - General anesthesia - Excessive uterine distension - Retained placenta - Coagulation abnormalities - Prolonged pre-labor rupture of membranes - Genital tract trauma during assistive deliveries / precipitous birth - Episiotomy - Antenatal bleeding - Abnormal placentation such as placenta accreta - Prolonged third stage of labor
Bowel
> Assess bowel sounds & abdominal distension > Monitor for constipation and provide stool softeners PRN
Episiotomy
> Assess episiotomy and/or perineal tear for redness, edema, ecchymosis, and discharge and approximation.
Lower Extremities
> Complete a thorough Neurovasc. assmt for DVT (redness, edema, pain, discoloration, peripheral pulses)
Emotional Status
> Complete postpartum mood screening & assessment of attachment w/ baby.
Lochia
> Monitor quantity & type of discharge including clots > Assess by positioning Ct. in DORSAL RECUMBENT POSITION (supine)
Bladder
> Palpate for distension > Monitor for voiding > Monitor for UTI
A female who thinks she could be pregnant calls her neighbor, a practical nurse (PN), to ask when she should use a home pregnancy test to diagnose pregnancy. Which response is best? a. "A home pregnancy test can be used right after your first missed period." b. "These tests are most accurate after you have missed your second period." c. "Home pregnancy tests often give false-positives and should not be trusted." d. "The test can provide accurate information when used right after ovulation."
A) "A home pregnancy test can be used right after your first missed period." Rationale: Home urine tests are based on the chemical detection of human chorionic gonadotrophin, which begins to increase 6 to 8 days after conception and is best detected at 2 weeks' gestation or immediately after the first missed period.
A client at 38 weeks' gestation calls the antepartal clinic stating she just experienced a small amount of bright red vaginal bleeding that has subsided. She denies uterine contractions or abdominal pain. What information should the practical nurse (PN) provide? a. Come to the clinic today to see the provider. b. You are likely experiencing false labor. c. Lie on your left side for about 1 hour and see if the bleeding stops. d. Tomorrow come to the lab to see if you have a urinary tract infection.
A) Come to the clinic today to see the provider. Rationale: The PN should instruct the client to come in to see the provider. Third-trimester painless bleeding is characteristic of a "placenta previa". Bright red bleeding may be intermittent, occur in gushes, or be continuous.
Which client statement indicates that a postpartum client understands the instructions of breastfeeding her newborn? (Select all that apply.) a. "Breastfeeding my infant consistently decreases the likelihood of me ovulating." b. "Breastfeeding my baby immediately after drinking alcohol is safer than waiting for the alcohol to clear my breast milk." c. "I should avoid foods that usually give me gas." d. "When I take a warm shower after I breastfeed, it relieves the pain from being engorged between breastfeedings." e. "When I feed my baby, I should start on the breast the baby stopped on last." f. "I should drink fluids when breastfeeding my baby, especially at night."
A) "Breastfeeding my infant consistently decreases the likelihood of me ovulating." C) "I should avoid foods that usually give me gas." E) "When I feed my baby, I should start on the breast the baby stopped on last." F) "I should drink fluids when breastfeeding my baby, especially at night." Rationale: Breastfeeding does reduce the likelihood of ovulation, but it does not completely eliminate the need to use another form of birth control. The mother should avoid foods that cause gas, because these could cause the baby to have gas also. The mother should start feeding the baby on the breast the baby stopped on last to decrease the risk for mastitis due to full breasts. The mother should drink plenty of fluids to establish the supply of breast milk. No alcohol use is safe during breastfeeding. Taking a warm shower will actually increase the production of breast milk.
The nurse is assisting with data collection for a 16-year-old client who is 12 weeks pregnant. Which client statement indicates instruction is necessary to ensure a safe pregnancy? (Select all that apply.) a. "I hate milk." b. "I only want to gain 10 pounds." c. "I will never have sex again." d. "My sister is pregnant too." e. "My mom smokes cigarettes when she was pregnant with me, so I can smoke too then."
A) "I hate milk." B) "I only want to gain 10 pounds." E) "My mom smokes cigarettes when she was pregnant with me, so I can smoke too then." Rationale: Pregnant adolescents need 1300 mg of calcium daily. Other sources of calcium will need to be taken if the client does not like milk. A weight gain of less than 20 pounds can lead to fetal complications. Cigarette smoking is associated with smaller birth weight babies. Not wanting to have sex again and having a pregnant sister may have a psychosocial impact but not a physical impact.
The practical nurse (PN) is teaching a couple about ovulation and conception. The nurse realizes the teaching is effective if the couple states which time is most likely for conception to occur? a. 2 weeks before menstruation b. Immediately after menstruation c. Immediately before menstruation d. 3 weeks before menstruation
A) 2 weeks before menstruation Rationale: Ovulation occurs 14 days before the first day of the menstrual period.
Twenty-four hours after a full-term newborn is admitted to the newborn nursery, the practical nurse (PN) observes a localized swelling on the right side of the head of the newborn that does not cross the suture line. How does the nurse document this finding? a. A cephalohematoma b. A subarachnoid hematoma c. Molding d. A subdural hematoma
A) A cephalohematoma Rationale: Cephalohematoma, a slight abnormal variation of the newborn, usually arises within the first 24 hours after delivery. "localized swelling on side of head of newborn that does not cross suture line"
The practical nurse (PN) is reinforcing teaching to a new mother about diet and breastfeeding. Which instruction is most important to include? a. Avoid alcohol because it is excreted in breast milk. b. Eat a high-fiber diet to help prevent constipation. c. Increase caloric intake by approximately 500 calories/day. d. Increase fluid intake to 3 quarts/day.
A) Avoid alcohol because it is excreted in breast milk. Rationale: Alcohol should be avoided while breastfeeding because when consumed by the mother, it is excreted in breast milk and may cause a variety of problems for the infant.
