NUR 208 MATERNITY TEST 1

The nurse is teaching nursing students about the risks that late preterm infants may experience. The nurse feels confident learning has taken place when the students make which statement?

"A late preterm newborn may have more clinical problems compared with full-term newborns."

The couple demonstrates understanding of the consequences of not treating Chlamydia when they state:

"He could get an infection in the tube that carries the urine out."

In talking to a mother who is 6 hours post-delivery, the mother reports that she has changed her perineal pad twice in the last hour. What question by the nurse would best elicit information needed to determine the mother's status?

"How much blood was on the two pads?"

Which of the following statements by the client verifies correct knowledge about vaginal herpes?

"I could have another breakout during my period."

The client gives correct information regarding ways to prevent a recurrence of her urinary tract infection when she states:

"I should urinate when I feel the urge."

A client with a history of cervical insufficiency is seen for reports of pink-tinged discharge and pelvic pressure. The primary care provider decides to perform a cervical cerclage. The nurse teaches the client about the procedure. Which client response indicates that the teaching has been effective?

"Purse-string sutures are placed in the cervix to prevent it from dilating."

A nursing student, observing care of a 30-week-gestation infant in the neonatal intensive care unit, asks the nurse, "Are premature infants more susceptible to infection as I have to wash my hands so often in this department?" What is the nurse's best response?

"That is correct; a 30-week-gestation infant lacks the protective antibody called IgG."

The nurse realizes the educational session conducted on due dates was successful when a participant is overheard making which statement?

"The ability of my placenta to provide adequate oxygen and nutrients to my baby after 42 weeks' gestation is thought to be compromised."

•Infection prevention

-Aseptic technique -handwashing -perineal hygiene -Screen visitors -antibiotics -wound care -Client teaching

Methamphetamines

-More common than cocaine use in pregnancy -Highly addictive stimulant -causes maternal tachycardia, tachypnea, rush, decreased appetite -Smoked form: ice, crystal, crank, glass -Chronic use: psychosis, paranoia, hallucinations, memory loss, aggressive behavior -Signs of use: track marks from IV, malnutrition, severe dental decay, skin abscesses ("skin picking")

magnesium sulfate therapeutic levels

4-7

The nurse weighs the new infant and calculates the child's measurements. The new mom asks, "Did my baby grow well? The doctor said he was LGA: What does that mean?" What is the best explanation?

90th percentile

What postpartum client should the nurse monitor most closely for signs of a postpartum infection?

A client who had a nonelective cesarean birth

Which of the following clients should be treated with ceftriaxone (Rocephin) IM and doxycycline (Vibramycin) orally?

A nonpregnant client with gonorrhea and Chlamydia

A woman at 31 weeks' gestation presents to the emergency department with bright red vaginal bleeding, reporting that the onset of the bleeding was sudden and without pain. Which diagnostic test should the nurse prioritize?

A transvaginal ultrasound For any pregnant woman who presents with painless bleeding, placenta previa needs to be ruled out by either transvaginal or abdominal ultrasound.

A nurse is caring for a preterm infant. Which intervention will prepare the newborn's GI tract to better tolerate feedings when initiated?

Administer 0.5 ml/kg/hr of breast milk enterally.

A client is hospitalized for pelvic inflammatory disease. Which of the following nursing interventions would have priority?

Administer cefotetan IV.

The nurse obtains a health history from the following clients. To which one should she give priority for teaching about cervical cancer prevention?

Age 30, treated for PID

A postpartal woman is developing a thrombophlebitis in her right leg. Which assessments would the nurse make to detect this?

Assess for pedal edema.

Six hours after birth, a client's first void is 70 mL. What is the nurse's next action?

Assess for residual urine.

A nurse is assessing a client with postpartal hemorrhage; the client is presently on IV oxytocin. Which interventions should the nurse perform to evaluate the efficacy of the drug treatment? Select all that apply.

