NSG 211 Postpartum & Newborn

Which assessment following an amniotomy should be conducted first? 1. Cervical dilation 2.Bladder distention 3.Fetal heart rate pattern 4.Maternal blood pressure

3.Fetal heart rate pattern Fetal heart rate is assessed immediately after amniotomy to detect any changes that may indicate cord compression or prolapse. When the membranes are ruptured, minimal vaginal examinations would be done because of the risk of infection. Bladder distention or maternal blood pressure would not be the first thing to check after an amniotomy.

True labor: cervix

Effacement and/or dilation of cervix occurs. Progressive effacement and dilation of cervix are most important characteristics.

First stage of labor

begins with the onset of regular uterine contractions and ends with full cervical effacement (100%) and dilation (10cm) of the cervix the LONGEST phase for both nulliparous and parous women contains three phases: latent, active, and transition bloody show

True labor: contractions

consistent pattern of increasing frequency, duration, and intensity usually develops walking tends to INCREASE strength

False labor: discomfort

felt in abdomen and groin may be more annoying than truly painful

The nurse is providing postpartum instructions to a client who will be breast-feeding her newborn. The nurse determines that the client has understood the instructions if she makes which statements? Select all that apply. "I should wear a bra that provides support." 2."Drinking alcohol can affect my milk supply." 3."The use of caffeine can decrease my milk supply." 4."I will start my estrogen birth control pills again as soon as I get home." 5."I know if my breasts get engorged, I will limit my breast-feeding and supplement the baby." 6."I plan on having bottled water available in the refrigerator so I can get additional fluids easily."

1, 2, 3, 6 The postpartum client should wear a bra that is well fitted and supportive. Common causes of decreased milk supply include formula use; inadequate rest or diet; smoking by the mother or others in the home; and use of caffeine, alcohol, or medications. Breast-feeding clients should increase their daily fluid intake; having bottled water available indicates that the postpartum client understands the importance of increasing fluids. If engorgement occurs, the client should not limit breast-feeding but should breast-feed frequently. Oral contraceptives containing estrogen are not recommended for breast-feeding mothers.

The nurse is assessing the fundus in a postpartum woman and notes that the uterus is soft and spongy and not firmly contracted. The nurse should prepare to implement which interventions? Select all that apply. 1. Massaging the uterus 2.Pushing gently on the uterus 3.Assisting the woman to urinate 4.Rechecking the uterus in 1 hour 5.Checking for a distended bladder 6.Calling the delivery room to schedule an abdominal hysterectomy

1, 3, 5 If the uterus is soft and spongy and not firmly contracted, the initial nursing action is to massage the fundus gently until it is firm; this will express clots that may have accumulated in the uterus. If the uterus does not remain contracted as a result of massage, the problem may be a distended bladder, which lifts and displaces the uterus and prevents effective contraction of the uterine muscles. The nurse should then check for a distended bladder and assist the woman to urinate. Pushing on an uncontracted uterus could invert it, potentially causing massive hemorrhage and rapid shock. Waiting for 1 hour without intervention could result in excessive blood loss. The primary health care provider (PHCP) will need to be notified if uterine massage is not helpful. Pharmacological measures may be necessary to maintain firm contraction of the uterus. An abdominal hysterectomy may need to be performed for massive hemorrhage that is uncontrollable. The question presents no data indicating that hemorrhage is a problem. In addition, the nurse should not schedule an operative procedure.

The nurse asks a nursing student to describe the procedure for administering erythromycin ointment to the eyes of a newborn. Which student statement indicates that further teaching is needed about administration of the eye medication? 1. "I will flush the eyes after instilling the ointment." 2."I will clean the newborn's eyes before instilling ointment." 3."I need to administer the eye ointment within 1 hour after delivery." 4."I will instill the eye ointment into each of the newborn's conjunctival sacs."

1. "I will flush the eyes after instilling the ointment." Eye prophylaxis protects the newborn against Neisseria gonorrhoeae and Chlamydia trachomatis. The eyes are not flushed after instillation of the medication because the flush would wash away the administered medication. Options 2, 3, and 4 are correct statements regarding the procedure for administering eye medication to the newborn.

Butorphanol tartrate is prescribed for a woman in labor, and the woman asks the nurse about the purpose of the medication. The nurse should make which appropriate response? 1. "The medication provides pain relief during labor." 2."The medication will assist in increasing the contractions." 3."The medication will help prevent any nausea and vomiting." 4."The medication prevents respiratory depression in the newborn infant."

1. "The medication provides pain relief during labor." Butorphanol tartrate is an opioid analgesic that provides systemic pain relief during labor. It does not relieve nausea, increase uterine contractions, or prevent respiratory depression in the newborn infant.

The postpartum nurse is providing instructions to a client after birth of a healthy newborn. Which time frame should the nurse relay to the client regarding the return of bowel function? 1. 3 days postpartum 2.7 days postpartum 3.On the day of birth 4.Within 2 weeks postpartum

1. 3 days postpartum After birth, the nurse should auscultate the client's abdomen in all 4 quadrants to determine the return of bowel sounds. Normal bowel elimination usually returns 2 to 3 days postpartum. Surgery, anesthesia, and the use of opioids and pain control agents also contribute to the longer period of altered bowel functions. Options 2, 3, and 4 are incorrect.

The nurse in the labor room is caring for a client in the active stage of the first phase of labor. The nurse is assessing the fetal patterns and notes a late deceleration on the monitor strip. What is the most appropriate nursing action? 1. Administer oxygen via face mask. 2.Place the mother in a supine position. 3.Increase the rate of the oxytocin intravenous infusion. 4.Document the findings and continue to monitor the fetal patterns.

1. Administer oxygen via face mask. Late decelerations are due to uteroplacental insufficiency and occur because of decreased blood flow and oxygen to the fetus during the uterine contractions. Hypoxemia results; oxygen at 8 to 10 L/minute via face mask is necessary. The supine position is avoided because it decreases uterine blood flow to the fetus. The client should be turned onto her side to displace pressure of the gravid uterus on the inferior vena cava. An intravenous oxytocin infusion is discontinued when a late deceleration is noted. The oxytocin would cause further hypoxemia because of increased uteroplacental insufficiency resulting from stimulation of contractions by this medication. Although the nurse would document the occurrence, option 4 would delay necessary treatment.

The mother of a newborn calls the clinic and reports that when cleaning the umbilical cord, she noticed that the cord was moist and that discharge was present. What is the most appropriate nursing instruction for this mother? 1. Bring the infant to the clinic. 2. This is a normal occurrence and no further action is needed. 3. Increase the number of times that the cord is cleaned per day. 4. Monitor the cord for another 24 to 48 hours and call the clinic if the discharge continues.

1. Bring the infant to the clinic. Signs of umbilical cord infection are moistness, oozing, discharge, and a reddened base around the cord. If signs of infection occur, the client should be instructed to notify the primary health care provider (PHCP). If these symptoms occur, antibiotics may be necessary. Options 2, 3, and 4 are not the most appropriate nursing interventions for an umbilical cord infection as described in the question.

A woman in active labor has requested a regional anesthetic. She is currently 5 cm dilated. The primary health care provider has prescribed an epidural block. Which nursing intervention should be implemented after the epidural block has been placed? 1. Palpate the bladder at frequent intervals. 2.Encourage the woman to walk to progress the labor. 3.Assess the blood pressure frequently for hypertension. 4.Encourage the woman to assume a supine position after the epidural has been placed.

1. Palpate the bladder at frequent intervals. The effect of the epidural is that anesthesia is felt from the fifth lumbar space to the sacral region of the vertebral column. The woman loses the sensation that she needs to urinate. The nurse must palpate the bladder frequently because a full bladder will impede progression of the fetus during the laboring process. Ambulation is not allowed because of the anesthesia. The woman is encouraged to lie on her side to increase placental perfusion to the fetus. Hypotension, not hypertension, is a concern.