A breastfeeding postpartum client is diagnosed with mastitis, and antibiotic therapy is prescribed. What instruction should the practical nurse (PN) reinforce to this client? a. Breastfeed the infant, ensuring that both breasts are completely emptied. b. Pump the infected breast to avoid pain of the infant latching onto the infected breast. c. Breastfeed on the unaffected breast only until the mastitis subsides. d. Dilute expressed breast milk with sterile water to reduce the antibiotic effect on the infant.
A) Breastfeed the infant, ensuring that both breasts are completely emptied. Rationale: Mastitis (caused by plugged milk ducts) is related to breast engorgement, and breastfeeding during mastitis facilitates the complete emptying of engorged breasts, eliminating the pressure on the inflamed breast tissue.
The nurse is providing care to a mother who has experienced a fetal demise in utero at 35 weeks' gestation. The nurse expects to see which aspects included in the client's plan of care? ( Select all that apply.) a. Contact the hospital chaplain if the mother prefers. b. Ask about the last fetal movements if not already documented in the medical record. c. Apply the electronic fetal cardiac monitor. d. Ask about plans for labor pain management. e. Ask the parents if they want to hold the baby after birth.
A) Contact the hospital chaplain if the mother prefers. B) Ask about the last fetal movements if not already documented in the medical record. D) Ask about plans for labor pain management. E) Ask the parents if they want to hold the baby after birth. Rationale: If the mother prefers, the chaplain can be contacted to provide additional support through this difficult time. The chaplain may baptize the baby, depending on the beliefs of the parents. Determining the last fetal movements can give an approximation of when the demise occurred. If the death occurred 3 weeks ago or longer, the mother is at risk of developing disseminated intravascular coagulation (DIC). Pain management will be important to the mother who has lost a child. Determine the parents' desire after the birth to facilitate bonding. There is no need to monitor the heart rate of a fetus that has died in utero.
Two hours following vaginal delivery in a birthing suite, the practical nurse (PN) observes that a newborn has respirations that are 58 breaths/min and cyanotic hands and feet. What action should the PN implement? a. Continue to observe the infant. b. Administer oxygen at 5 L/m. c. Notify the pediatrician immediately. d. Transfer the infant to the nursery.
A) Continue to observe the infant. Rationale: A newborn infant's respirations should range between 40 and 60 breaths/min. Acrocyanosis (bluing of the hands and feet) is a normal occurrence at birth.
The nurse is assisting with data collection on a woman in her first trimester of pregnancy. Which findings should be reported to the health care provider immediately? (Select all that apply.) a. Cramping with bright red spotting b. Increased urination c. Lack of breast tenderness d. Increased amount of vaginal discharge e. Right-sided flank pain
A) Cramping with bright red spotting C) Lack of breast tenderness E) Right-sided flank pain Rationale: Cramping with bright red spotting and lack of breast tenderness could indicate that miscarriage is occurring. Option E could be an indication of an ectopic pregnancy, which could be fatal if not treated before rupture. Options B and D are common occurrences during the first trimester of pregnancy.
The nurse is preparing a 3-day-old, full-term newborn for discharge home. The baby's mother is HIV-positive. For which procedures should the practical nurse (PN) wear gloves? (Select all that apply.) a. Diaper changes b. Obtaining vital signs c. Formula feeding d. Newborn hearing screening e. Heel stick for metabolic screening f. Discharge bath
A) Diaper changes E) Heel stick for metabolic screening Rationale: The PN should wear gloves after diaper changes and only in those situations in which there is the potential for the presence of HIV-positive blood and body fluids.
Twenty four hours after forceps-assisted birth, the nurse assesses a full-term infant who has developed localized swelling on the right side of the head. The swelling occurs between the periosteum and skull and does not cross over the suture line. What action is most appropriate for the nurse to take? a. Document the findings as cephalohematoma. b. Reassure the parents this is called molding. c. Ask the health care provider for a prescription for an ice pack to reduce swelling. d. Notify the health care provider that this child likely is experiencing a subdural hematoma.
A) Document the findings as cephalohematoma. Rationale: Cephalohematoma is a slight abnormal variation of the newborn, common after a forceps delivery. An ice pack will not have any effect on this condition. There is no evidence the newborn is experiencing a subdural hematoma.
The practical nurse (PN) is caring for a gravida 4, para 3, with a history of rheumatic heart disease, admitted to the antepartum unit in preterm labor at 32 weeks' gestation. Which assessment findings indicate the onset of cardiac failure requiring immediate intervention? a. Edema, adventitious lung sounds, and tachycardia b. Increased urinary output and irregular heart rate c. Shortness of breath, bradycardia, and hypertension d. Regular heart rate and hypertension
A) Edema, adventitious lung sounds, and tachycardia Rationale: Edema, adventitious lung sounds, and an irregular pulse indicate cardiac decompensation and require immediate intervention.
The nurse is taking the temperature of a client who is 6 hours postpartum. The nurse notes that the client's temperature is 38° C (100.4° F). Which intervention should the nurse implement? a. Encourage fluids to increase hydration. b. Recheck the temperature in 15 minutes. c. Place an ice pack on the client's forehead. d. Obtain a prescription for acetaminophen.
A) Encourage fluids to increase hydration. Rationale: It is normal for the postpartum client to have a temperature up to 38° C (100.4° F) because of dehydration caused by labor. The most appropriate intervention is to encourage fluids to rehydrate the patient. *Above 38° C (100.4° F) is critical
The practical nurse (PN) attempts to help a teenage client with her feelings following a spontaneous abortion at 8 weeks' gestation. What type of emotional response should the PN anticipate? a. Grief related to her perceptions about the loss of this child. b. Relief of ambivalent feelings experienced with this pregnancy. c. Shock because she may not have realized that she was pregnant. d. Guilt because she had not followed her health care provider's instructions.
A) Grief related to her perceptions about the loss of this child. Rationale: A grief and loss response occurs at all stages of pregnancy loss.