Assess the client's uterine tone. Monitor the client's vital signs. Get a pad count.

risk factors for postpartum hemorrahage

Big Baby Multiples Hydramnios Multiparity Long oxytocin induction (uterus is tired)

The nurse is caring for a postpartum woman who exhibits a large amount of bleeding. Which areas would the nurse need to assess before the woman ambulates?

Blood pressure, pulse, reports of dizziness

abruptio placentae tests

CBC fibrinogen levels PT/PTT type and cross-match non-stress test biophysical profile

The nurse is caring for a neonate in the neonatal intensive care unit (NICU). Which nursing action exemplifies developmental care?

Clustering care and activities Clustering care and activities in the NICU decreases stress and helps developmentally support premature and sick infants. Developmental care can decrease assistance needed and length of hospital stay

Which maternal factors should the nurse consider contributory to a newborn being large for gestational age?

DM prepregnancy obesity postdates gestation

A client just gave birth to a preterm baby in the 30th week of gestation. Which nursing measures does the nurse anticipate for this newborn?

Dress the baby in a stockinette cap. Place the baby under isolette care. Estimate the urinary flow by weighing the diaper.

A 28-year-old client with a history of endometriosis presents to the emergency department with severe abdominal pain and nausea and vomiting. The client also reports her periods are irregular with the last one being 2 months ago. The nurse prepares to assess for which possible cause for this client's complaints?

Ectopic pregnancy

progesterone

IM reduces risk of PTL of recurrent preterm birth or short cervix

The nurse is assisting a new mother who is several hours postpartum. Which reaction by the new mother should the nurse prioritize?

Ignores the newborn crying Ignoring the newborn's crying may be an indication of malattachment and should be further evaluated and brought to the attention of the RN and/or health care provider.

A nurse is caring for an infant born with an elevated bilirubin level. When planning the infant's care, what interventions will assist in reducing the bilirubin level?

Increase the infant's hydration. Offer early feedings. Initiate phototherapy.

The nurse is assessing a client 48 hours postpartum and notes on assessment: temperature 101.2oF (38.4oC), HR 82, RR 18, BP 125/78 mm Hg. The nurse should suspect the vital signs indicate which potential situation?

Infection Temperatures elevated above 100.4° F (38° C) 24 hours after birth are indicative of possible infection.

Which safety precautions should a nurse take to prevent infection in a newborn?

Initiate universal precautions when caring for the infant. Use sterile gloves for an invasive procedure. Avoid coming to work when ill.

The nurse is performing a postpartum check on a 40-year-old client. Which nursing measure is appropriate?

Instruct the client to empty her bladder before the examination.

A nonpregnant client reports a fishy-smelling, thin, white, watery vaginal discharge. She is diagnosed with bacterial vaginosis (BV). The nurse would be expecting to administer:

Metronidazole (Flagyl) 500 mg p.o. b.i.d. for a week.

Betamethasone (Celestone)

PTL between 24-34 weeks IM corticosteroid reduce the risk of RDS and IVH given in two doses of 12 mg given IM 24 hours apart

A client comes in complaining of wart-like lesions on the vulva, painful wrist and finger joints, and a chronic and hoarse sore throat. The appropriate treatment would be:

Penicillin G (Bicillin) IM.

Cervical Insufficiency (Incompetent Cervix)

Premature dilation second or early in third trimester no contractions reason unknown asymptomatic-no pain or bleeding strict or modified bedrest

A woman in labor suddenly reports sharp fundal pain accompanied by slight dark red vaginal bleeding. The nurse should prepare to assist with which situation?

Premature separation of the placenta

The nurse is teaching a client with newly diagnosed mastitis about her condition. The nurse would inform the client that she most likely contracted the disorder from which organism?

Staphylococcus aureus

Which situation should concern the nurse treating a postpartum client within a few days of birth?

The client feels empty since she gave birth to the neonate. A client experiencing postpartum blues may say she feels empty now that the infant is no longer in her uterus. She may also verbalize that she feels unprotected now.

