OB Exam 1

A nurse is working with a postpartum client about resumption of menstrual activity following childbirth. Which of the following statements indicate that the client has a correct understanding? "My first menstrual cycle will be heavier than normal and then will be light for several months after." "My first menstrual cycle will be lighter than normal and then will get heavier every month thereafter." "My first menstrual cycle will be heavier than normal and will return to my prepregnant volume within three or four cycles." "I will not have a menstrual cycle for 6 months after childbirth."

"My first menstrual cycle will be heavier than normal and will return to my prepregnant volume within three or four cycles." This is an accurate statement and indicates her understanding of her expected menstrual activity. The woman can expect her first menstrual cycle, which occurs by 3 months after childbirth, to be heavier than normal, and the volume of her subsequent cycles to return to prepregnant levels within three or four cycles.

A nurse is caring for a postpartum client who has a significant bleed. In which clincial situations would the nurse identify the use of Methergine or prostaglandin be contraindicated even if the client was experiencing a postpartum significant bleed? (Select all that apply.) Select all that apply. Client's blood pressure postpartum is 180/90. Client has delivered twin pregnancies. Client has a history of asthma. Client has a mitral valve prolapse. Client is a grand multip.

- Client's blood pressure postpartum is 180/90. - Client has a history of asthma. -Client has a mitral valve prolapse. Twin pregnancies successfully delivered and grand multiparity are not contraindications to the use of these medications. If a client is hypertensive or has cardiovascular disease, these medications would not be used. If a client has a history of asthma, prostaglandin medication would not be used.

A nurse is reviewing concepts related to infants of diabetic mothers. Which factor would the nurse identified as increasing the risk of complications for infants of diabetic mothers? Duration of maternal disease Hemoglobin A1c level of 7 prior to pregnancy Glycemic control Hemoglobin A1c level of 7

- Duration of maternal disease The duration and severity of maternal disease are significant factors in increasing the risk for complications in infants of diabetic mothers. Glycemic control would be a positive factor indicating that blood glucose levels were maintained within normal range. A hemoglobin A1c level of 7 is within normal range.

With regard to the classification of neonatal bacterial infection, nurses should be aware that: - Health care-associated infection can be prevented by effective handwashing; early-onset infection cannot. - Infections occur with about the same frequency in boy and girl infants, although female mortality is higher. - The clinical sign of a rapid, high fever makes infection easier to diagnose. - Congenital infection progresses slower than health care-associated infection.

- Health care-associated infection can be prevented by effective handwashing; early-onset infection cannot. Handwashing is an effective preventive measure for late-onset (health care-associated) infections because these infections come from the environment around the infant. Early-onset (congenital) infections are caused by the normal flora at the maternal vaginal tract. Congenital (early-onset) infections progress more rapidly than health care-associated (late-onset) infections. Infection occurs about twice as often in boys and results in higher mortality. Clinical signs of neonatal infection are nonspecific and similar to noninfectious problems, making diagnosis difficult.

An infant weighing 4.1 kg was born 2 hours ago at 37 weeks of gestation. The infant appears chubby with a flushed complexion and is very tremulous. What would the nurse identify as being the most likely cause of the tremors? Hypoglycemia. Seizures. Birth injury. Hypocalcemia.

- Hypoglycemia. The description is indicative of a macrocosmic infant. Hypoglycemia is common in the infant with macrosomia. The tremors are jitteriness that is associated with hypoglycemia. Other signs of hypoglycemia are apnea, tachypnea, and cyanosis.

A nurse is caring for a preterm infant in the nursery setting. Why would the nurse anticpate that a preterm infants would be more likely to become septic? - IgG level is directly proportional to gestational age. - Serum complement levels are adequate. - Immune function is suppressed because of increased IgG levels. - IgG and IgA levels are adequate at birth.

- IgG level is directly proportional to gestational age. IgG levels are directly proportional to gestational age, being decreased in preterm infants, and reflect immune function. Levels of IgG and IgA are not adequate at birth and require time to become optimal. Serum complement levels are decreased at birth in preterm infants.

A pregnant client is receiving a selective serotonin reuptake inhibitor(SSRI) to treat depression. Which medication would the nurse identify as being associated with cardiac defects during pregnancy?

- Paroxetine The American College of Obstetricians and Gynecologists (ACOG) has issued a recommendation that paroxetine be avoided both during pregnancy and in women considering pregnancy. There have also been reports linking paroxetine to other abnormalities, such as omphalocele, craniosynostosis, and anencephaly. The absolute risk of any congenital abnormality associated with use of citalopram, fluoxetine, or sertraline is small.

A nurse is reviewing the concept of birth injuries. Which factors would the nurse identify so as to predispose an infant to birth injuries? (Select all that apply.) Select all that apply. Vacuum-assisted birth Multip between the ages of 25 and 30 Vertex presentation Application of an internal fetal scalp electrode

- Vacuum-assisted birth - Application of an internal fetal scalp electrode The use of an internal fetal scalp electrode could result in a scalp injury, which would be evident upon birth. The use of vacuum extraction could lead to a birth injury. Very young age (less than 16) and older age (more than 35) in a primipara are more likely to predispose an infant to birth injuries. Vertex presentation is a normal finding and as such would not typically lead to a birth injury.