The nurse is assisting with data collection on a client who is in her last trimester of pregnancy. Which findings should the nurse report urgently to the health care provider? (Select all that apply.) a. Increased heartburn that is not relieved with doses of antacids b. Increase of the fetal heart rate from 126 to 156 beats/min from the last visit c. Shoes and rings which are too tight because of peripheral edema in extremities d. Decrease in ability for the client to sleep for more than 2 hours at a time e. Headaches that have been lingering for a week behind the client's eyes
A) Increased heartburn that is not relieved with doses of antacids E) Headaches that have been lingering for a week behind the client's eyes Rationale: Intractable indigestion and lingering headaches are not unusual during pregnancy, but can be symptoms of preeclampsia and should be reported to the health care provider. The fetal heart rate normally ranges between 120 and 160. Peripheral edema and difficulty sleeping are common during pregnancy and do not warrant immediate notification of the health care provider.
A client who is 40 weeks into pregnancy is having a vaginal examination at the clinic when the nurse notes a sudden gush of yellowish, clear fluid from the vaginal area. What should be the nurse's first action? a. Measure the fetal heart rate. b. Monitor for uterine contractions. c. Note the color and odor of the fluid. d. Apply a dry pad under the client for her comfort.
A) Measure the fetal heart rate. Rationale: When the amniotic sac ruptures, there is a risk that the umbilical cord could prolapse, causing fetal bradycardia and decreased blood supply to the fetus. The nurse should measure the fetal heart rate immediately when the amniotic sac ruptures. If the cord has prolapsed, the fetus needs to be delivered immediately. It is important to note the color and odor of the fluid for signs of infection and to assess for uterine contractions; however, the priority is assessing for a prolapsed cord by assessing the fetal heart rate. Placing a dry pad under the client is not a priority action.
The nurse explains to a new mother why the baby needs a vitamin K injection. Which statement by the mother indicates adequate understanding? a. Newborn babies need vitamin K to prevent bleeding. b. Vitamin K is given to newborns to boost their immunity. c. Vitamin K goes in my baby's eyes to prevent a bacterial infection. d. My baby needs vitamin K because the baby has a low potassium level.
A) Newborn babies need vitamin K to prevent bleeding. Rationale: The body requires vitamin K for coagulation. Newborns are born with deficient levels of vitamin K; therefore, the vitamin K injections are given to prevent bleeding disorders.
Twenty minutes after a continuous epidural anesthetic is administered, a laboring client's blood pressure drops from 120/80 to 90/60 mm Hg. Which actions should the practical nurse (PN) take immediately? (Select all that apply.) a. Notify the registered nurse (RN) or anesthesiologist. b. Continue to assess the blood pressure every 5 minutes. c. Place the client in a lateral position. d. Turn off the continuous epidural. e. Elevate the head of the bed.
A) Notify the registered nurse (RN) or anesthesiologist. B) Continue to assess the blood pressure every 5 minutes. C) Place the client in a lateral position. Rationale: The PN should immediately turn the client to a lateral position and place a pillow or wedge under one hip to tilt the uterus. Administer oxygen by face mask at 10 to 12 L/m and notify the RN and increase the rate of the main line IV infusion. If the blood pressure remains low or decreases further after these interventions, the anesthesiologist should be notified.
A client at term presents to the labor and delivery in spontaneous labor; contractions are occurring every 3 to 4 minutes and they are 60 seconds in durations. The client states to the nurse, "I think I am having a breakout of my genital herpes." What actions will the nurse take next? (Select all that apply.) a. Observe the client's perineum. b. Contact the health care provider. c. Ask the patient about her antiviral therapy. d. Open a vaginal delivery pack. e. Assess her partner's penis for lesions
A) Observe the client's perineum. B) Contact the health care provider. C) Ask the patient about her antiviral therapy. Rationale: The nurse needs to assess the client's perineum, and the health care provider will determine the status of the lesions. If active lesions are present, the recommendation is for a Cesarean section; therefore, opening a vaginal delivery pack may be unnecessary. It would not be appropriate for the nurse to assess the partner's penis.
The nurse is assisting with data collection for a client who is in her 10th week of pregnancy. Which finding should be reported immediately to the health care provider? a. The client's rubella titer is less than 1:10. b. The client's hematocrit value is measured at 34%. c. The client states "I'm not really sure I want to have a baby." d. The client states she will not be able to visit the health care provider every 2 weeks.
A) The client's rubella titer is less than 1:10. Rationale: The client's rubella titer indicates she is not immune to rubella, making the fetus at risk for serious birth defects. A rubella titer over 1:10 indicates immunity. During the first trimester, the hematocrit should be over 33%, so 34% is adequate for this client. Ambivalence about the pregnancy is common in the first trimester. The client will need to visit the health care provider every 4 weeks, not every 2 weeks.
A pregnant client is scheduled for an amniocentesis. The client asks the practical nurse (PN) what to expect during the procedure. How should the PN respond? (Select all that apply.) a. The nurse will be checking your vital signs every 15 minutes. b. You should expect to have a low-grade fever after the procedure. c. Amniocentesis is noninvasive, and it is used to look for fetal anomalies. d. You will be positioned on your back during the procedure and on your left side following the procedure. e. Uterine contractions or cramping following the procedure are not normal and should be reported to your health care provider.
A) The nurse will be checking your vital signs every 15 minutes. D) You will be positioned on your back during the procedure and on your left side following the procedure. E) Uterine contractions or cramping following the procedure are not normal and should be reported to your health care provider. Rationale: During the procedure and recovery, the client's vital signs should be monitored every 15 minutes. The client should expect to be positioned supine during the procedure and on the left side following the procedure. Uterine contractions or cramping may be a sign of premature labor and should be reported to the health care provider immediately.
During labor, a client is experiencing a fetal heart rate of 68, which lasts longer than 45 seconds. Which is the nurse's first action? a. Turn the client to her left side. b. Administer additional oral fluids. c. Assess the client's blood glucose level. d. Assess the client's vital signs and oxygen saturation.