At birth, the newborn was at the 8th percentile with a weight of 2350g and born at 36 weeks gestation. Which documentation is most accurate?

The infant was a preterm low birth weight small for gestational age

At birth, the newborn was at the 8th percentile with a weight of 2350g and born at 36 weeks gestation. Which documentation is most accurate?

The infant was a preterm, low birth weight and small for gestational age Born at 36 weeks gestation is a preterm age (under 37 weeks). The infant was a low birthweight (under 2500g) and small for gestational age at the 8th percentile (under the 10th percentile)

A woman is married to an intravenous drug user. She had a negative HIV screening test just after missing her first menstrual period. Which of the following would indicate that the client needs to be retested for HIV?

Unusual fatigue and recurring candida vaginitis

A nurse is caring for a client with idiopathic thrombocytopenic purpura (ITP). Which intervention should the nurse perform first?

administration of platelet transfusions as prescribed When caring for a client with ITP, the nurse should administer platelet transfusions as ordered to control bleeding. Glucocorticoids, IV immunoglobulin and IV anti-Rho D are also given

abruptio placentae

after 20 weeks of gestation dark red bleeding knifelike pain firm-rigid uterus cause unknown fetal distress or absent HR

The nurse examines a 26-week-old premature infant. The skin temperature is lowered. What could be a consequence of the infant being cold?

apnea

A pregnant woman is admitted to the hospital with a diagnosis of placenta previa. Which action would be the priority for this woman on admission?

assessing fetal heart tones by use of an external monitor

The nurse is required to assess a pregnant client who is reporting vaginal bleeding. Which nursing action is the priority?

assessing the amount and color of the bleeding

What action by the nurse provides the neonate with sensory stimulation of a human face?

assisting the mother to position the infant in an enface position To allow the infant to see a human face, assist the mother to assume an enface position with the infant. Mother and child need to be in the same plane and about 6 to 10 inches (15 to 25 cm) apart.

risk factors for metritis

c/s hemorrhage Operative or traumatic deliveries PROM Precipitous delivery Manual removal of the placenta

risks for placenta previa

c/s older age multiples multiple terminated pregnancies cocaine use prev placenta previa

A nurse is caring for a postpartum client diagnosed with von Willebrand disease. What should be the nurse's priority for this client?

check the lochia

A newborn does not breathe spontaneously at birth. The nurse administers oxygen by bag and mask. If oxygen is entering the lungs, the nurse should notice that the:

chest rises with each bag compression.

A nurse is caring for a pregnant client with eclamptic seizure. Which is a characteristic of eclampsia?

coma after seizure

When discussing heat loss in newborns, placing a newborn on a cold scale would be an example of what type of heat loss?

conduction

significantly indented anterior fontanelle

dehydrated

A woman is being closely monitored and treated for severe preeclampsia with magnesium sulfate. Which finding would alert the nurse to the development of magnesium toxicity in this client?

diminished reflexes Diminished or absent reflexes occur when a client develops magnesium toxicity.

The nurse recognizes that the postpartum period is a time of rapid changes for each client. What is believed to be the cause of postpartum affective disorders?

drop in estrogen and progesterone levels after birth

A premature infant develops respiratory distress syndrome. With this condition, circulatory impairment is likely to occur because with increased lung tension, the:

ductus arteriosus remains open.

A nurse is providing care to a preterm neonate. Which interventions would be most effective in minimizing the newborn's pain?

encouraging kangaroo care during procedures removing tape gently from the skin using a colorful mobile for distraction

A common symptom that would alert the nurse that a preterm infant is developing respiratory distress syndrome is:

expiratory grunting.

