NSG 330: Davis Advantage

The instructor is teaching the modes of fetal heart rate (FHR) and contraction assessment to a class of nursing students. What are the modes of uterine monitoring? Select all that apply. Auscultation Palpation Fetal spiral electrode Intrauterine pressure catheter (IUPC) Tocodynamometer

- palpation -IUPC - tocodynamometer

The postpartum nurse is preparing to administer Rho (D) immune globulin (RhoGAM) to a post-cesarean section client on the mother-baby unit. What statements made by the client indicate an understanding of RhoGAM? Select all that apply. -"I need this because my blood type is negative and my baby is positive." -"I will avoid pregnancy for 4 weeks." -"This medication will help protect my future babies." -"I only need to get this once in my lifetime." -"I need to receive RhoGAM within 48 hours of giving birth."

-"I need this because my blood type is negative and my baby is positive." -"This medication will help protect my future babies."

Which response by a postpartum client indicates to the nurse the client understands uterine involution? Select all that apply. -"My uterus will stay this big until I get my period again." -"It will take between 6 and 8 weeks for my uterus to return to normal size." -"Contractions will cause my uterus to shrink." -"In about 7 weeks, I won't be able to feel my uterus." -"If there are any complications like infection, my uterus won't shrink as much."

-"It will take between 6 and 8 weeks for my uterus to return to normal size." -"Contractions will cause my uterus to shrink." -"If there are any complications like infection, my uterus won't shrink as much."

When educating a non-breastfeeding primiparous client, what information is important for the nurse to include? Select all that apply. -"Wear a supportive bra or sports bra 24 hours a day." -"If your breasts become engorged, you should pump to relieve the pressure." -"Do not apply ice packs to the breasts because it will stimulate milk production." -"You can take an analgesic for pain." -"You may experience milk leakage for the first 1 to 2 weeks."

-"Wear a supportive bra or sports bra 24 hours a day." -"You can take an analgesic for pain."

The labor and delivery (L&D) educator has explained to a group of nurses how the uteroplacental unit functions. Which components are necessary for the fetus to receive appropriate oxygenation? Select all that apply. -Adequate oxygenation of the mother -Adequate uteroplacental circulation -Adequate umbilical circulation -Adequate fetal blood volume -Adequate blood flow to the placenta

-Adequate oxygenation of the mother -Adequate uteroplacental circulation -Adequate umbilical circulation -Adequate blood flow to the placenta

A postpartum nurse caring for a client who had a vaginal delivery 3 hours ago notices heavy lochia. What are the priority nursing interventions for this client? Select all that apply. -Assess the position, tone, and location of the fundus. -Massage a boggy uterus. -Document the findings and reassess in 1 hour. -Quantify blood loss. -Instruct the client to void and reevaluate.

-Assess the position, tone, and location of the fundus. -Massage a boggy uterus. -Quantify blood loss. -Instruct the client to void and reevaluate.

A nurse is caring for a G2P2002 client in the initial hour after giving birth. What are the appropriate nursing interventions to be taken with this client? Select all that apply. -Assess the uterus for location, position, and tone of fundus every 15 minutes. -Titrate IV oxytocin infusion rate to uterine tone. -Provide information regarding afterpains. -Assess lochia for color, amount, and odor. -Inspect the inside of the vagina for tearing.

-Assess the uterus for location, position, and tone of fundus every 15 minutes. -Titrate IV oxytocin infusion rate to uterine tone. -Provide information regarding afterpains. -Assess lochia for color, amount, and odor.

The labor and delivery (L&D) unit educator discusses the prioritization of fetal monitoring goals, creating a plan of care, and setting goals for implementation with a group of nurses. Which goals are correct? Select all that apply. -Interpret ongoing assessment of fetal oxygenation. -Prevent significant fetal academia. -Minimize unnecessary interventions. -Promote a satisfying family-centered birth experience. -Use of electronic fetal monitors (EFM) for all laboring women in the United States is required.

-Interpret ongoing assessment of fetal oxygenation. -Prevent significant fetal academia. -Minimize unnecessary interventions. -Promote a satisfying family-centered birth experience.