The nurse is caring for a client who is receiving oxytocin for induction of labor and notes a nonreassuring fetal heart rate (FHR) pattern on the fetal monitor. On the basis of this finding, the nurse should take which action first? 1. Stop the oxytocin infusion. 2. Check the client's blood pressure. 3. Check the client for bladder distention. 4. Place the client in a side-lying position.

1. Stop the oxytocin infusion. Oxytocin stimulates uterine contractions and is used to induce labor. If uterine hypertonicity or a nonreassuring FHR pattern occurs, the nurse needs to intervene to reduce uterine activity and increase fetal oxygenation. The oxytocin infusion is stopped, the client is placed in a side-lying position, and oxygen by face mask at 8 to 10 L/min is administered. The primary health care provider is notified. The nurse should monitor the client's blood pressure and intake and output; however, the nurse should first stop the infusion.

The nurse is teaching a postpartum client about breast-feeding. Which instruction should the nurse include? 1. The diet should include additional fluids. 2.Prenatal vitamins should be discontinued. 3.Soap should be used to cleanse the breasts. 4.Birth control measures are unnecessary while breast-feeding.

1. The diet should include additional fluids. The diet for a breast-feeding client should include additional fluids. Prenatal vitamins should be taken as prescribed, and soap should not be used on the breasts because it tends to remove natural oils, which increases the chance of cracked nipples. Breast-feeding is not a method of contraception, so birth control measures should be resumed.

The nurse is collecting data during an admission assessment of a client who is pregnant with twins. The client has a healthy 5-year-old child who was delivered at 38 weeks and tells the nurse that she does not have a history of any type of abortion or fetal demise. Using GTPAL, what should the nurse document in the client's chart? 1. G = 3, T = 2, P = 0, A = 0, L = 1 2. G = 2, T = 1, P = 0, A = 0, L = 1 3. G = 1, T = 1, P = 1, A = 0, L = 1 4. G = 2, T = 0, P = 0, A = 0, L = 1

2. G = 2, T = 1, P = 0, A = 0, L = 1 Pregnancy outcomes can be described with the acronym GTPAL. G is gravidity, the number of pregnancies; T is term births, the number born at term (longer than 37 weeks); P is preterm births, the number born before 37 weeks of gestation; A is abortions or miscarriages, the number of abortions or miscarriages (included in gravida if before 20 weeks of gestation; included in parity if past 20 weeks of gestation); and L is the number of current living children. A woman who is pregnant with twins and has a child has a gravida of 2. Because the child was delivered at 38 weeks, the number of term births is 1, and the number of preterm births is 0. The number of abortions is 0, and the number of living children is 1.

The nurse has created a plan of care for a client experiencing dystocia and includes several nursing actions in the plan of care. What is the priority nursing action? 1. Providing comfort measures 2.Monitoring the fetal heart rate 3.Changing the client's position frequently 4.Keeping the significant other informed of the progress of the labor

2. Monitoring the fetal heart rate Dystocia is difficult labor that is prolonged or more painful than expected. The priority is to monitor the fetal heart rate. Although providing comfort measures, changing the client's position frequently, and keeping the significant other informed of the progress of the labor are components of the plan of care, the fetal status would be the priority.

The nurse has a routine prescription to administer an injection of phytonadione (vitamin K) to the newborn. Which statement made by the new mother indicates that teaching on this medication was effective? 1. "I know that this medication is used to stimulate the liver to produce vitamin K." 2."I know that this medication is used to prevent clotting abnormalities in the newborn." 3."I know that this medication is used to prevent vitamin deficiency of fat-soluble vitamins." 4."I know that this medication is used to supplement my baby because breast milk and formula are low in vitamin K."

2."I know that this medication is used to prevent clotting abnormalities in the newborn." Vitamin K is given to the newborn to prevent clotting abnormalities. Vitamin K is usually produced by bacteria in the gastrointestinal tract, which is sterile in the newborn. The other options are incorrect reasons for administering this medication to a newborn.

The nurse should make which statement to a pregnant client found to have a gynecoid pelvis? 1. "Your type of pelvis has a narrow pubic arch." 2."Your type of pelvis is the most favorable for labor and birth." 3. "Your type of pelvis is a wide pelvis, but it has a short diameter." 4. "You will need a cesarean section because this type of pelvis is not favorable for a vaginal delivery."

2."Your type of pelvis is the most favorable for labor and birth." A gynecoid pelvis is a normal female pelvis and is the most favorable for successful labor and birth. An android pelvis (resembling a male pelvis) would be unfavorable for labor because of the narrow pelvic planes. An anthropoid pelvis has an outlet that is adequate, with a normal or moderately narrow pubic arch. A platypelloid pelvis (flat pelvis) has a wide transverse diameter, but the anteroposterior diameter is short, making the outlet inadequate.

After the spontaneous rupture of a laboring woman's membranes, the fetal heart rate drops to 85 beats/minute. Which should be the nurse's priority action? 1. Reposition the laboring woman to knee-chest. 2.Assess the vagina and cervix with a gloved hand. 3.Notify the primary health care provider of the need for an amnioinfusion. 4.Document the description of the fetal bradycardia in the nursing notes.

2.Assess the vagina and cervix with a gloved hand. It is most common to see an umbilical cord prolapsed directly after the rupture of membranes, when gravity washes the cord in front of the presenting part. A cord prolapse can be evidenced by fetal bradycardia with variable decelerations occurring with uterine contractions. Because the fetal heart rate became bradycardic immediately following the spontaneous rupture of the client's membranes, the nurse's initial action should be to glove the examining hand and insert 2 fingers into the vagina to assess for the presence of a prolapsed cord and then to relieve compression of the cord by exerting upward pressure on the presenting part. Repositioning the woman to a knee-chest position is a correct intervention for prolapsed cord, but confirmation of the prolapsed cord and relieving compression is the first intervention that should be implemented; therefore, option 1 can be eliminated. An amnioinfusion may be used to minimize the effects of cord compression in utero, not a prolapsed cord, so option 3 can be eliminated. Although documentation of this occurrence is important, it is not the priority in this situation, so option 4 can also be eliminated.

Methylergonovine is prescribed for a woman to treat postpartum hemorrhage. Before administration of methylergonovine, what is the priority assessment? 1. Uterine tone 2.Blood pressure 3.Amount of lochia 4.Deep tendon reflexes

2.Blood pressure Methylergonovine, an ergot alkaloid, is used to prevent or control postpartum hemorrhage by contracting the uterus. Methylergonovine causes continuous uterine contractions and may elevate the blood pressure. A priority assessment before the administration of the medication is to check the blood pressure. The obstetrician needs to be notified if hypertension is present. Although options 1, 3, and 4 may be components of the postpartum assessment, blood pressure is related specifically to the administration of this medication.

The postpartum nurse is providing instructions to the mother of a newborn with hyperbilirubinemia who is being breast-fed. The nurse should provide which instruction to the mother? 1. Feed the newborn less frequently. 2.Continue to breast-feed every 2 to 4 hours. 3.Switch to bottle-feeding the infant for 2 weeks. 4.Stop breast-feeding and switch to bottle-feeding permanently.

2.Continue to breast-feed every 2 to 4 hours. Hyperbilirubinemia is an elevated serum bilirubin level. At any serum bilirubin level, the appearance of jaundice during the first day of life indicates a pathological process. Early and frequent feeding hastens the excretion of bilirubin. Breast-feeding should be initiated within 2 hours after birth and every 2 to 4 hours thereafter. The infant should not be fed less frequently. Switching to bottle-feeding for 2 weeks or stopping breast-feeding permanently is unnecessary.