A nurse is monitoring a client with PROM who is in labor and observes meconium in the amniotic fluid. What does the observation of meconium indicate?

fetal distress related to hypoxia

cerclage

for cervical insufficency give tocolytic to prevent contractions after procedure epidural for pain control small amt of spotting after procedure

A nurse is conducting an in-service presentation for a group of neonatal nurses. After teaching the group about the effects of prematurity on various body systems, the nurse determines that the class was successful when the group identifies which condition as an effect of prematurity?

fragile cerebral blood vessels

A client has come to the office for a prenatal visit during her 22nd week of gestation. On examination, it is noted that her blood pressure has increased to 138/90 mm Hg. Her urine is negative for proteinuria. The nurse recognizes which factor as the potential cause?

gestational hypertension

Prevention and early identification of newborns at risk are necessary nursing functions. A nurse anticipates the need for newborn resuscitation secondary to birth asphyxia based on which prenatal risk factors? Select all that apply.

gestational hypertension maternal infection congenital heart disease

abruptio placentae (mild)

grade 1 10-20% separation tender uterus no shock or distress to baby

A client has been admitted with abruptio placentae. She has lost 1,200 mL of blood, is normotensive, and ultrasound indicates approximately 30% separation. The nurse documents this as which classification of abruptio placentae?

grade 2

abruptio placentae (moderate)

grade 2 20-50% separation continuous abdominal pain mild shock tachycardia-mom

What is a consequence of hypothermia in a newborn?

holds breath 25 seconds Apnea is the cessation of breathing for a specific amount of time, and in newborns it usually occurs when the breath is held for 15 seconds. Apnea, cyanosis, respiratory distress, and increased oxygen demand are all consequences of hypothermia.

A client in her seventh week of the postpartum period is experiencing bouts of sadness and insomnia. The nurse suspects that the client may have developed postpartum depression. What signs or symptoms are indicative of postpartum depression?

inability to concentrate loss of confidence decreased interest in life

The nurse is caring for a small-for-gestational-age infant at 1 hour old, after a difficult birth, with a glucose level of 40 mg/dL (2.5 mmol/L). Which nursing action would be the priority?

initiate early oral feedings

placenta previa

last 2 trimesters of pregnancy placenta implants in lower uterus painless bleeding

Deep vein thrombosis

may cause pulmonary embolism heparin would be given to reduce the risk of further clot formation

A 35-year-old client has just given birth to a healthy newborn during her 43rd week of gestation. What should the nurse expect when assessing the condition of the newborn?

meconium aspiration in utero or at birth

Which finding is indicative of hypothermia of the preterm infant?

nasal flaring

DIC

no specific lab test to dx, but: -Decreased fibrinogen -Prolonged PT and PTT -Positive D-dimer and fibrin

placenta previa

non life threatening, episodic dx by transvaginal u/s no digital exams/no sex bedrest fetal mvmnt counts

Placenta previa

painful dark red bleeding during pregnancy caused by an abnormally implanted placenta that is too close to or covers the fundus

A pregnant woman with preeclampsia is to receive magnesium sulfate IV. Which assessment should the nurse prioritize before administering a new dose?

patellar reflex A symptom of magnesium sulfate toxicity is loss of deep tendon reflexes. Assessing for the patellar reflex or ankle clonus before administration is assurance the drug administration will be safe.

At birth, the infant has dry, cracked skin, absence of vernix, lack of subcutaneous fat, fingernail extending beyond the fingertips, and poor skin turgor. Based on these findings, how would the nurse would classify this neonate?

postterm

A 24-year-old client presents in labor. The nurse notes there is an order to administer RhoGAM after the birth of her infant. When asked by the client the reason for this injection, which reason should the nurse point out?

prevent maternal D antibody formation.

A woman has presented to the emergency department with symptoms that suggest an ectopic pregnancy. Which finding would lead the nurse to suspect that the fallopian tube has ruptured?

referred shoulder pain Referred pain to the shoulder area indicates bleeding into the abdomen caused by phrenic nerve irritation when a tubal pregnancy ruptures.