The nurse has just completed a fetal monitoring course and is explaining the normal findings of structured intermittent auscultation (SIA) with a handheld Doppler. Which would the nurse identify as a normal finding of SIA? Select all that apply. -Moderate variability -Normal baseline between 110 to 160 bpm -Regular rhythm -Presence of fetal heart rate (FHR) increases from baseline -Absence of fetal heart rate (FHR) decreases from baseline

-Normal baseline between 110 to 160 bpm -Regular rhythm -Presence of fetal heart rate (FHR) increases from baseline -Absence of fetal heart rate (FHR) decreases from baseline

The nurse is caring for a patient on the postpartum unit who has been diagnosed with subinvolution post-delivery. The nurse understands that subinvolution is associated with what labor and birth complications? -Coagulation disorders such as DIC. -Postpartum hemorrhage due to perineal laceration. -Uterine tetany and overproduction of oxytocin. -Retained placental tissue and infection. -Presence of uterine fibroids.

-Retained placental tissue and infection. -Presence of uterine fibroids.

A nurse enters the room of a new mother and newborn. The mother is sleeping in the bed and the infant is lying in the bassinet. The nurse notices the baby showing early signs of hunger and wakes the mother to breastfeed. What did the nurse notice? Select all that apply. -The newborn was placing a hand near the mouth. -The newborn was in a deep sleep state. -The newborn was sucking on their hand. -The newborn was crying loudly. -The newborn was in need of a diaper change.

-The newborn was placing a hand near the mouth. -The newborn was sucking on their hand.

Which assessments of uterine activity are obtained by the nurse when the client has an intrauterine pressure catheter (IUPC) placed? Select all that apply. -Frequency -Intensity -Duration -Fetal heart rate (FHR) -Resting tone

-frequency -intensity -duration -resting tone

The nurse is triaging a postpartum patient who reports heavy vaginal bleeding 7 days after delivering a term infant. The estimated blood loss is 750 mL. Which postpartum complication is she experiencing? Endometritis Uterine atony Early postpartum hemorrhage Late postpartum hemorrhage

Late PP hemorrhage

The nurse understands that which of the following is a reason women stop breastfeeding before the eighth week? Engorgement Painful nipples Mastitis Thrush

Painful nipples

The nurse is assessing a postpartum patient who had an uncomplicated vaginal delivery one hour ago. Which assessment finding requires immediate intervention? Blood pressure 152/88 mmHg Temperature 99.8 F (37.7 C) Pulse 120 beats/min Respiratory rate 16 breaths/min

Pulse 120 beats/min

A preeclamptic patient who delivered four hours ago via cesarean section calls the nurse to the bedside. The patient reports dizziness, diaphoresis, and oozing of blood from her current IV site. The nurse determines these findings are consistent with which of the 4 Ts? Tone Tissue Trauma Thrombin

Thrombin

The nurse is assessing a patient who is a G5P5005 and delivered vaginally four hours ago. The patient's labor history includes a 16 hour oxytocin induction for a macrosomic infant. Assessment findings include a boggy uterus and a completely saturated peri pad with the presence of blood clots. What does the nurse identify as the most likely cause for the increased bleeding? Tone Tissue Trauma Thrombin

Tone

The nurse is describing baseline fetal heart rate (FHR) to a practicum student. What would the nurse include when teaching about the definition and assessment criteria related to baseline FHR? Select all that apply. a. "Periodic changes in baseline of FHR occur in relation to uterine contractions." b. "Recurrent changes in baseline of FHR occur in less than 50% of the contractions in 20 minutes." c. "Intermittent changes in baseline of FHR occur in greater than 50% of the contractions in 20 minutes." d. "Episodic changes in baseline of FHR occur independent of uterine contractions (UCs)." e. "FHR is rounded to increments of 5 beats per minute during a 10-minute window. This must be at least 2 minutes of identifiable baseline segment."

a. "Periodic changes in baseline of FHR occur in relation to uterine contractions." d. "Episodic changes in baseline of FHR occur independent of uterine contractions (UCs)." e. "FHR is rounded to increments of 5 beats per minute during a 10-minute window. This must be at least 2 minutes of identifiable baseline segment."

The oncoming nurse is reviewing her assignment for the day, and would like to identify who see first based on acuity. Which woman is at greatest risk for primary postpartum hemorrhage? a. A G5P4 patient diagnosed with polyhydramnios who is undergoing labor induction. b. A G2P2 patient who delivered a baby vaginally after an 8-hour labor augmented by oxytocin. c. A G1P1 woman who just delivered via emergency cesarean section for fetal distress. d. A G2P2 woman delivering vaginally after a cesarean section with her first pregnancy.

a. A G5P4 patient diagnosed with polyhydramnios who is undergoing labor induction.