As the placenta separates, it settles downward into the lower uterine segment. The umbilical cord lengthens, and a sudden trickle or spurt of blood appears. Options 1, 2, and 3 are incorrect interpretations. 1. Contact the obstetrician. 2.Continue to monitor the client. 3.Report the FHR to the anesthesiologist. 4.Prepare for imminent delivery of the fetus.

2.Continue to monitor the client. The FHR normally is 110 to 160 beats/minute. Signs of potential complications of labor are contractions consistently lasting 90 seconds or longer or consistently occurring 2 minutes or less apart; fetal bradycardia, tachycardia, or persistently decreased variability; and irregular FHR. The assessment findings identified in the question are not signs of potential complications.

The nurse is assisting a client undergoing induction of labor at 41 weeks of gestation. The client's contractions are moderate and occurring every 2 to 3 minutes, with a duration of 60 seconds. An internal fetal heart rate monitor is in place. The baseline fetal heart rate has been 120 to 122 beats/minute for the past hour. What is the priority nursing action? 1. Notify the primary health care provider. 2.Discontinue the infusion of oxytocin. 3.Place oxygen on at 8 to 10 L/minute via face mask. 4.Contact the client's primary support person(s) if not currently present.

2.Discontinue the infusion of oxytocin. The priority nursing action is to stop the infusion of oxytocin. Oxytocin can cause forceful uterine contractions and decrease oxygenation to the placenta, resulting in decreased variability. After stopping the oxytocin, the nurse should reposition the laboring mother. Notifying the primary health care provider, applying oxygen, and increasing the rate of the intravenous (IV) fluid (the solution without the oxytocin) are also actions that are indicated in this situation but not the priority action. Contacting the client's primary support person(s) is not the priority action at this time.

The nurse performs a vaginal assessment on a pregnant client in labor. On assessment, the nurse notes the presence of the umbilical cord protruding from the vagina. Which is the initial nursing action? 1. Gently push the cord into the vagina. 2.Place the client in Trendelenburg's position. 3.Find the closest telephone and page the primary health care provider (PHCP) stat. 4.Call the delivery room to notify the staff that the client will be transported immediately.

2.Place the client in Trendelenburg's position. When cord prolapse occurs, prompt actions are taken to relieve cord compression and increase fetal oxygenation. The mother should be positioned with her hips higher than her head to shift the fetal presenting part toward the diaphragm. The nurse should push the call light to summon help, and other staff members should call the PHCP and notify the delivery room. If the cord is protruding from the vagina, no attempt should be made to replace it because that could traumatize it and further reduce blood flow. Oxygen at 8 to 10 L/min by face mask is administered to the mother to increase fetal oxygenation.

The postpartum nurse is caring for a woman who just delivered a healthy newborn. The nurse should be most concerned about the presence of subinvolution if which occurs? 1. Afterpains 2.Retained placental fragments from delivery 3.An oral temperature of 99.0º F (37.2º C) following delivery 4.Increased estrogen and progesterone levels as noted on laboratory analysis

2.Retained placental fragments from delivery Retained placental fragments and infection are the primary causes of subinvolution. When either of these processes is present, the uterus will have difficulty contracting. The presence of afterpains and a temperature of 99.0º F (37.2º C) after delivery are expected findings. Hormonal levels are not a cause of subinvolution and are unrelated to the subject of the question.

The nurse is caring for a client in labor. Which assessment findings indicate to the nurse that the client is beginning the second stage of labor? Select all that apply. 1. The contractions are regular. 2. The membranes have ruptured. 3. The cervix is dilated completely. 4. The client begins to expel clear vaginal fluid. 5. The Ferguson reflex is initiated from perineal pressure.

3, 5 The second stage of labor begins when the cervix is dilated completely and ends with birth of the neonate. The woman has a strong urge to push in stage 2 when the Ferguson reflex is activated. Options 1, 2, and 4 are not specific assessment findings of the second stage of labor and occur in stage 1.

The nurse is reviewing the primary health care provider's (PHCP's) prescriptions for a client admitted for premature rupture of the membranes. Gestational age of the fetus is determined to be 37 weeks. Which prescription should the nurse question? 1. Monitor fetal heart rate continuously. 2.Monitor maternal vital signs frequently. 3.Perform a vaginal examination every shift. 4.Administer an antibiotic per prescription and per agency protocol.

3. Perform a vaginal examination every shift. Vaginal examinations should not be done routinely on a client with premature rupture of the membranes because of the risk of infection. The nurse would expect to monitor fetal heart rate, monitor maternal vital signs, and administer an antibiotic.

The nurse is administering an intravenous analgesic to a laboring woman. The woman inquires as to why the nurse is waiting for a contraction to begin before she infuses the medication into the intravenous line. Which is the nurse's most appropriate response? 1. "The medication will affect you and your pain level only when given during a contraction." 2."The medication will provide optimal relief when it is given while your pain level is highest." 3."Because the uterine blood vessels constrict during a contraction, the fetus will be less affected by the medication." 4."You will experience a lower incidence of adverse effects from the medication when administered during a contraction."

3."Because the uterine blood vessels constrict during a contraction, the fetus will be less affected by the medication." Intravenous medication should be administered slowly in small doses starting at the beginning of a contraction and carrying over for 3 to 5 contractions. This intervention minimizes the amount of the medication that crosses the placenta and enters the fetal circulation, thus minimizing its effects on the fetus. Although this method of administration may decrease the amount of medication reaching the fetus, it does not totally eliminate effects of the medication on the fetus. The statements in the remaining options are incorrect information about the medication effects.

The nurse has provided instructions about measures to clean the penis to a mother of a male newborn who is not circumcised. Which statement, if made by the mother, indicates an understanding of how to clean the newborn's penis? 1. "I should retract the foreskin and clean the penis every time I change the diaper." 2."I need to retract the foreskin and clean the penis every time I give my infant a bath." 3."I need to avoid pulling back the foreskin to clean the penis because this may cause adhesions." 4."I should gently retract the foreskin as far as it will go on the penis and then pull the skin back over the penis after cleaning."

3."I need to avoid pulling back the foreskin to clean the penis because this may cause adhesions." In male newborn infants, the prepuce is continuous with the epidermis of the glans and is not retractable. If retraction is forced, this may cause adhesions to develop. The mother should be told to allow separation to occur naturally, which usually occurs between 3 years and puberty. Most foreskins are retractable by 3 years of age and should be pushed back gently at this time for cleaning. Options that identify actions that retract the foreskin are therefore incorrect.

The nursing instructor asks the student to describe fetal circulation, specifically the ductus venosus. Which statement by the student indicates an understanding of the ductus venosus? 1. "It connects the pulmonary artery to the aorta." 2."It is an opening between the right and left atria." 3."It connects the umbilical vein to the inferior vena cava." 4."It connects the umbilical artery to the inferior vena cava."

3."It connects the umbilical vein to the inferior vena cava." The ductus venosus connects the umbilical vein to the inferior vena cava. The foramen ovale is a temporary opening between the right and left atria. The ductus arteriosus joins the aorta and the pulmonary artery.

The nurse is preparing to care for four assigned clients. Which client is at most risk for hemorrhage? 1. A primiparous client who delivered 4 hours ago 2.A multiparous client who delivered 6 hours ago 3.A multiparous client who delivered a large baby after oxytocin induction 4.A primiparous client who delivered 6 hours ago and had epidural anesthesia

3.A multiparous client who delivered a large baby after oxytocin induction The causes of postpartum hemorrhage include uterine atony; laceration of the vagina; hematoma development in the cervix, perineum, or labia; and retained placental fragments. Predisposing factors for hemorrhage include a previous history of postpartum hemorrhage, placenta previa, abruptio placentae, overdistention of the uterus from polyhydramnios, multiple gestation, a large neonate, infection, multiparity, dystocia or labor that is prolonged, operative delivery such as a cesarean or forceps delivery, and intrauterine manipulation. The multiparous client who delivered a large fetus after oxytocin induction has more risk factors associated with postpartum hemorrhage than do other clients. In addition, there are no specific data in the client descriptions in options 1, 2, and 4 that present the risk for hemorrhage.