A) Turn the client to her left side. Rationale: The client should be turned to her left side immediately, as turning her may take the weight of the uterus and reduce the pressure the heavy uterus is placing on the client's blood vessels. Administering oral fluids may be contraindicated, because a Caesarian section may be required if the fetal bradycardia persists. The client's symptoms do not correlate with a blood sugar disorder. Assessing the client's vital signs and oxygen saturation is necessary, but it is not a priority action.
The nurse is assisting with data collection for a newborn that is 1 hour old, with an estimated gestational age of 39 to 40 weeks. Which findings does the nurse expect to note? (Select all that apply.) a. Vernix in the creases of the neck b. Lanugo covering the entire back c. Creases over the anterior 1/3 of the foot d. Breast tissue less than 0.5 cm in both breasts e. The labia majora cover the labia minora
A) Vernix in the creases of the neck E) The labia majora cover the labia minora Rationale: Vernix in neck creases and the labia majora covering the labia minora are signs of a term infant. Lanugo covering the back, foot creases on the anterior third of the foot, and breast tissue less than 0.75 cm are assessment findings associated with preterm infants.
Breasts
Assess for: > Filling > Engorgement > Nipple pain & damage > Plugged ducts > Signs of infection
Uterus
Assess: > Fundal height measurements - height should be midline & position above/below umbilicus. > Firmness of fundus
The nurse educates the pregnant client about a new diagnosis of gestational diabetes. Which statement made by the client indicates the need for further education? a. "I should watch for signs of infection and report them to my doctor." b. "My doctor will prescribe oral medication to help keep my blood sugars normal." c. "I should continue to exercise because it will help keep my blood glucose levels down." d. "If I cannot control my blood sugar with diet alone, my provider may prescribe insulin."
B) "My doctor will prescribe oral medication to help keep my blood sugars normal." Rationale: Oral hypoglycemics are not prescribed during pregnancy.
A new mother asks the practical nurse (PN), "How do I know that my daughter is getting enough breast milk?" Which explanation best supports that the mother has adequate milk supply? a. "Weigh the baby daily, and if she is gaining weight, she is getting enough to eat." b. "Your milk is sufficient if the baby is voiding pale, straw-colored urine 6 to 10 times a day." c. "Offer the baby extra bottle milk after her feeding, and see if she is still hungry." d. "If you're concerned, you might consider bottle feeding so that you can monitor her intake."
B) "Your milk is sufficient if the baby is voiding pale, straw-colored urine 6 to 10 times a day." Rationale: The urine will be dilute (straw-colored) and frequent (greater than six to ten times/day) if the infant is adequately hydrated.
While reviewing a new postpartum client's plan of care, the practical nurse (PN) notes that the client has a fourth-degree laceration. Based on this, which interventions should the PN implement? (Select all that apply.) a. Apply ice to the perineum for the next 48 hours. b. Administer prescribed docusate sodium (Colace). c. Ambulate with assistance q4-6h prn. d. Medicate client for pain q4-6h prn. e. Demonstrate positions of comfort when sitting.
B) Administer prescribed docusate sodium (Colace). D) Medicate client for pain q4-6h prn. E) Demonstrate positions of comfort when sitting. Rationale: The PN should administer the prescribed stool softener because a fourth-degree laceration extends through the anal sphincter and anterior rectal wall, to prevent constipation or straining with stool from causing damage to the repaired tissue. Ice is recommended only for the first 24 hours; after that, heat should be used. A comfortable position and pain management are useful interventions for clients with fourth-degree lacerations.
The practical nurse (PN) caring for a laboring client encourages her to void at least every 2 hours and records each time the client empties her bladder. What is the rationale for implementing this nursing intervention? a. Emptying the bladder during delivery is difficult because of the position of the presenting fetal part b. An overdistended bladder could be traumatized during labor and could prolong the progress of labor. c. Urine specimens for glucose and protein must be obtained at certain intervals throughout labor. d. Frequent voiding minimizes the need for catheterization, which increases the chance of bladder infection.
B) An overdistended bladder could be traumatized during labor and could prolong the progress of labor. Rationale: A full bladder can impair the efficiency of the uterine contractions and impede descent of the fetus during labor. Also, because of the close proximity of the bladder to the uterus, the bladder can be traumatized by the descent of the fetus.
The practical nurse (PN) is caring for a client who has had a normal vaginal delivery. The first 4 hours after delivery, the nurse palpates the uterine fundus and bladder every hour. What is the primary reason for implementing this nursing intervention? a. A full bladder after delivery is an indicator to ambulate the client in order to prevent phlebothrombosis. b. An overdistended bladder could inhibit uterine contraction and predispose to postpartum bleeding. c. Urine specimens for glucose and protein must be obtained at intervals to monitor for preeclampsia states. d. A firm fundus will promote frequent voiding and minimizes the need for urinary catheterization.
B) An overdistended bladder could inhibit uterine contraction and predispose to postpartum bleeding. Rationale: A distended, full bladder can impair the efficiency of uterine contraction, which will allow uterine sinuses to bleed and result in the fundus becoming displaced and boggy in consistency.
The practical nurse (PN) calls for help and gives two breaths to a newborn who is not breathing. Which area on the image would the PN check for the newborn's pulse? a. A b. B c. C d. D
B) B Rationale: The brachial pulse is used to determine the presence of a pulse in the infant during cardiopulmonary resuscitation.
The findings of a maternal triple screen test indicate that an 18-week primigravida has an elevated serum alpha-fetoprotein (AFP) level. Which information is best for the practical nurse to provide? a. The baby's father should be present for a discussion of these findings. b. Elevation of any part of this test may indicate the need for further studies. c. The possibility of a birth defect is higher when these values are elevated. d. This test should be performed later in pregnancy to determine its significance.
B) Elevation of any part of this test may indicate the need for further studies. Rationale: A maternal triple screen test measures the serum levels of AFP, human chorionic gonadotrophin (hCG), and maternal estriol, and it is performed between 15 and 21 weeks' gestation to identify serum levels associated with Down syndrome, other chromosomal defects, or neural tube defects, such as spina bifida.