While assessing a pregnant client, the nurse notes the fetal heart rate (FHR) is 125 with moderate variability, no accelerations, and no decelerations. Using the National Institute of Child Health and Human Development (NICHD) criteria, which would the nurse record as the appropriate category related to the assessment findings? a. Category I: Strongly predictive of a well- oxygenated, non-acidotic fetus. No action required. b. Category II: Indeterminate. Requires continued surveillance and reevaluation. c. Category III: Abnormal requiring prompt evaluation and intervention. d. Category IV: Fetal demise.

a. Category I: Strongly predictive of a well- oxygenated, non-acidotic fetus. No action required.

The nurse is caring for a patient who delivered via cesarean section two hours ago and is now in the PACU. Upon reviewing the delivery record, the nurse notices that the patient's quantified blood loss was 800mL. What is the appropriate nursing intervention? a. Document on the report sheet as "normal" and proceed with plan of care. b. Call the provider to obtain an order for a complete blood count (CBC) and IV fluids. c. Explain to the patient that she will not be able to breastfeed until her hemoglobin and hematocrit increases by 10%. d. Prepare the patient for a dilation and curettage (D&C).

a. Document on the report sheet as "normal" and proceed with plan of care.

Immediately after birth, the nurse notes the client's fundus is palpated midway between the umbilicus and symphysis pubis. What is the priority nursing action? a. Document the findings as within normal limits. b. Perform fundal massage. c. Instruct the woman to empty her bladder. d. Reassess every 5 minutes.

a. Document the findings as within normal limits.

During an office visit 2 weeks' postpartum, a G3P3003 patient mentions an increase in her stress level following delivery of this child. The nurse explains that the increase may be attributed to which considerations? Select all that apply. a. Increase in childcare tasks b. Financial concerns c. Lack of paternal participation d. Increase in fatigue level e. Decrease in partner intimacy

a. Increase in childcare tasks b. Financial concerns d. Increase in fatigue level

The nurse is caring for a patient following the delivery of a 36-week infant due to maternal preeclampsia. The infant is stable and rooming-in with the mother. The nurse observes the mother demonstrating a slow response to the infant cues. What does the nurse attribute this slow response to? a. Magnesium sulfate infusion b. Increased blood pressure c. Hyperactive reflexes d. Subtle cues due to prematurity

a. Magnesium sulfate infusion

The nurse assesses a mother's bonding with her new baby. Which action made by the mother does the nurse identify as the initial maternal phase? a. The mother relives and speaks of the birthing experience. b. The mother responds to and picks up the infant when she cries. c. The mother shows signs of baby blues. d. The mother asks questions about infant care.

a. The mother relives and speaks of the birthing experience.

A nursing instructor explains to a group of students that an amnioinfusion is a procedure that can be used in the first stage of labor to treat which type of decelerations? a. Variable b. Late c.Early d. Prolonged

a. Variable

When performing a fundal assessment on a client, 2 hours following an uncomplicated vaginal delivery, the postpartum nurse notes a boggy uterus. What is the priority nursing action for this client? a. Massage the fundus with the palm of the hand. b. Place an indwelling catheter. c. Notify the physician or midwife. d. Give oxytocin as per the physician's orders.

a. massage the fundus with the palm of the hand

The nurse is caring for a patient whose fetus has been diagnosed with intrauterine growth restriction. The patient asks the nurse how this could have happened. Which does the nurse recognize as a possible cause?

available oxygen chronically falls below 50% of normal levels and there is a redistribution of blood to vital organs

A postpartum client asks the nurse why her temperature is slightly elevated. What is the correct response from the nurse? Select all that apply. a. "You had a fever during labor and the antibiotics have not started working yet." b. "The hard work of labor can cause your temperature to increase." c. "It is common for women to experience mild temperature elevation after giving birth." d. "Your body is going through a lot of hormonal changes right now, which can increase your temperature." e. "Do you feel hot? I will get you some Tylenol."

b. "The hard work of labor can cause your temperature to increase." c. "It is common for women to experience mild temperature elevation after giving birth." d. "Your body is going through a lot of hormonal changes right now, which can increase your temperature.