Nifedipine (Procardia)

relaxes smooth muscle greater than 32 weeks

What would be appropriate for the nurse to document in a child suffering from meconium aspiration syndrome?

respirations as increased and high

When assessing a pregnant woman with vaginal bleeding, the nurse would suspect a threatened abortion based on which finding?

slight vaginal bleeding

risks of smoking

spontaneous abortion preterm labor & birth maternal hypertension placenta previa abruptio placentae

The newborn may be in pain if the following are exhibited:

sudden high-pitched cry; facial grimace with furrowing of brown and quivering chin; increased muscle tone; oxygen desaturation; body posturing, such as squirming, kicking, and arching; limb withdrawal and thrashing movements; increase in heart rate, blood pressure, pulse, and respirations; fussiness and irritability

The nurse needs to conduct a procedure on a preterm newborn. Which measures would be most effective in reducing pain?

swaddling the newborn closely encouraging kangaroo care during procedures offering a pacifier prior to a procedure

The nurse is caring for a woman at 32 weeks gestation with severe preeclampsia. Which assessment finding should the nurse prioritize after the administration of hydralazine to this client?

tachycardia

Signs of impending shock

weak and rapid pulse decreased blood pressure tachypnea cool, clammy skin

The nurse is concerned that a newborn is hypoglycemic. Which blood glucose level would support the nurse's suspicion?

30

Hypoglycemia in a mature infant is defined as a blood glucose level below which amount?

40

During pregnancy a woman's blood volume increases to accommodate the growing fetus to the point that vital signs may remain within normal range without showing signs of shock until the woman has lost what percentage of her blood volume?

40%

cocaine use

•Increased risk for SIDS •Irritable & difficult to calm •Poor feeders with diarrhea,weak/absent abdominal muscles (prune belly syndrome) •Fetal anomalies: cardiac, neuro, GU, GI •Learning disabilities & delayed language, motor & intellectual development

Signs of Postpartum Depression (PPD)

•Major depressive episode associated with childbirth •Symptoms lasting beyond 6 weeks and worsening •Lack of interest in infant or self care •Does not resolve on its own •Sleeplessness or increased sleep

risk factors for abruption

•Maternal hypertension •Pre-eclampsia, chronic hypertension •Increased maternal age and/or parity •Multiple gestation •Polyhydramnios •Alcohol ingestion, cigarette smoking, cocaine or methamphetamine use •Pervious history of abruption, placenta abnormalities •Severe trauma

Causes of Postpartum Hemorrhage

•Most common uterine atony •Lacerations of the genital tract •Episiotomy •Retained placental fragments •Uterine inversion •Coagulation disorders •Hematomas of the vulva, vagina, or subperitoneal areas

Marijuana (THC)

•Most commonly used •tachycardia and decreased BP -increase risk of miscarriage and preterm delivery •Newborn: increased tremulousness, high pitched cry—CNS Long-term effects on child are unknown

Risk Factors for postpartum depression (PPD)

•Primiparous (pregnant for 1st time) patients •History of PPD, depression or bipolar disorders •Lack of support

sedatives

•Relax CNS •Used for sleep, relief of tension, seizures •birth defects and behavioral problems Infant: physically dependent and more prone to respiratory problems, feeding difficulty, disturbed sleep, sweating, irritability, fever

In reviewing the postpartum G3, P3 woman's history the nurse notes it is positive for obesity and smoking. The nurse recognizes this client is at risk for which complication?

DVT

The nurse is assessing a new client who is being admitted with gestational hypertension. Which nursing diagnosis should the nurse prioritize for this client?

Deficient fluid volume related to vasospasm of arteries

Signs of Postpartum Psychosis

•Surfaces within 3 months of giving birth •Sleep disturbances •Fatigue •Depression •Hypomania (mood state characterized by persistent disinhibition and mood elevation (euphoria), with behavior that is noticeably different from the person's typical behavior when in a non-depressed state) •Agitation poor judgement •Hallucinations •This is an EMERGENT situation as risk of suicide and/or infantcides

The client being given discharge instructions with a diagnosis of vulvovaginal candidiasis (VVC) demonstrates understanding when she states:

"I need to add yogurt to my diet."