The nurse is preparing to administer an analgesic to a client in labor. Which analgesic is contraindicated for a client who has a history of opioid dependency? 1. Fentanyl 2.Morphine sulfate 3.Butorphanol tartrate 4.Meperidine hydrochloride

3.Butorphanol tartrate Butorphanol tartrate is an opioid analgesic that can precipitate withdrawal symptoms in an opioid-dependent client. Therefore, it is contraindicated if the client has a history of opioid dependency. Fentanyl, morphine sulfate, and meperidine are opioid analgesics but do not tend to precipitate withdrawal symptoms in opioid-dependent clients.

The nurse in the postpartum unit notes that a new mother was given methylergonovine intramuscularly following delivery. What assessment finding indicates that the medication was effective? 1. Lochia that is serous 2.Normal blood pressure 3.Decreased uterine bleeding 4.Decreased uterine contractions

3.Decreased uterine bleeding Methylergonovine, an oxytocic, is an agent that is used to prevent or control postpartum hemorrhage by contracting the uterus. The immediate dose usually is given intramuscularly; if additional medication is needed, it is given by mouth. No relationship exists between the action of this medication and lochial drainage. This medication may elevate the blood pressure and increase the strength and frequency of contractions. A priority assessment component before the administration of methylergonovine is blood pressure.

The nurse is assessing a newborn after circumcision and notes that the circumcised area is red with a small amount of bloody drainage. Which nursing action is most appropriate? 1. Apply gentle pressure. 2.Reinforce the dressing. 3.Document the findings. 4.Contact the primary health care provider (PHCP).

3.Document the findings. The penis is normally red during the healing process after circumcision. A yellow exudate may be noted in 24 hours, and this is part of normal healing. The nurse would expect that the area would be red with a small amount of bloody drainage. Only if the bleeding were excessive would the nurse apply gentle pressure with a sterile gauze. If bleeding cannot be controlled, the blood vessel may need to be ligated, and the nurse would notify the PHCP. Because the findings identified in the question are normal, the nurse would document the assessment findings.

The nurse is caring for a client in active labor. Which nursing intervention would be the best method to prevent fetal heart rate (FHR) decelerations? 1. Prepare the client for a cesarean delivery. 2.Monitor the FHR every 30 minutes. 3.Encourage an upright or side-lying maternal position. 4.Increase the rate of the oxytocin infusion every 10 minutes.

3.Encourage an upright or side-lying maternal position. Side-lying and upright positions such as walking, standing, and squatting can improve venous return and encourage effective uterine activity. Many nursing actions are available to prevent FHR decelerations, without necessitating surgical intervention. Monitoring the FHR every 30 minutes will not prevent FHR decelerations. The nurse should discontinue an oxytocin infusion in the presence of FHR decelerations, thereby reducing uterine activity and increasing uteroplacental perfusion.

The postpartum nurse is assessing a client who delivered a healthy infant by cesarean section for signs and symptoms of superficial venous thrombosis. Which sign should the nurse note if superficial venous thrombosis were present? 1. Paleness of the calf area 2.Coolness of the calf area 3.Enlarged, hardened veins 4.Palpable dorsalis pedis pulses

3.Enlarged, hardened veins Thrombosis of superficial veins usually is accompanied by signs and symptoms of inflammation, including swelling, redness, tenderness, and warmth of the involved extremity. It also may be possible to palpate the enlarged, hard vein. Clients sometimes experience pain when they walk. Palpable dorsalis pedis pulses is a normal finding.

The nurse is reviewing true and false labor signs with a multiparous client. The nurse determines that the client understands the signs of true labor if she makes which statement? 1. "I won't be in labor until my baby drops." 2."My contractions will be felt in my abdominal area." 3."My contractions will not be as painful if I walk around." 4."My contractions will increase in duration and intensity."

4. "My contractions will increase in duration and intensity." True labor is present when contractions increase in duration and intensity. Lightening or dropping leads to engagement (presenting part reaches the level of the ischial spine) and occurs when the fetus descends into the pelvis about 2 weeks before delivery. Contractions felt in the abdominal area and contractions that ease with walking are signs of false labor.

The postpartum nurse is taking the vital signs of a client who delivered a healthy newborn 4 hours ago. The nurse notes that the client's temperature is 100.2° F. What is the priority nursing action? 1. Document the findings. 2.Notify the obstetrician. 3.Retake the temperature in 15 minutes. 4.Increase hydration by encouraging oral fluids.

4. Increase hydration by encouraging oral fluids. The client's temperature should be taken every 4 hours while she is awake. Temperatures up to 100.4° F (38° C) in the first 24 hours after birth often are related to the dehydrating effects of labor. The appropriate action is to increase hydration by encouraging oral fluids, which should bring the temperature to a normal reading. Although the nurse also would document the findings, the appropriate action would be to increase hydration. Taking the temperature in another 15 minutes is an unnecessary action. Contacting the obstetrician is not necessary.

A postpartum client is attempting to breast-feed for the first time. The nurse notes that the client has inverted nipples. What nursing action should the nurse take to assist the client in breast-feeding the newborn infant? 1. Massage the breasts, applying gentle pressure on the areolas with the thumb and forefinger. 2.Have the mother grasp her areola between the thumb and forefinger and tug firmly to get the nipple to protrude. 3.Encourage the mother to take a cool shower, allowing the water to run over the breasts, because this will encourage the nipples to protrude. 4.Provide breast shells and assist the mother with using a breast pump before each feeding to make the nipples easier for the newborn infant to grasp.

4. Provide breast shells and assist the mother with using a breast pump before each feeding to make the nipples easier for the newborn infant to grasp. Wearing breast shells and using a breast pump before each feeding will make it easier for the newborn infant to grasp the nipple. Massaging the breast is an appropriate instruction for the mother with engorgement but will not help with resolving inverted nipples. True inverted nipples will retract if the areola is pressed between the thumb and forefinger. Having the client take a cool shower will only make the mother cold, and it has no effect on inverted nipples.

The nurse is monitoring a client in labor. The nurse suspects umbilical cord compression if which is noted on the external monitor tracing during a contraction? 1. Variability 2.Accelerations 3.Early decelerations 4.Variable decelerations

4. Variable decelerations Variable decelerations occur if the umbilical cord becomes compressed, reducing blood flow between the placenta and the fetus. Variability refers to fluctuations in the baseline fetal heart rate. Accelerations are a reassuring sign and usually occur with fetal movement. Early decelerations result from pressure on the fetal head during a contraction.

The nurse prepares to administer a phytonadione (vitamin K) injection to a newborn, and the mother asks the nurse why her infant needs the injection. What best response should the nurse provide? 1. "Your newborn needs the medicine to develop immunity." 2."The medicine will protect your newborn from being jaundiced." 3."Newborns have sterile bowels, and the medicine promotes the growth of bacteria in the bowel." 4."Newborns are deficient in vitamin K, and this injection prevents your newborn from bleeding."

4."Newborns are deficient in vitamin K, and this injection prevents your newborn from bleeding." Phytonadione is necessary for the body to synthesize coagulation factors. It is administered to the newborn to prevent bleeding disorders. It also promotes liver formation of the clotting factors II, VII, IX, and X. Newborns are vitamin K-deficient because the bowel does not have the bacteria necessary to synthesize fat-soluble vitamin K. The normal flora in the intestinal tract produces vitamin K. The newborn's bowel does not support the normal production of vitamin K until bacteria adequately colonize it. The bowel becomes colonized by bacteria as food is ingested. Vitamin K does not promote the development of immunity or prevent the infant from becoming jaundiced.