A client in active labor begins to experience cramps in her leg. What intervention should the practical nurse (PN) implement? a. Massage the calf and foot. b. Extend the leg and dorsiflex the foot. c. Lower the leg off the side of the bed. d. Elevate the leg above the heart.
B) Extend the leg and dorsiflex the foot. Rationale: Dorsiflexing the foot by pushing the foot upward or by standing and putting the heel of the foot on the floor is the best means of relieving leg cramps, because it creates an opposing action to relax the gastrocnemius.
During a prenatal visit, the practical nurse (PN) discusses with a client the effects that smoking has on the fetus. The nurse realizes the teaching is effective if the client identifies which possible effect on the fetus? a. Lower Apgar score recorded at delivery. b. Lower initial weight documented at birth. c. Higher oxygen used to stimulate breathing. d. Higher prevalence of congenital anomalies.
B) Lower initial weight documented at birth. Rationale: Smoking is associated with low-birth-weight infants.
During a routine prenatal visit, a female at 38 weeks' gestation tells the practical nurse (PN) that both her cousin and her cousin's 1-year-old daughter have phenylketonuria (PKU). The client is concerned that her unborn child may also have PKU and become mentally retarded. Which information should the PN provide? a. An infant with PKU is treated with thyroid medication. b. PKU screening is performed after the newborn ingests milk. c. Genetic testing of the client can identify PKU in the infant. d. The fetus's risk for PKU is only slightly higher than usual.
B) PKU screening is performed after the newborn ingests milk. Rationale: PKU is an inborn error of metabolism resulting in an elevated serum amino acid, phenylalanine, which causes mental retardation; therefore, it's important to PKU screening after the newborn has ingested breast milk or formula milk protein.
A mother who is positive for the HIV virus delivers a 7-pound boy. Which intervention should the practical nurse initiate to prevent transfer of the virus to the infant? a. Provide a particulate filter mask for the mother to wear. b. Prevent breastfeeding but encourage rooming-in. c. Remind the mother to wash hands carefully after bowel movements. d. Teach the mother to glove during diaper changes.
B) Prevent breastfeeding but encourage rooming-in. Rationale: Rooming-in should be allowed, but transmission of the mother's body fluids (breast milk) should be prevented. Standard precautions should be instituted.
As part of the preoperative plan of care for a client who is scheduled for a repeat cesarean section, the practical nurse (PN) plans to administer the nonparticulate antacid sodium citrate by mouth. What is the purpose of administering this drug preoperatively? a. Prevent postoperative nausea and vomiting. b. Raise the gastric pH to above 2.5. c. Improve gastric motility. d. Decrease the risk of aspiration.
B) Raise the gastric pH to above 2.5. Rationale: Sodium citrate is prescribed to increase the pH of gastric secretions and make them more alkaline so that if the client should vomit and aspirate, the chance of pneumonitis occurring is decreased.
Which maternal behavior is the practical nurse (PN) most likely to see when a new mother receives her infant for the first time? a. She eagerly undresses the infant and examines the infant completely. b. She receives the infant and touches the infant's face with her fingertips. c. She reaches and cuddles the infant to her own body. d. She reaches but hesitates for the nurse's encouragement.
B) She receives the infant and touches the infant's face with her fingertips. Rationale: Attachment/bonding theory indicates that most mothers will touch the infant's face during the first visit with the newborn.
A nurse receives shift change report for a newborn who was delivered vaginally 12 hours ago. The nurse recognizes which report should be given the highest priority to evaluate further? a. Cyanosis of the hands and feet b. Skin color that is slightly jaundiced c. Hair located on the back of the shoulders d. Red patches on the cheeks and the trunk
B) Skin color that is slightly jaundiced Rationale: Jaundice, a yellow skin discoloration, should be evaluated further because it occurred in a newborn less than 24 hours old. An Rh blood incompatibility can also cause jaundice in a newborn. Acrocyanosis (bluish color of the hands and feet) is a common finding in newborns. Hair on the back of the shoulders and red patches on the cheeks and trunk are common findings on the skin of newborns.
The nurse is assisting with data collection for a client who is at 20 weeks' gestation. Which findings does the nurse expect to note? (Select all that apply.) a. The fundus is located under the xiphoid process. b. The mother's areolae have darkened. c. The mother has noted fetal movement. d. The fetal outline is palpable. e. Urinary frequency is common.
B) The mother's areolae have darkened. C) The mother has noted fetal movement. Rationale: The mother's areolae have darkened and the mother has noted fetal movement by 20 weeks' gestation. The fundus is at the level of the umbilicus. The fetal outline is not palpable and urinary frequency does not occur until later in the pregnancy.
The nurse is reinforcing instructions regarding nutritional needs during pregnancy. Which client instructions should be included? a. Your protein intake should increase by 40 g/day. b. Your calories should increase by 300 calories/day. c. You should drink 10 to 12 glasses of fluid per day. d. You should lose weight if you weigh over 200 pounds (88kg).
B) Your calories should increase by 300 calories/day. Rationale: Calorie intake is increased by 300 calories/day. Protein intake should increase by 30 g/day. The pregnant client should drink 8 to 10 glasses of fluid daily. Weight loss should not be undertaken during pregnancy.
Post-Partum Assessment (BUBBLE)
B-reasts U-terus B-owels B-ladder L-ochia E-pisiotomy/lateration/C-section incision
The nurse has reinforced education for a client who is 11 weeks pregnant and has had no pregnancy complications. Which client comment indicates adequate understanding of the instructions? a. "I can exercise as long as I do not start sweating." b. "I will reduce my fluid intake if I take a trip by airplane." c. "I can expect my nausea to be reduced in the next few weeks." d. "As long as I do not have more than 1 drink a day, I can continue to take alcohol."
C) "I can expect my nausea to be reduced in the next few weeks." Rationale: Pregnancy-related nausea usually resolves by the 13th week. If the client travels via airplane, the client should take additional fluids to prevent deep vein thrombosis. The healthy client can exercise as long as she is able to converse easily while exercising. No level of alcohol is considered safe while pregnant.