Postpartum Hemorrhage: Therapeutic Management

•Underlying cause •Massage uterus •Remove placenta fragments •Antibiotics for infection •Repair lacerations

postpartum hematoma

•external genitalia or in the vagina •Blood escapes from injured blood vessels into the connective tissue -PAIN!!

A client admits to being HIV-positive, and that she is at about 16 weeks' gestation. Which statements made by the client indicate an understanding of the plan of care both during the pregnancy and postpartally? Select all that apply.

"My baby will be started on Zidovudine (ZVD) within 12 hours of delivery." "During labor and delivery, I can expect the Zidovudine (ZVD) to be given in my IV." "I will take my Zidovudine (ZVD) at the same time every day."

A client in her first trimester arrives at the emergency room with reports of severe cramping and vaginal spotting. On examination, the health care provider informs her that no fetal heart sounds are evident and orders a dilatation and curettage. The client looks frightened and confused and states that she does not believe in abortion. Which statement by the nurse is best?

"Unfortunately, the pregnancy is already lost. The procedure is to clear the uterus to prevent further complications."

The nurse walks in to find the client crying after the physician informed her of her diagnosis of human papillomavirus (HPV). Which of the following statements by the nurse conveys an attitude of acceptance toward the client with a sexually transmitted infection?

"You seem upset. Can I help answer any questions?"

A nurse has been assigned to assess a pregnant client for abruptio placenta. For which classic manifestation of this condition should the nurse assess?

"knife-like" abdominal pain with vaginal bleeding

heroin

-affects the brain of developing fetus ànd may lead to behavioral abnormalities in childhood •Withdrawal from opiates during pregnancy is dangerous for fetus -prescribe oral methadone maintenance for mother to reduce risks •SEVERE withdrawal (neonatal abstinence syndrome)

Indomethacin (Indocin)

-contraindicated if less than 32 weeks -premature closure of fetal ductus arteriosus -increased risk of necrotizing enterocolitis & intraventricular hemorrhage

nursing mgmnt for postpartum infections

-metritis: Broad-spectrum antibiotics -wound infections: Wound care -UTIs: Fluids and antibiotics -mastitis: Breast emptying and antibiotics

A nurse is administering prescribed enteral feedings to assist in preparing the gut of a preterm newborn. The nurse integrates understanding of this measure, administering the feedings at which rate?

0.5 to 1 mL/kg/h

On the third day postpartum, which temperature is internationally defined as a postpartal infection?

100.4° F (38° C)

A nurse is assigned to care for a client with deep vein thrombosis who has to undergo anticoagulation therapy. Which instruction should the nurse offer the client as a caution when the client receives anticoagulation therapy?

Avoid products containing aspirin.

A nurse is preparing a nursing care plan for a client who is admitted at 22 weeks' gestation with advanced cervical dilatation to 5 cm, cervical insufficiency, and a visible amniotic sac at the cervical opening. Which primary goal should the nurse prioritize at this point?

Bed rest to maintain pregnancy as long as possible

A nurse is caring for an infant. A serum blood sugar of 40 was noted at birth. What care should the nurse provide to this newborn?

Begin early feedings either by the breast or bottle.

cocaine use

Catecholamine release causes: •Increase in HR & B/P (r/t vasoconstriction) in both mother and baby-risk of abruption •Increased uterine activity—risk of preterm labor and birth •Decreased uterine blood flow—hypoxia/low birth weight

The nurse is comforting and listening to a young couple who just suffered a miscarriage. When asked why this happened, which reason should the nurse share as a common cause?

Chromosomal abnormality

A nurse in the maternity triage unit is caring for a client with a suspected ectopic pregnancy. Which nursing intervention should the nurse perform first?

vital signs

A nurse is developing a plan of care for a postpartum woman with superficial venous thrombosis of the left leg. Which intervention would the nurse most likely include?