The nurse is performing Apgar scoring for a newborn infant immediately after birth. The nurse notes that the heart rate is greater than 100 beats/min, the respiratory effort is good, muscle tone is active, the newborn infant sneezes when suctioned by the bulb syringe, and the skin color is pink. On the basis of these findings, the nurse should document which Apgar score? 1.3 2.5 3.7 4.10

4.10 One of the earliest indicators of successful adaptation of the newborn infant is the Apgar score. Scoring ranges from 0 to 10. Five criteria are used to measure the infant's adaptation. Heart rate: absent = 0; less than 100 beats/min = 1; greater than 100 beats/min = 2. Respiratory effort: absent = 0; slow or irregular weak cry = 1; good, crying lustily = 2. Muscle tone: limp or hypotonic = 0; some extremity flexion = 1; active, moving, and well-flexed = 2. Irritability or reflexes (measured by response to bulb suctioning): no response = 0; grimace = 1; cough, sneeze, or vigorous cry = 2. Color: cyanotic or pale = 0; acrocyanotic, cyanosis of extremities = 1; pink = 2.

The nurse in the labor room measures the Apgar score in a newborn infant and notes that the score is 4. Which action by the nurse has highest priority? 1. Initiate an intravenous (IV) line on the newborn infant. 2.Place the newborn infant on a cardiorespiratory monitor. 3.Place the newborn infant in the radiant warmer incubator. 4.Administer oxygen via resuscitation bag to the newborn infant.

4.Administer oxygen via resuscitation bag to the newborn infant. Newborn infants with an Apgar score of 5 to 7 often require resuscitative interventions. Scores of less than 5 indicate that the newborn infant is having difficulty adjusting to extrauterine life and requires more vigorous resuscitation. The immediate nursing action should be to administer oxygen via resuscitation bag. Although the newborn infant may require a cardiorespiratory monitor and an IV line and may need to be placed in a radiant warmer incubator, the initial action of the nurse should be to provide resuscitative measures.

Rho(D) immune globulin is prescribed for a client after delivery, and the nurse provides information to the client about the purpose of the medication. The nurse determines that the woman understands the purpose if the woman states that it will protect her next baby from which condition? 1. Having Rh-positive blood 2.Developing a rubella infection 3.Developing physiological jaundice 4.Being affected by Rh incompatibility

4.Being affected by Rh incompatibility Rh incompatibility can occur when an Rh-negative mother becomes sensitized to the Rh antigen. Sensitization may develop when an Rh-negative woman becomes pregnant with a fetus who is Rh positive. During pregnancy and at delivery, some of the fetus's Rh-positive blood can enter the maternal circulation, causing the mother's immune system to form antibodies against Rh-positive blood. Administration of Rho(D) immune globulin prevents the mother from developing antibodies against Rh-positive blood by providing passive antibody protection against the Rh antigen.

Methylergonovine has been prescribed for a woman who is at risk for postpartum bleeding in the immediate postpartum period. The nurse preparing to administer the medication ensures that which priority item is at the bedside? 1. Peripads 2.Tape measure 3.Reflex hammer 4.Blood pressure cuff

4.Blood pressure cuff Methylergonovine is an oxytocic agent used to prevent or control postpartum hemorrhage by contracting the uterus. It causes constant uterine contractions and may cause the blood pressure to elevate. A priority assessment before administering this medication is obtaining a baseline blood pressure. The client's blood pressure also should be monitored during the administration of the medication. Methylergonovine is administered cautiously in the presence of hypertension, and the primary health care provider should be notified if hypertension occurs. Peripads, a tape measure, and a reflex hammer are not priority items.

The nurse in a delivery room is assessing a client immediately after delivery of the placenta. Which maternal observation could indicate uterine inversion and require immediate intervention? 1. Chest pain 2.A rigid abdomen 3.A soft and boggy uterus 4.Complaints of severe abdominal pain

4.Complaints of severe abdominal pain Signs of uterine inversion include a depression in the fundal area, visualization of the interior of the uterus through the cervix or vagina, severe abdominal pain, hemorrhage, and shock. Chest pain and a rigid abdomen are signs of a ruptured uterus. A soft and boggy uterus indicates that the muscle is not contracting.

The nurse in the labor room is caring for a client who is in the first stage of labor. On assessing the fetal patterns, the nurse notes an early deceleration of the fetal heart rate (FHR) on the monitor strip. Based on this finding, which is the appropriate nursing action? 1. Contact the primary health care provider (PHCP). 2.Place the client in Trendelenburg's position. 3.Administer oxygen to the client by face mask. 4.Document the findings and continue to monitor fetal patterns.

4.Document the findings and continue to monitor fetal patterns. Early deceleration of the FHR refers to a gradual decrease in the heart rate, followed by a return to baseline, in response to compression of the fetal head. It is a normal and benign finding. Because early decelerations are considered benign, interventions are not necessary. Therefore, contacting the PHCP, changing the client' position, or administering oxygen is not necessary.

The nurse is caring for a client in labor and is monitoring the fetal heart rate patterns. The nurse notes the presence of episodic accelerations on the electronic fetal monitor tracing. Which action is most appropriate? 1. Notify the primary health care provider of the findings. 2.Reposition the mother and check the monitor for changes in the fetal tracing. 3.Take the mother's vital signs and tell the mother that bed rest is required to conserve oxygen. 4.Document the findings and tell the mother that the pattern on the monitor indicates fetal well-being.

4.Document the findings and tell the mother that the pattern on the monitor indicates fetal well-being. Accelerations are transient increases in the fetal heart rate that often accompany contractions or are caused by fetal movement. Episodic accelerations are thought to be a sign of fetal well-being and adequate oxygen reserve. Options 1, 2, and 3 are inaccurate nursing actions and are unnecessary.

The nurse is reviewing the record of a newborn infant in the nursery and notes that the primary health care provider (PHCP) has documented the presence of a cephalohematoma. Based on this documentation, what should the nurse expect to note on assessment of the infant? 1. A suture split greater than 1 cm 2.A hard, rigid, immobile suture line 3.Swelling of the soft tissues of the head and scalp 4.Edema resulting from bleeding below the periosteum of the cranium

4.Edema resulting from bleeding below the periosteum of the cranium A cephalohematoma indicates edema resulting from bleeding below the periosteum of the cranium. It does not cross the suture line. It is most likely to be caused by ruptured blood vessels from head trauma during birth. The lesion develops within 24 to 48 hours after birth and may take 2 to 3 weeks to resolve. A suture split greater than 1 cm may indicate increased intracranial pressure. A hard, immobile suture may be associated with premature closure or craniosynostosis and should be investigated further. Edema of cranial tissues identifies a caput succedaneum.

Methylergonovine is prescribed for a client with postpartum hemorrhage. Before administering the medication, the nurse should contact the obstetrician who prescribed the medication if which condition is documented in the client's medical history? 1. Hypotension 2.Hypothyroidism 3.Diabetes mellitus 4.Peripheral vascular disease

4.Peripheral vascular disease Methylergonovine is an ergot alkaloid used to treat postpartum hemorrhage. Ergot alkaloids are contraindicated in clients with significant cardiovascular disease, peripheral vascular disease, hypertension, preeclampsia, or eclampsia. These conditions are worsened by the vasoconstrictive effects of the ergot alkaloids. Options 1, 2, and 3 are not contraindications related to the use of ergot alkaloids.

The nurse is preparing to teach a new mother how to sponge bathe a 1-day-old newborn. Which actions should the nurse take? Select all that apply. 1. Pat the baby dry gently. 2.Use shampoo to wash the scalp and hair. 3.Support the newborn's body during the bath. 4.Make sure that the room temperature is 75º F (23.9º C). 5.Cleanse one body area at a time keeping other body areas covered.