A client at 30 weeks' gestation is on bed rest at home because of increased blood pressure. The home health nurse has taught her how to take her own blood pressure (BP). When the client calls the clinic complaining of indigestion and headache, which information is best for the practical nurse (PN) to provide? a. "Lie on your left side and call an ambulance to take you to the emergency room immediately." b. "Take an antacid and call back if the pain has not subsided within 1 hour after taking the antacid." c. "Take your blood pressure, and if it has significantly increased, go to the hospital immediately." d. "Drink a carbonated drink to help with belching, and call back if the indigestion has not subsided within an hour."
C) "Take your blood pressure, and if it has significantly increased, go to the hospital immediately." Rationale: Obtaining a BP reading is the best instruction. An elevated blood pressure (140/90 mm Hg, or an increase of 15 mm Hg diastolic and/or 30 mm Hg systolic) is a sign of gestational hypertension (GH); headache and epigastric pain can be the signs of an impending seizure (eclampsia).
Before discharge, what information should the practical nurse (PN) give to parents regarding the newborn's umbilical cord care at home? a. Wash the cord frequently with mild soap and water. b. Cover the cord with a sterile dressing. c. Allow the cord to air dry as much as possible. d. Apply baby lotion after the baby's daily bath.
C) Allow the cord to air dry as much as possible. Rationale: Recent studies indicate that air drying or plain water application may be equal to or more effective than alcohol in the cord-healing process.
Which over-the-counter medication should the practical nurse recommend that a breastfeeding mother avoid? a. Famotidine b. Ibuprofen c. Aspirin d. Loratadine
C) Aspirin Rationale: Breastfeeding mothers should avoid any products containing aspirin because of the possible association with Reye syndrome in the infant.
When a client who delivered an 8-pound, 12-ounce infant 6 hours earlier is ambulating to the bathroom for the second time since delivery, the practical nurse (PN) observes blood running down her leg. What action should the PN take? a. Escort the client to the toilet and assess the perineal pad. b. Guide the client to floor and call for additional help. c. Assist the client back to bed and check her fundus. d. Place the client in a chair and take her blood pressure.
C) Assist the client back to bed and check her fundus. Rationale: The client who delivers a large-for-gestational age (LGA) infant is at risk for postpartum hemorrhage because of uterine atony. The nurse should assist the client to bed and assess the consistency of the fundus. A fundus that is boggy or displaced from the midline can predispose the client to bleeding.
When should the practical nurse (PN) encourage a laboring client to begin pushing? (Select all that apply.) a. At complete cervical effacement b. When the client describes the need to have a bowel movement c. At complete cervical dilation d. Upon palpation of an anterior or posterior lip of the cervix e. At complete cervical effacement and dilation
C) At complete cervical dilation E) At complete cervical effacement and dilation Rationale: Pushing begins with the second stage of labor, when the cervix is completely dilated at 10 cm.
A newborn infant is breathing satisfactorily but appears dusky. What action should the practical nurse (PN) take first? a. Notify the pediatrician immediately. b. Suction the infant's nares and then the oral cavity. c. Check the infant's oxygen saturation rate. d. Position the infant on the right side.
C) Check the infant's oxygen saturation rate. Rationale: The PN should first obtain measurable objective data; an oxygen saturation rate provides such information. The pediatrician should be notified if the oxygen saturation rate is below 90%.
A client at 30 weeks' gestation is complaining of pressure over the pubic area. At the client's admission to the antepartum unit for observation, vaginal examination shows that her cervix is closed, thick, and high. The fetal monitor reveals irregular contractions and underlying uterine irritability. Which intervention should the practical nurse (PN) implement first? a. Provide oral hydration. b. Encourage ambulation to stop contractions. c. Collect a specimen for urine analysis. d. Place the client on strict bed rest.
C) Collect a specimen for urine analysis. Rationale: Obtaining a urine analysis should be done first, because preterm clients with uterine irritability and contractions are often experiencing a urinary tract infection, and this should be ruled out first.
The total bilirubin level of a 36-hour, breastfeeding newborn is 14 mg/dL. Based on this finding, which intervention should the practical nurse (PN) implement? a. Provide phototherapy for 30 minutes q8h. b. Feed the newborn with sterile water hourly. c. Encourage the mother to breastfeed frequently. d. Assess the newborn's blood glucose level.
C) Encourage the mother to breastfeed frequently. Rationale: Breast milk provides calories and enhances GI motility, which will assist the bowel in eliminating bilirubin. The normal total bilirubin level is 6 to 12 mg/dL after day 1 of life. The infant should be monitored to prevent further complications.
A new mother is having trouble breastfeeding her newborn son. He is making frantic rooting motions and will not grasp the nipple. Which intervention should the practical nurse (PN) implement? a. Encourage frequent use of a pacifier so that the infant becomes accustomed to sucking. b. Hold the infant's head firmly against the breast until he latches onto the nipple. c. Encourage the mother to stop feeding for a few minutes and comfort the infant. d. Provide formula for the infant until he becomes calm and then offer the breast again.
C) Encourage the mother to stop feeding for a few minutes and comfort the infant. Rationale: The infant is becoming frustrated and so is the mother; both need a time-out. The mother should be encouraged to comfort the infant and to relax herself.
A new father asks the practical nurse (PN) why ointment is instilled into the eyes of his newborn infant. Which infection should the PN identify when describing the purpose of this treatment? a. Herpes b. Staphylococcus c. Gonorrhea d. Syphilis
C) Gonorrhea Rationale: Erythromycin ointment is instilled into the lower conjunctiva of each eye within 2 hours after birth to prevent ophthalmia neonatorum, an infection caused by gonorrhea, and inclusion conjunctivitis, an infection caused by Chlamydia.