Encouraging elevation of the left leg For the woman with superficial venous thrombosis: (NSAIDs) for analgesia rest and elevation of the affected leg warm compresses to the affected area to promote healing antiembolism stockings to promote circulation

A nurse is caring for an infant born with polycythemia. Which intervention is most appropriate when caring for this infant?

Focus on decreasing blood viscosity by increasing fluid volume.

Subinvolution (uterus does not return to nml size) complications

Hemorrhage pelvic peritonitis salpingitis (inflammation of the fallopian tubes) abscess

The nurse determines a newborn is small-for-gestational age based on which characteristics?

wasted appearance of extremities thin umbilical cord reduced subcutaneous fat stores

small-for-gestational-age

weigh less than 2,500 g

If she is bleeding

•Call for HELP!!! •Palpate and massage fundus •Check bladder for distension •Increase IV rate •Administer med to contract the uterus (oxytocin)

A nurse is caring for an infant born with an elevated bilirubin level. When planning the infant's care, what interventions will assist in reducing the bilirubin level? Select all that apply.

Initiate phototherapy. Increase the infant's hydration. Offer early feedings.

A 32-year-old gravida 3 para 2 at 36 weeks' gestation comes to the obstetric department reporting abdominal pain. Her blood pressure is 164/90 mm/Hg, her pulse is 100 beats per minute, and her respirations are 24 per minute. She is restless and slightly diaphoretic with a small amount of dark red vaginal bleeding. What assessment should the nurse make next?

Palpate the fundus, and check fetal heart rate.

A preterm infant will be hospitalized for an extended time. Assuming the infant's condition is improving, which environment would the nurse feel is most suitable for the child

Provide a mobile the child can see no matter how the child is turned.

Mastitis

•Can be and often is very painful •The breast may become red, swollen, and very tender •fever Treatment includes: •Rest •Hydration •Antibiotics •Continue breast feeding •Antipyretics

Subinvolution (uterus does not return to nml size) is caused by

Retained placental fragments distended bladder uterine myoma (fibroids) infection

DIC

•Circulating blood is unable to clot •Patient bleeds from uterus, IV site, ears, nose, subq tissues, etc. -deliver baby/placenta -give blood products -at risk for hemorrhage and renal

cocaine use

•Effects are prolonged in mom & baby •What lasts 30 minutes for mom lasts 3-5 days for baby -Effects are dose related

A 20-year-old client gave birth to a baby boy during the 43rd week of gestation. What might the nurse observe in the newborn during routine assessment?

The newborn may look wrinkled and old at birth.

Signs of Postpartum or Baby Blues

•Emotional lability •Irritability •Insomnia •Typically resolves within 2 weeks •Usually self-limiting

If metritis occurs

•Fertility may be compromised •Increase risk for exacerbation of the infection •Risk for hysterectomy Watch for Fever Malaise tender uterus Purulent or foul lochia

The nurse observes a neonate born at 28 weeks' gestation. Which finding would the nurse expect to see?

The pinna of the ear is soft and flat and stays folded.

Postpartum Infections

•Fever >38°C or 100.4°F after first 24 hours •Organisms usually those of normal vaginal flora (aerobic and anaerobic) •Metritis: infection of endometrium, decidua, and adjacent myometrium •Wound infections •Urinary tract infections Mastitis: inflammation of the breast

A preterm newborn has just received synthetic surfactant through an endotracheal tube by a syringe. Which intervention should the nurse implement at this point?

Tip the infant into an upright position.

A postpartum client is recovering from the birth and emergent repair of a cervical laceration. Which sign on assessment should the nurse prioritize and report to the RN and/or health care provider?

Weak and rapid pulse (signs of impending shock )

A woman at 32 weeks' gestation is HIV-positive but asymptomatic. What would be important in managing her pregnancy and delivery?