Washing the hair comes toward the end of the bath so that the baby does not get cold. There is no need to use shampoo on the scalp and hair; water is sufficient. The newborn is supported throughout the procedure and one body area at a time is cleansed keeping other body areas covered to prevent chilling. The room temperature is also kept warm at 75º F (23.9º C) to prevent chilling. Each area is patted dry after washing; rubbing the skin will irritate it.

first stage of labor: active phase

begins at 4cm of cervical dilation ends at 7 cm cervical dilation internal rotation occurs as the fetus descends in the pelvis during active labor

False labor: contractions

inconsistent in frequency, duration, and intensity activity, such as walking, does not alter contractions, or activity may DECREASE them

first stage of labor: latent phase

lasts from the beginning of labor to 3cm cervical effacement and subtle fetal position change occur mom is usually sociable and excited during this phase

False labor: cervix

no significant change in effacement or dilation of the cervix after an observation period of 1 to 2 hours

fourth stage of labor

physical recovery begins with delivery of the placenta and lasts 1 to 4 hours after birth vaginal drainage called lochia rubra; small clots normal

first stage of labor: transition

begins at 7 or 8 cm ends at 10 cm dilation short phase, but very intense contractions leg tremors, nausea, and vomiting are common

True labor: discomfort

begins in lower back and gradually sweeps around to the lower abdomen like a girdle back pain may persist in some women. early labor often feels like menstrual cramps

third stage of labor

begins with the birth of the baby ends with expulsion of the placenta

A client in labor is dilated 10 cm. At this point in the labor process, at least how often should the nurse assess and document the fetal heart rate? 1. Hourly 2.Every 15 minutes 3.Every 30 minutes 4.Before each contraction

2.Every 15 minutes The second stage of labor begins when the cervix is dilated completely (10 cm). Maternal pulse, blood pressure, and fetal heart rate are assessed every 5 to 15 minutes, depending on agency protocol; some agency protocols recommend assessment after each contraction. Hourly and every 30 minutes represent lengthy time intervals for assessment in this stage of labor.

The purpose of a vaginal examination for a client in labor is to specifically assess the status of which findings? Select all that apply. 1.Station 2.Dilation 3.Effacement 4.Bloody show 5.Contraction effort

1, 2, 3 The vaginal examination for a client in labor specifically determines effacement 0% to 100%, dilation 0 to 10 cm, and station -5 cm (above the maternal ischial spine) to +5 cm (below the maternal ischial spine). Bloody show is the brownish or blood-tinged cervical mucus that may be passed preceding labor and is not a specific part of the assessment when performing a vaginal examination. Contraction effort is not determined by vaginal examination.

The nurse is preparing a list of self-care instructions for a postpartum client who was diagnosed with mastitis. Which instructions should be included on the list? Select all that apply. 1. Wear a supportive bra. 2.Rest during the acute phase. 3.Maintain a fluid intake of at least 3000 mL/day. 4.Continue to breast-feed if the breasts are not too sore. 5.Take the prescribed antibiotics until the soreness subsides. 6.Avoid decompression of the breasts by breast-feeding or breast pump.

1, 2, 3, 4 Mastitis is an inflammation of the lactating breast as a result of infection. Client instructions include resting during the acute phase, maintaining a fluid intake of at least 3000 mL/day (if not contraindicated), and taking analgesics to relieve discomfort. Antibiotics may be prescribed and are taken until the complete prescribed course is finished. They are not stopped when the soreness subsides. Additional supportive measures include the use of moist heat or ice packs and wearing a supportive bra. Continued decompression of the breast by breast-feeding or breast pump is important to empty the breast and prevent the formation of an abscess.

The nurse in a newborn nursery is monitoring a preterm newborn for respiratory distress syndrome. Which assessment findings should alert the nurse to the possibility of this syndrome? Select all that apply. 1. Cyanosis 2.Tachypnea 3.Hypotension 4.Retractions 5.Audible grunts 6.Presence of a barrel chest

1, 2, 4, 5 A newborn infant with respiratory distress syndrome may present with clinical signs of cyanosis, tachypnea or apnea, nasal flaring, chest wall retractions, or audible grunts. Hypotension and a barrel chest are not clinical manifestations associated with respiratory distress syndrome.

The nurse is monitoring a client in preterm labor who is receiving intravenous magnesium sulfate. The nurse should monitor for which adverse effects of this medication? Select all that apply. 1. Flushing 2.Hypertension 3.Increased urine output 4.Depressed respirations 5.Extreme muscle weakness 6.Hyperactive deep tendon reflexes

1, 4, 5 Magnesium sulfate is a central nervous system depressant and relaxes smooth muscle, including the uterus. It is used to halt preterm labor contractions and is used for preeclamptic clients to prevent seizures. Adverse effects include flushing, depressed respirations, depressed deep tendon reflexes, hypotension, extreme muscle weakness, decreased urine output, pulmonary edema, and elevated serum magnesium levels.

The nurse is administering magnesium sulfate to a client for preeclampsia at 34 weeks' gestation. What is the priority nursing action for this client? 1. Assess for signs and symptoms of labor. 2.Assess the client's temperature every 2 hours. 3.Schedule a daily ultrasound to assess fetal movement. 4.Schedule a nonstress test every 4 hours to assess fetal well-being.

1. Assess for signs and symptoms of labor. As a result of the sedative effect of the magnesium sulfate, the client may not perceive labor. This client is not at high risk for infection. Daily ultrasound exams are not necessary for this client. A nonstress test may be done, but not every 4 hours.

On delivery of a newborn, the nurse performs an initial assessment. When should the nurse plan to determine the Apgar score? 1. At 1 minute after birth and 5 minutes after birth 2.Immediately at birth, 3 minutes after birth, and 10 minutes after birth 3.At 1 minute after birth, 5 minutes after birth, and 15 minutes after birth 4.Immediately at birth, after the cord is cut, and after the mother delivers the placenta

1. At 1 minute after birth and 5 minutes after birth One of the earliest indicators of successful adaptation of the newborn is the Apgar score. This test is performed 1 minute after birth and again 5 minutes after birth. If the Apgar is still a very low score, a protocol to repeat again every 5 minutes until 20 minutes of age is typically employed.

An opioid analgesic is administered to a client in labor. The nurse assigned to care for the client ensures that which medication is readily accessible should respiratory depression occur? 1. Naloxone 2.Morphine sulfate 3.Betamethasone 4.Hydromorphone hydrochloride

1. Naloxone Opioid analgesics may be prescribed to relieve moderate to severe pain associated with labor. Opioid toxicity can occur and cause respiratory depression. Naloxone is an opioid antagonist, which reverses the effects of opioids and is given for respiratory depression. Morphine sulfate and hydromorphone hydrochloride are opioid analgesics. Betamethasone is a corticosteroid administered to enhance fetal lung maturity.

What pulse scores a 2 for APGAR?

100 or greater

The client delivered a newborn baby 3 hours ago. The assigned nurse is reviewing the electronic health record to determine if the new mother is a candidate for Rh immune globulin administration. Which criteria must be present to determine that the client needs the medication? Select all that apply. 1. The father must be Rh negative. 2.The mother must be Rh negative. 3.The newborn must be Rh positive. 4.The indirect Coombs' test must be negative. 5.The newborn must be a second or subsequent child delivered to this mother.

2, 3, 4 Following the birth of a first child, if eligible, the mother should receive Rh immune globulin as a protection against the development of Rh isoimmunization in her next child. To be a candidate, the mother must be Rh negative, the newborn must be Rh positive, and the father must be Rh positive. The indirect Coombs' test should be negative and not contain any Rh antibodies.