A 25-year-old client has a positive pregnancy test. One year earlier she had a spontaneous abortion at 3 months' gestation. What is the description that the practical nurse (PN) should use to document gravida and parity in this client's medical record? a. Gravida 1, para 0 b. Gravida 1, para 1 c. Gravida 2, para 0 d. Gravida 2, para 1
C) Gravida 2 , para 0 Rationale: This is the client's second pregnancy or second "gravid" event, the spontaneous abortion occurred at 3 months' gestation (12 weeks), so she is a para 0. Parity when delivery occurs at 20 weeks' gestation or beyond. Gravida: The number of times a woman has been pregnant, current pregnancy included Para: The number of viable births (multiples pregnancies count as one birth). G: gravida (number of pregnancies) T: term births or pregnancies delivered between 38 and 42 weeks of gestation P: preterm births (between 20th and 38th week of gestation) A: abortions L: living children
A client who is 8 hours postpartum uses the call system and tells the nurse "I think I'm bleeding a lot." The nurse notes a large amount of rubra flow on the sanitary pad and linen protector. What is the nurse's first action? a. Take the client's vital signs. b. Notify the health care provider. c. Massage the client's fundus until it firms. d. Change the sanitary pad and the linen protector.
C) Massage the client's fundus until it firms. Rationale: The initial action for postpartum hemorrhage is to massage the fundus. Taking the vital signs and notifying the health care provider may be necessary, but massaging the fundus is the primary action.
A client who is in active labor requests pain relief measures and prefers epidural anesthesia. Which action should the nurse take when caring for this client? (Select all that apply.) a. Restrict oral and intravenous fluids for 2 hours prior to the epidural. b. Explain to the client she will be having a metal taste in her mouth soon. c. Monitor the client's vital signs and immediately report hypotension. d. Assist the client into a prone position while the epidural is administered.
C) Monitor the client's vital signs and immediately report hypotension. Rationale: Hypotension is a common adverse effect of epidural anesthesia. Intravenous fluids are infused to provide 500 to 1000 mL additional fluids prior to the procedure; fluids are not restricted. A metallic taste in the mouth indicates the medication has entered the bloodstream. Immediately notify the health care provider if this occurs. Epidural anesthesia is administered while the client is in the sitting position.
Which parental behavior is a warning to the practical nurse that there may be negative bonding between parents and a newborn infant? a. Parents frequently touch the infant and call the infant by name. b. Parents hold the infant away from the body to show the infant's face. c. Parents frequently leave the newborn infant wrapped in blankets. d. Parents give immediate attention to infant's hunger and wet diapers.
C) Parents frequently leave the newborn infant wrapped in blankets. Rationale: Attachment/bonding theory indicates that parents have an extreme interest in visualizing every part of the newborn in a head to toe examination and exploration process.
A new mother has delivered her first baby vaginally and says to the practical nurse (PN), I saw the baby in the recovery room. The baby sure has a funny-looking head. Which response by the PN is best? a. This is not an unusual-shaped head, especially for a first baby. b. It may look odd, but newborn babies are often born with heads like that. c. That is normal. The head will return to a round shape within 7 to 10 days. d. Your pelvis was too small, so the head had to adjust to the birth canal.
C) That is normal. The head will return to a round shape within 7 to 10 days. Rationale: Reassure the mother that this shape is normal in the newborn and then provide information regarding the return to a normal shape of the molded neonate's head after a vaginal delivery.
The practical nurse is teaching a primigravida about breastfeeding. Which finding requires follow-up? a. The client wears push-up bras because of small breasts. b. The client plans to enroll in an exercise class to regain her figure. c. The client drinks one or two beers each evening to relax. d. The client uses warm water, but no soap, to wash her nipples.
C) The client drinks one or two beers each evening to relax. Rationale: Alcohol of all kinds should be avoided while breastfeeding, because it can be transferred through the breast milk to the infant and can cause CNS depression in the infant.
Following a vaginal delivery, a postpartum client complains of severe cramping after breastfeeding her newborn. Which explanation describes the most likely reason for the client's pain? a. A retained placenta b. Problems with the process of involution c. The release of oxytocin hormone d. A possible ileus
C) The release of oxytocin hormone Rationale: During breastfeeding, oxytocin is released and will cause uterine contractions and cramping.
The nurse is reinforcing instructions on newborn care for expectant parents. Which instruction is correct for the nurse to include concerning the newborn infant born at term? a. Milia are red marks made by forceps and will disappear within 7 to 10 days. b. Meconium is the first stool and is firm, and usually yellow gold in color. c. Vernix is a white cheesy substance, predominately seen in skin folds. d. Pseudostrabismus found in newborns is treated by minor surgery.
C) Vernix is a white cheesy substance, predominately seen in skin folds. Rationale: Vernix, found in skin folds, is a common characteristic of term infants. Milia are white pinpoint spots usually found over the nose and chin, caused by sebaceous glands blockages. Meconium is the first stool, but it is tarry black, not golden yellow. Pseudostrabismus (crossed eyes) is normal at birth and does not require surgery.
A client is in active labor with her first child. She has expressed a firm desire to not receive pain medications. Her pulse is 92 beats/min and her respirations are 28 breaths/min. She tells the nurse "My fingers are tingling, and I'm beginning to feel dizzy. What's wrong with me?" Which nursing intervention should the nurse provide? a. Explain to the client that she is experiencing respiratory acidosis. b. Inform the client she should reconsider her option regarding pain management. c. Apply a snug oxygen mask to the client to provide additional oxygen to the fetus. d. Ask the client to breathe into her cupped hands, and assist her with relaxation techniques.
D) Ask the client to breathe into her cupped hands, and assist her with relaxation techniques. Rationale: The client is hyperventilating and experiencing respiratory alkalosis. She can be helped by cupping her hands and breathing into them at a slow, relaxed rate. The nurse can also assist her with relaxation techniques. It is inappropriate for the nurse to suggest she reconsider pain medication if she does not want it. An oxygen mask will not benefit the client, since the client is not experiencing a low oxygen level, she has a low carbon dioxide level.
During labor, the fetal heart rate slowly decelerates at the beginning of the contraction and returns to baseline at the end of the contraction. What action should the nurse take? a. Turn the mother to her left side. b. Administer oxygen to the mother via face mask. c. Notify the health care provider regarding the findings. d. Continue to monitor the progress of the client's labor.