Weekly nonstress testing beginning at 32 weeks' gestation

A woman who has given birth to a postterm newborn asks the nurse why her baby looks so thin with so little muscle. The nurse integrates understanding about which concept when responding to the mother?

With postterm birth, the fetus uses stored nutrients to stay alive, and wasting occurs.

Which intervention would be helpful to a bottle-feeding client who is experiencing hard or engorged breasts?

apply ice

During the newborn's assessment, which finding would lead the nurse to suspect that a large-for-gestational-age newborn has experienced birth trauma?

asymmetrical movement

A nurse is caring for a client who has had an intrauterine fetal death with prolonged retention of the fetus. For which signs and symptoms should the nurse watch to assess for an increased risk of disseminated intravascular coagulation?

bleeding gums tachycardia acute renal failure

What would be the physiologic basis for a placenta previa?

low placental implantation

The nurse is required to assess a client for HELLP syndrome. Which are the signs and symptoms of this condition? Select all that apply.

epigastric pain upper right quadrant pain hyperbilirubinemia

abruptio placentae (severe)

grade 3 greater than 50% separation shock decreased BP tachycardia DIC excruciating pain

A nurse is assessing a preterm newborn. The nurse determines that the newborn is comfortable and without pain based on which finding?

lack of body posturing such as squirming, kicking, and arching; limb withdrawal and thrashing movements

A pregnant client is in labor. The nurse reviews a mother's prenatal history and finds that the client has diabetes mellitus. The nurse anticipates that the newborn is at risk for being:

large-for-gestational-age.

An Rh positive client vaginally gives birth to a 6 lb, 10 oz (3,005 g) neonate after 17 hours of labor. Which condition puts this client at risk for infection?

length of labor

extremely low birth weight

less than 1000 grams

abruptio placentae

painless bright red bleeding caused by premature separation of the placenta from the wall of the uterus before the end of labor

A client has just given birth at 42 weeks' gestation. What would the nurse expect to find during her assessment of the neonate?

peeling and wrinkling of the neonate's epidermis

total placenta previa

placenta completely covers the cervical opening no oxytocin!!

The nurse is assessing a small-for-gestational age (SGA) newborn, 12 hours of age, and notes the newborn is lethargic with cyanosis of the extremities, jittery with handling, and a jaundiced, ruddy skin color. The nurse expects which diagnosis as a result of the findings?

polycythemia

A nurse is caring for a client who gave birth vaginally 2 hours ago. What postpartum complication can the nurse assess within the first few hours following birth?

postpartal hemorrhage

A nurse is caring for a client in the postpartum period. When observing the client's condition, the nurse notices that the client tends to speak incoherently. The client's thought process is disoriented, and she frequently indulges in obsessive concerns. The nurse notes that the client has difficulty in relaxing and sleeping. The nurse interprets these findings as suggesting which condition?

postpartum psychosis

A newborn is being monitored for retinopathy of prematurity. Which condition predisposes an infant to this condition?

respiratory distress syndrome

Superficial thrombosis

saphenous vein in lower leg

abruptio placentae managment

strict bedrest left lateral position fundal height O2 continuous monitoring c/s

A pregnant woman has arrived to the office reporting vaginal bleeding. Which finding during the assessment would lead the nurse to suspect an inevitable abortion?

strong abdominal cramping

Which finding would lead the nurse to suspect that a large-for-gestational-age newborn is developing hyperbilirubinemia?

tea colored urine

The nurse encourages a mother to rock, sing, and talk to her premature newborn. What is the purpose of these activities with the infant?

to develop trust in people

The nurse is admitting a newborn male for observation with the diagnosis of preterm. What assessment finding corresponds with this gestational age diagnosis?

undescended testes

hypoglycemia in baby

unstable temp seizures feeble sucking

A woman at 8 weeks' gestation is admitted for ectopic pregnancy. She is asking why this has occurred. The nurse knows that which factor is a known risk factor for ectopic pregnancy?

use of IUD for contraception