A pregnant client is receiving magnesium sulfate for the management of preeclampsia. The nurse determines that the client is experiencing toxicity from the medication if which findings are noted on assessment? Select all that apply. 1. Proteinuria of 3+ 2.Urine output of 20 mL in an hour 3.Presence of deep tendon reflexes 4.Respirations of 10 breaths/minute 5.Serum magnesium level of 4 mEq/L (2 mmol/L)

2, 4 Magnesium toxicity can occur from magnesium sulfate therapy. Signs of magnesium sulfate toxicity relate to the central nervous system depressant effects of the medication and include respiratory depression, loss of deep tendon reflexes, and a sudden decline in fetal heart rate and maternal heart rate and blood pressure. Respiratory rate below 12 breaths per minute is a sign of toxicity. Urine output should be at least 25 to 30 mL per hour. Proteinuria of 3+ is an expected finding in a client with preeclampsia. Presence of deep tendon reflexes is a normal and expected finding. Therapeutic serum levels of magnesium are 4 to 7.5 mEq/L (2 to 3.75 mmol/L).

The nurse is monitoring a client in the immediate postpartum period for signs of hemorrhage. Which sign, if noted, would be an early sign of excessive blood loss? 1. A temperature of 100.4° F (38° C) 2.An increase in the pulse rate from 88 to 102 beats per minute 3.A blood pressure change from 130/88 to 124/80 mm Hg 4.An increase in the respiratory rate from 18 to 22 breaths per minute

2. An increase in the pulse rate from 88 to 102 beats per minute During the fourth stage of labor, the maternal blood pressure, pulse, and respiration should be checked every 15 minutes during the first hour. An increasing pulse is an early sign of excessive blood loss because the heart pumps faster to compensate for reduced blood volume. A slight increase in temperature is normal. The blood pressure decreases as the blood volume diminishes, but a decreased blood pressure would not be the earliest sign of hemorrhage. The respiratory rate is slightly increased from normal.

The nurse is preparing to assess the uterine fundus of a client in the immediate postpartum period. After locating the fundus, the nurse notes that the uterus feels soft and boggy. Which nursing intervention is appropriate? 1 Elevate the client's legs. 2.Massage the fundus until it is firm. 3.Ask the client to turn on her left side. 4.Push on the uterus to assist in expressing clots.

2. Massage the fundus until it is firm. If the uterus is not contracted firmly, the initial intervention is to massage the fundus until it is firm and to express clots that may have accumulated in the uterus. Elevating the client's legs and positioning the client on the side would not assist in managing uterine atony. Pushing on an uncontracted uterus can invert the uterus and cause massive hemorrhage.

A client arrives at the clinic for the first prenatal assessment. She tells the nurse that the first day of her last normal menstrual period was October 19, 2020. Using Naegele's rule, which expected date of delivery should the nurse document in the client's chart? 1. July 12, 2021 2.July 26, 2021 3.August 12, 2021 4.August 26, 2021

2.July 26, 2021 Accurate use of Naegele's rule requires that the woman have a regular 28-day menstrual cycle. Subtract 3 months and add 7 days to the first day of the last menstrual period, and then add 1 year to that date: first day of the last menstrual period, October 19, 2020; subtract 3 months, July 19, 2020; add 7 days, July 26, 2020; add 1 year, July 26, 2021.

The nurse is performing Apgar scoring for a newborn immediately after birth. The nurse notes that the heart rate is less than 100 beats per minute, respiratory effort is irregular, and muscle tone shows some extremity flexion. The newborn grimaces when suctioned with a bulb syringe, and the skin color indicates some cyanosis of the extremities. What should be the immediate nursing intervention for this newborn? 1. Continued monitoring of vital signs 2.Oxygen supplementation and suctioning 3.Initiating cardiopulmonary resuscitation 4.Documenting findings and notifying the primary health care provider (PHCP)

2.Oxygen supplementation and suctioning One of the earliest indicators of successful adaptation of the newborn is the Apgar score. Scores range from 0 to 10. Five criteria are used to measure the infant's adaptation. Heart rate: absent = 0; less than 100 = 1; greater than 100 = 2. Respiratory effort: absent = 0; slow or irregular weak cry = 1; good, crying lustily = 2. Muscle tone: limp or hypotonic = 0; some extremity flexion = 1; active, moving, and well flexed = 2. Irritability or reflexes (measured by bulb suctioning): no response = 0; grimace = 1; cough, sneeze, or vigorous cry = 2. Color: cyanotic or pale = 0; acrocyanotic, cyanosis of extremities = 1; pink = 2. Newborn infants with an Apgar score of 5 to 7 often require some resuscitative interventions such as suctioning, additional oxygen, and physical stimulation. Scores of less than 5 indicate that the newborn infant is having difficulty adjusting to extrauterine life and requires more vigorous resuscitation, such as cardiopulmonary resuscitation (CPR). Continuing to monitor the newborn will not correct the situation. This infant is not in severe distress necessitating CPR. Documenting the findings and informing the PHCP are appropriate actions but are not what is immediately needed.

The nurse is monitoring a client who is receiving oxytocin to induce labor. Which assessment findings should cause the nurse to immediately discontinue the oxytocin infusion? Select all that apply. 1. Fatigue 2.Drowsiness 3.Uterine hyperstimulation 4.Late decelerations of the fetal heart rate 5.Early decelerations of the fetal heart rate

3, 4 Oxytocin stimulates uterine contractions and is a pharmacological method to induce labor. Late decelerations, a nonreassuring fetal heart rate pattern, is an ominous sign indicating fetal distress. Oxytocin infusion must be stopped when any signs of uterine hyperstimulation, late decelerations, or other adverse effects occur. Some primary health care providers prescribe the administration of oxytocin in 10-minute pulsed infusions rather than as a continuous infusion. This pulsed method, which is more like endogenous secretion of oxytocin, is reported to be effective for labor induction and requires significantly less oxytocin use. Drowsiness and fatigue may be caused by the labor experience. Early decelerations of the fetal heart rate are a reassuring sign and do not indicate fetal distress.

The nurse is caring for a client in labor and notes that minimal variability is present on a fetal heart rate (FHR) monitor strip. Which conditions are most likely associated with minimal variability? Select all that apply. 1. Early labor 2.Amniotomy 3.Tachycardia 4.Fetal hypoxia 5.Metabolic acidemia 6.Congenital anomalies

3, 4, 5, 6 The fluctuations in the baseline FHR are the definition of variability. Variability can be classified into 4 different categories: absent, minimal, moderate, and marked. Minimal variability is defined as fluctuations that are fewer than 6 beats/minute. Tachycardia, fetal hypoxia, metabolic acidemia, and congenital anomalies are all associated with possible minimal variability. Rupturing membranes and early labor are not correlated to this condition.

A client arrives at a birthing center in active labor. Following examination, it is determined that her membranes are still intact and she is at a -2 station. The primary health care provider prepares to perform an amniotomy. What will the nurse relay to the client as the most likely outcomes of the amniotomy? Select all that apply. 1. Less pressure on her cervix 2.Decreased number of contractions 3.Increased efficiency of contractions 4.The need for increased maternal blood pressure monitoring 5.The need for frequent fetal heart rate monitoring to detect the presence of a prolapsed cord

3, 5 Amniotomy (artificial rupture of the membranes) can be used to induce labor when the condition of the cervix is favorable (ripe) or to augment labor if the progress begins to slow. Rupturing of the membranes allows the fetal head to contact the cervix more directly and may increase the efficiency of contractions. Increased monitoring of maternal blood pressure is unnecessary following this procedure. The fetal heart rate needs to be monitored frequently, as there is an increased likelihood of a prolapsed cord with ruptured membranes and a high presenting part.

The nurse is assessing a client who is 6 hours postpartum after delivering a full-term healthy newborn. The client complains to the nurse of feelings of faintness and dizziness. Which nursing action is most appropriate? 1. Raise the head of the client's bed. 2.Obtain hemoglobin and hematocrit levels. 3.Instruct the client to request help when getting out of bed. 4.Inform the nursery room nurse to avoid bringing the newborn to the client until the client's symptoms have subsided.