D) Continue to monitor the progress of the client's labor. Rationale: Early decelerations during labor are frequently caused by head compression within the uterus, and no nursing intervention is required except to monitor the mother's progress during labor.
What nursing intervention does the nurse expect to see in the plan of care to aid in preventing postpartum thrombophlebitis for a client who has had a Caesarean delivery? a. Apply supportive stockings bilaterally. b. Place moist heat to varicose veins. c. Complete a focused cardiac assessment. d. Encourage early ambulation after delivery.
D) Encourage early ambulation after delivery. Rationale: Early ambulation increases venous return and prevents thrombophlebitis. Clotting factors are normally elevated in the postpartum period to heal the placental site, thereby predisposing clients to thrombus formation.
The nurse is assisting the health care provider who will be performing an amniocentesis on a client who is 37 weeks pregnant. Which is the priority action for the nurse to take prior to the procedure? a. Give the client at least 2000 mL fluid orally before the procedure. b. Turn the client to the left lateral position before the procedure. c. Inform the client to expect contractions after the procedure. d. Instruct the client to empty her bladder prior to the procedure.
D) Instruct the client to empty her bladder prior to the procedure. Rationale: The client who is in late pregnancy should empty her bladder before the procedure to prevent injury to the bladder. It is not necessary to give the client fluids prior to the procedure, or to turn the client to the left lateral position. It is not normal to experience contractions after this procedure, if these happen, the health care provider should be notified.
A pregnant client is being discharged after presenting to the labor and delivery unit in false labor. The nurse explains to the client the signs of true labor. Which statement made by the client indicates that further teaching is required? a. My contractions will not go away if I walk around. b. My contractions will get stronger and closer together. c. My contractions may feel like really bad menstrual cramps. d. My contractions will be irregular and felt in my abdomen.
D) My contractions will be irregular and felt in my abdomen. Rationale: False labor contractions are irregular, do not progress, and are usually felt in the abdomen or groin.
Just after delivery, a new mother tells the practical nurse (PN) that breastfeeding was unsuccessful with the client's first child, but the client would like to try with this baby. Which intervention should the PN implement first? a. Assess the husband's feelings about his wife's decision to breastfeed their baby. b. Ask the client to describe why she was unsuccessful with breastfeeding her last child. c. Encourage the client to develop a positive attitude about breastfeeding to help ensure success. d. Provide assistance to the mother to begin breastfeeding as soon as possible after delivery.
D) Provide assistance to the mother to begin breastfeeding as soon as possible after delivery. Rationale: Infants respond to breastfeeding best when feeding is initiated in the active phase soon after delivery.
An off-duty practical nurse (PN) finds a female in a supermarket parking lot who has delivered an infant while her husband is screaming for someone to help his wife. Which intervention has the highest priority? a. Use thread to tie off the umbilical cord. b. Provide as much privacy as possible for the female. c. Reassure the husband and try to keep him calm. d. Put the newborn to the breast.
D) Put the newborn to the breast. Rationale: Putting the newborn to the breast will help contract the uterus and prevent a postpartum hemorrhage. This intervention has the highest priority.
A client comes to the OB clinic for her first prenatal visit and complains of feeling nauseated every morning. The client tells the practical nurse (PN), I'm having second thoughts about wanting to have this baby. Which response is best for the PN to make? a. It's normal to feel ambivalent about a pregnancy when you are not feeling well. b. I think you should discuss these feelings with your health care provider. c. How does the father of your child feel about you having this baby? d. Tell me about these second thoughts you are having about this pregnancy.
D) Tell me about these second thoughts you are having about this pregnancy. Rationale: Although ambivalence is normal during the first trimester; however, it's best to ask the client to verbalize her feelings to clarify and determine any underlying concerns. Ambivalence: the state of having mixed feelings or contradictory ideas about something or someone. "the law's ambivalence about the importance of a victim's identity"
The practical nurse (PN) is reviewing characteristics of the newborn and is sharing common growth and development milestones with new parents when they ask, when will the soft spots close? The PN should respond that they can expect the infant's fontanels to close during what age span? a. The anterior fontanel closes at 2 to 4 months and the posterior by the end of the first week. b. The anterior fontanel closes at 5 to 7 months and the posterior by the end of the second week. c. The anterior fontanel closes at 8 to 11 months and the posterior by the end of the first month. d. The anterior fontanel closes at 12 to 18 months and the posterior by the end of the second month.
D) The anterior fontanel closes at 12 to 18 months and the posterior by the end of the second month. Rationale: In the normal infant, the anterior fontanel closes at 12 to 18 months of age and the posterior fontanel by the end of the second month.
The practical nurse (PN) is assessing a client at 20 weeks' gestation. Which measurement should be compared with the client's current weight to obtain data about her weight gain during the entire pregnancy? a. Usual pre-pregnancy weight b. Weight at the first prenatal visit c. Previous pregnancy weight gain d. Daily weight gains or losses
a. Usual pre-pregnancy weight Rationale: Comparing the client's current weight with her pre-pregnancy weight allows for a calculation of total weight gain.
A client who is in labor with her 3rd child tells the nurse, "I have to push." The health care provider had performed a vaginal examination on the client an hour ago and determined the client was 5 cm dilated, 50% effaced. What should be the nurse's next action? a. Encourage the client to push when she has a contraction. b. Inform the mother she is not dilated enough to begin pushing. c. Contact the client's health care provider to assess the client's cervix. d. Instruct the client on ways to relax, and allow her privacy while she relaxes.
c. Contact the client's health care provider to assess the client's cervix. Rationale: The nurse's next action should be to contact the health care provider to assess the client's cervix. Clients who have had more than one delivery can progress through labor quickly. The client should not push when she has a contraction until her cervix has been assessed. The nurse should not inform the client she is not dilated enough until her cervix has been assessed. The client should not be left alone to relax, as delivery is likely imminent.