The nurse is reviewing the clinical diagnosis of necrotizing enterocolitis (NEC). What would the nurse indicate as being a generalized sign associated with NEC? Hypertonia, tachycardia, and metabolic alkalosis. Scaphoid abdomen, no residual with feedings, and increased urinary output. Abdominal distention, temperature instability, and grossly bloody stools. Hypertension, absence of apnea, and ruddy skin color.

-Abdominal distention, temperature instability, and grossly bloody stools. Explanation: Some generalized signs of NEC include decreased activity, hypotonia, pallor, recurrent apnea and bradycardia, decreased oxygen saturation values, respiratory distress, metabolic acidosis, oliguria, hypotension, decreased perfusion, temperature instability, cyanosis, abdominal distention, residual gastric aspirates, vomiting, grossly bloody stools, abdominal tenderness, and erythema of the abdominal wall.

A nurse is reviewing types of accretas that occur during pregnancy. Which of the following would the nurse identify as the most common kind of placental adherence? -Increta -Accreta -Placenta previa -Percreta

-Accreta Placenta accreta is the most common kind of placental adherence seen in pregnant women and is characterized by slight penetration of myometrium. In placenta previa, the placenta does not embed correctly and results in what is known as a low-lying placenta. It can be marginal, partial, or complete in how it covers the cervical os, and it increases the client's risk for painless vaginal bleeding during the pregnancy and/or delivery process. Placenta percreta leads to perforation of the uterus and is the most serious and invasive of all types of accrete. Placenta increta leads to deep penetration of the myometrium.

A nurse is reviewing types of thrombosis. Which thromboembolic condition would the nurse identify as not being associated with postpartum period? -Pulmonary embolism -Superficial venous thrombosis -Deep vein thrombosis -Amniotic fluid embolism (AFE)

-Amniotic fluid embolism (AFE) An AFE occurs during the intrapartum period, when amniotic fluid containing particles of debris enters the maternal circulation. Although AFE is rare, the mortality rate is as high as 80%. A superficial venous thrombosis includes involvement of the superficial saphenous venous system. With deep vein thrombosis, the involvement varies but can extend from the foot to the iliofemoral region. A pulmonary embolism is a complication of deep vein thrombosis, occurring when part of a blood clot dislodges and is carried to the pulmonary artery, where it occludes the vessel and obstructs blood flow to the lungs.

A group of nurses are discussing postpartum hemorrahge (PPH). Which PPH conditions would the nurses consider as medical emergencies that require immediate treatment? -Uterine atony and disseminated intravascular coagulation (DIC). -Subinvolution of the uterus and idiopathic thrombocytopenic purpura (ITP) -Inversion of the uterus and hypovolemic shock -Hypotonic uterus and coagulopathies

-Inversion of the uterus and hypovolemic shock Inversion of the uterus and hypovolemic shock are considered medical emergencies. A hypotonic uterus can be managed with massage and oxytocin; coagulopathies should have been identified prior to delivery and treated accordingly. Although subinvolution of the uterus and ITP are serious conditions, they do not always require immediate treatment; ITP can be safely managed with corticosteroids or IV immunoglobulin. DIC and uterine atony are very serious obstetric complications but are not medical emergencies requiring immediate intervention.

For diagnostic and treatment purposes, nurses should know the birth weight classifications of high risk infants. What description would the nurse identify for an infant who was categorized as an extremely low birth weight (ELBW)infant? -Dependent on the gestational age. -Less than 1500 g. -Less than 1000 g. -Less than 2000 g.

-Less than 1000 g. Explanation:ELBW is defined as less than 1000 g. At such weights, problems are so numerous that ethical issues regarding when to treat arise. Less than 1500 g is the designation for very low birth rate (VLBW). Less than 2000 g is less than LBW but too high for VLBW. Gestational age is a factor with weight in the condition of the preterm birth, but it is not part of the birth weight categorization.

A male infant at 26 weeks of gestation arrives from the delivery room intubated. The nurse weighs the infant, places him under the radiant warmer, and attaches him to the ventilator at the prescribed settings. A pulse oximeter and cardiorespiratory monitor are placed. The pulse oximeter is recording oxygen saturation values of 80%. The prescribed saturation value is 92%. What is the most appropriate nursing action? -Continue with the admission process to ensure that a thorough assessment is completed. -Listen to breath sounds and ensure the patency of the endotracheal tube, increase oxygen, and notify a physician. -Notify the parents that their infant is not doing well. -Continue to observe and make no changes until the saturations are 75%.