3. Instruct the client to request help when getting out of bed. Orthostatic hypotension may be evident during the first 8 hours after birth. Feelings of faintness or dizziness are signs that caution the nurse to focus interventions on the client's safety. The nurse should advise the client to get help the first few times she gets out of bed. Option 1 is not a helpful action in this situation and would not relieve the symptoms. Option 2 requires a prescription. Option 4 is unnecessary.

On assessment of a client who is 30 minutes into the fourth stage of labor, the nurse finds the client's perineal pad saturated with blood and blood soaked into the bed linen under the client's buttocks. Which is the nurse's initial action? 1. Call the obstetrician. 2.Assess the client's vital signs. 3.Gently massage the uterine fundus. 4.Administer a 300-mL bolus of a 20 units/L oxytocin solution.

3.Gently massage the uterine fundus. The most frequent cause of excessive bleeding after childbirth is uterine atony. A major initial intervention to restore adequate tone is stimulation of the uterine muscle via gently massaging the uterine fundus. In addition, a prescription is needed to administer a medication. Calling the obstetrician, assessing the client's vital signs, and administering a bolus of oxytocin may be necessary, but they are not initial actions.

The nurse gave an intramuscular dose of methylergonovine to a client following delivery of an infant. The nurse determines that this medication had the intended effect if which finding is noted? 1. Decreased pulse rate 2.Increased urine output 3.Improved uterine tone 4.Increased blood pressure

3.Improved uterine tone Methylergonovine is an ergot alkaloid that is given following delivery to treat postpartum hemorrhage. It acts by vasoconstricting arterioles and directly stimulating uterine muscle contractions. Blood pressure may increase, but this is not the intended therapeutic effect. Decreased pulse rate and increased urine output are unrelated to the effects of this medication.

The nurse is performing an initial assessment on a newborn infant. When assessing the infant's head, the nurse notes that the ears are low-set. Which nursing action is most appropriate? 1. Document the findings. 2.Arrange for hearing testing. 3.Notify the pediatrician. 4.Cover the ears with gauze pads.

3.Notify the pediatrician. Low or oddly placed ears are associated with various congenital defects and should be reported immediately. Although the findings should be documented, the most appropriate action would be to notify the primary health care provider. Options 2 and 4 are inaccurate and inappropriate nursing actions.

The nurse in the delivery room is performing an assessment on a newborn to determine the Apgar score. The nurse notes a heart rate of 92, a weak cry, some flexion of extremities, grimacing with stimulation, and pink body with blue extremities. On the basis of this score, what should the nurse determine? 1. The newborn requires vigorous resuscitation. 2.The newborn is adjusting well to extrauterine life. 3.The newborn requires some resuscitative interventions. 4.The newborn is having some difficulty adjusting to extrauterine life.

3.The newborn requires some resuscitative interventions. One of the earliest indicators of successful adaptation of the newborn to extrauterine life is the Apgar score. Scoring ranges from 0 to 10. A score of 8 to 10 indicates that the newborn is adjusting well to extrauterine life. A score of 5 to 7 often indicates that the newborn requires some resuscitative interventions. Scores of less than 5 indicate that the newborn is having difficulty adjusting to extrauterine life and requires vigorous resuscitation. Based on the criteria in the question, this newborn would have an Apgar score of 5.

Shortly after receiving epidural anesthesia, a laboring woman's blood pressure drops to 95/43 mm Hg. Which immediate actions should the nurse take? Select all that apply. 1. Prepare for delivery. 2.Administer a tocolytic. 3.Administer an opioid antagonist. 4.Turn the woman to a lateral position. 5.Increase the rate of the intravenous infusion. 6.Administer oxygen by face mask at 10 L/minute.

4, 5, 6 Maternal hypotension results in decreased placental perfusion, so the focus of nursing care should be to initiate interventions that increase oxygen perfusion to the fetus. Turning the woman to left lateral position assists in deflecting the uterus off of the vena cava, thus improving maternal circulation. Increasing the rate of the intravenous infusion will increase blood volume, which will increase the maternal blood pressure. An increase in blood pressure would increase placental perfusion. Administering a high flow rate of oxygen will increase the oxygen levels in the maternal circulation and increase oxygen delivery to the fetus. The woman is not revealing any signs or symptoms of imminent delivery, as she just received an epidural which is typically administered at 6 cm or earlier dilation, so option 1 can be eliminated. Administering a tocolytic can be eliminated because the decrease in placental perfusion is the result of maternal hypotension, not uterine hyperstimulation. Administering an opioid antagonist can be eliminated because the client is not experiencing an ineffective breathing pattern caused by opioid administration.

The nurse is providing instructions about measures to prevent postpartum mastitis to a client who is breast-feeding her newborn. Which client statement would indicate a need for further instruction? 1. "I should breast-feed every 2 to 3 hours." 2."I should change the breast pads frequently." 3."I should wash my hands well before breast-feeding." 4."I should wash my nipples daily with soap and water."

4. "I should wash my nipples daily with soap and water." Mastitis is inflammation of the breast as a result of infection. It generally is caused by an organism that enters through an injured area of the nipples, such as a crack or blister. Measures to prevent the development of mastitis include changing nursing pads when they are wet and avoiding continuous pressure on the breasts. Soap is drying and could lead to cracking of the nipples, and the client should be instructed to avoid using soap on the nipples. The mother is taught about the importance of hand washing and that she should breast-feed every 2 to 3 hours.

The labor room nurse assists with the administration of a lumbar epidural block. How should the nurse check for the major side effect associated with this type of regional anesthesia? 1. Assessing the mother's reflexes 2. Taking the mother's temperature 3. Taking the mother's apical pulse 4. Monitoring the mother's blood pressure

4. Monitoring the mother's blood pressure A major side effect of regional anesthesia is hypotension, which results from vasodilation in the lower body and a reduction in venous return. After regional anesthesia, the blood pressure is taken every 1 to 2 minutes for 15 minutes and then every 10 to 15 minutes. Reflexes, temperature, and apical pulse are not specifically related to this type of anesthesia.

The nurse assists in the vaginal delivery of a newborn infant. After the delivery, the nurse observes the umbilical cord lengthen. The nurse documents these observations as signs of which condition? 1. Hematoma 2.Uterine atony 3.Placenta previa 4.Placental separation

4.Placental separation As the placenta separates, it settles downward into the lower uterine segment. The umbilical cord lengthens, and a sudden trickle or spurt of blood appears. Options 1, 2, and 3 are incorrect interpretations.

The nurse administers erythromycin ointment (0.5%) to the eyes of a newborn and the mother asks the nurse why this is performed. Which explanation is best for the nurse to provide about neonatal eye prophylaxis? 1. Protects the newborn's eyes from possible infections acquired while hospitalized. 2.Prevents cataracts in the newborn born to a woman who is susceptible to rubella. 3.Minimizes the spread of microorganisms to the newborn from invasive procedures during labor. 4.Prevents an infection called ophthalmia neonatorum from occurring after birth in a newborn born to a woman with an untreated gonococcal infection.

4.Prevents an infection called ophthalmia neonatorum from occurring after birth in a newborn born to a woman with an untreated gonococcal infection. Erythromycin ophthalmic ointment 0.5% is used as a prophylactic treatment for ophthalmia neonatorum, which is caused by the bacterium Neisseria gonorrhoeae. Preventive treatment of gonorrhea is required by law. Options 1, 2, and 3 are not the purposes for administering this medication to a newborn infant.

second stage of labor

LABOR begins with complete dilation (10cm) and full effacement (100%) ends with the birth of the baby mom may say she needs to have a bowel movement or the baby is coming crowning