A nurse is caring for a client in the first hour following a vaginal delivery. What is the priority nursing intervention? a. Facilitate bonding between the mother and infant. b. Assess the fundus for location, position, and tone. c. Administer pain medications. d. Inspect the perineum for tearing.

b. Assess the fundus for location, position, and tone.

The recovery room nurse is completing a postpartum assessment on a newly delivered patient. Upon assessment, the nurse finds the peripad saturated with lochia andlarge, visible clots. What is the priority nursing intervention based on these findings? a. Document the findings on the medical record. b. Massage the uterus until firm. c. Start an IV and give a bolus of oxytocin. d. Walk the patient to the bathroom.

b. Massage the uterus until firm.

When palpating the client's fundus during a contraction, the nurse notes that it feels like a "chin." The nurse documents this finding as which contraction intensity? a. Mild b. Moderate c. Strong d. Firm

b. Moderate

The nurse is caring for a primiparous woman who just delivered her child. Which action should the nurse take to adhere to the taking-in stage? a. Help the mother change the diaper. b. Give the patient time to reflect. c. Start to teach about her new mother body. d. Start to promote maternal independence.

b. give the patient time to reflect

A mother who has been breastfeeding for three months calls the clinic to speak to the nurse. She reports a fever, unilateral breast swelling, pain and redness. She is worried about continuing to breastfeed. What is the appropriate nursing response? a. "Pump and discard your breastmilk until you finish your course of prescribed antibiotics." b. "Massaging the area while you breastfeed will treat the infection." c. "Your milk is not infected, so you can continue to breastfeed and we will prescribe an antibiotic today." d. "You need to be more diligent about cleaning your pump supplies."

c. "Your milk is not infected, so you can continue to breastfeed and we will prescribe an antibiotic today."

The nurse is assessing a patient and suspects postpartum hemorrhage. Which method of measuring blood loss should the nurse use? a. Examining all pads and linens for saturation b. Weigh soaked pads and add the weight of dry pads c. Use under-buttock calibrated drapes d. Compare the patient's hemoglobin level to the last hemoglobin level obtained prenatally

c. Use under-buttock calibrated drapes

The nurse notes a FHR deceleration that begins after the peak of the contraction and ends once the contraction is over. Which is the priority nursing action for this patient?

change maternal position

A postpartum mother delivered two hours ago and has a history of recurrent urinary tract infections (UTIs). She is very anxious about the risk of UTI after delivery and asks the nurse what she can do to decrease her risk. Which response by the new nurse would require further education regarding recommendations to prevent UTI? a. "If you are unable to get up and walk to the bathroom to void in the next hour, I will need to insert a catheter to empty your bladder." b. "I will need you to keep track of your urine output with the goal of voiding at least 150 mL." c. "It is important to be changing your peri pad every 3-4 hours." d. "I will need you to keep track of your oral intake with the goal of drinking at least 1500 mL each day."

d. "I will need you to keep track of your oral intake with the goal of drinking at least 1500 mL each day."

The obstetrics (OB) nurse is assessing a client utilizing structured intermittent auscultation (SIA). Which intervention assists the nurse in identifying fetal heart tones (FHT)? a. Perform a 20-minute nonstress test (NST). b. Auscultate FHT for at least 20 minutes. c. Auscultate FHTs during and after contractions for 30 seconds. d. Auscultate FHTs between contractions for at least 30 to 60 seconds.

d. Auscultate FHTs between contractions for at least 30 to 60 seconds.

A nurse observes a 14-year-old and her new baby. The nurse notes the grandmother doing most of the holding and care of the infant. What is the appropriate nursing intervention? a. Show the patient more baby care videos and ask if she is depressed. b. Tell the mother, "It's time to grow up." c. Point out how well the grandmother is doing with the infant. d. Tell the patient how well she does when she performs care activities for the infant.

d. Tell the patient how well she does when she performs care activities for the infant.

The nurse is assessing a pregnant client who is externally monitored and contracting every 3 to 4 minutes with each contraction lasting 40 to 60 seconds. The peak of the contraction reads 90 on the graph paper with a resting tone of 20. The client rates her contractions as 10/10 and she is crying. Which can the nurse document, based on these findings? a.The contractions are very strong, and the client will probably deliver soon. b. The contractions are not adequate to make cervical changes. c. The resting tone is too high. d. The frequency and duration of contractions should be reviewed.

d. the frequency and duration of contractions should be reviewed