-Listen to breath sounds and ensure the patency of the endotracheal tube, increase oxygen, and notify a physician. Explanation: The actions described in A are appropriate nursing interventions to assist in optimal O2 saturation of the infant. Oxygenation of the infant is crucial. O2 saturation should be maintained at more than 92%, and the nurse should delay other tasks to stabilize the infant. The action described in D is not appropriate. Further assessment and intervention are warranted prior to determination of fetal status.

During rounds, a nurse suspects that a client who has recently delivered via vaginal route is having excessive postpartum bleeding. Which intervention would be the priority action taken by the nurse at this time? -Increase the rate of intravenous fluids. -Monitor pad count and perform catheterization. -Call the physician. -Massage the uterine fundus.

-Massage the uterine fundus. Massaging of the uterine fundus would be a priority action to help expel clots and stimulate uterine contractions to constrict blood flow. The other actions described, as well as catheterization (if bladder distention is noted) and lochia flow monitoring, may be needed, but none of them is the priority action required at this time.

A nurse is caring for a first-time mother who is breastfeeding. Which postpartum infection would the nurse identify as being most often contracted by this client type? -Urinary tract infections (UTIs) -Wound infections -Endometritis -Mastitis

-Mastitis Mastitis is infection in a breast, usually confined to a milk duct. Most women who get it are first-timers who are breastfeeding. Endometritis is the most common postpartum infection. Its incidence is higher after a cesarean birth, not in first-time mothers. Wound infections are also a common postpartum complication. Sites of infection include both a cesarean incision and the episiotomy or repaired laceration. The gravidity of the mother and her feeding choice are not factors in the development of a wound infection. UTIs occur in 2% to 4% of all postpartum women. Risk factors include catheterizations, frequent vaginal exams, and epidural anesthesia.

A nurse is caring for a postpartum client who is experiencing hypovolemic shock. Which ratio would the nurse use to restore effective circulating volume? 3:1 2:1 1:1 4:1

3:1 A 3:1 ratio, of 3 ml fluid infused for every 1 ml of estimated blood loss, is recommended to restore circulating volume.

A nurse is monitoring a healthy newborn's blood glucose level 90 minutes after birth. Which result should the nurse anticipate in terms of mg/dL? 80 to 100 60 to 70 Less than 40 55 to 60

55 to 60 In most healthy term newborns, blood glucose levels stabilize at 50 to 60 mg/dL between 30 and 90 minutes after birth. 80 to 100 mg/dL is the normal plasma glucose level in the adult. A blood glucose level less than 40 mg/dL in the newborn is considered abnormal and warrants intervention. An infant with this level can display classic symptoms of jitteriness, lethargy, apnea, feeding problems, or seizures. By the third day of life the blood glucose levels should be approximately 60 to 70 mg/dL.

The maternity nurse must be cognizant that cultural practices have significant influence on infant feeding methods. Which statement should the maternity identify as correct? A common practice among Mexican women is known as las dos cosas. Muslim cultures do not encourage breastfeeding because of modesty concerns. Latino women born in the United States are more likely to breastfeed. East Indian and Arab women believe that cold foods are best for a new mother.

A common practice among Mexican women is known as las dos cosas. Las dos cosas refers to combining breastfeeding and commercial infant formula. It is based on the belief that combining the two feeding methods gives the mother and infant the benefits of breastfeeding along with the additional vitamins from formula. In the Muslim culture, breastfeeding for 24 months is customary; Muslim women may, however, choose to bottle-feed formula or expressed breast milk while in the hospital. Latino women born in the United States are less likely to breastfeed. East Indian and Arab women believe that hot foods, such as chicken and broccoli, are best for the new mother. The cultural descriptor hot has nothing to do with the temperature or spiciness of the food.

A nurse is providing care for a mother who has abused (or is abusing) alcohol and for her infant. Which statement would the nurse identify as being accurate? - Alcohol-related neurodevelopmental disorders (ARNDs) not sufficient to meet FAS criteria (learning disabilities, speech and language problems) are often not detected until the child goes to school. - Two thirds of newborns with fetal alcohol syndrome (FAS) are boys. - Both the distinctive facial features of the FAS infant and the diminished mental capacities tend toward normal over time. - The pattern of growth restriction of the fetus begun in prenatal life is halted after birth, and normal growth takes over.

Alcohol-related neurodevelopmental disorders (ARNDs) not sufficient to meet FAS criteria (learning disabilities, speech and language problems) are often not detected until the child goes to school. Some learning problems do not become evident until the child is in school. The pattern of growth restriction persists after birth. Two thirds of newborns with FAS are girls. Although the distinctive facial features of the FAS infant tend to become less evident with growth, the mental capacities never become normal.

Following birth, the nurse assigns an Apgar score of 10 at 1 minute to a newborn. How would the nurse explain this score? An infant having no difficulty adjusting to extrauterine life but who should be assessed again at 5 minutes after birth. An infant having no difficulty adjusting to extrauterine life and needing no further testing. A prediction of a future free of neurologic problems. An infant in severe distress that needs resuscitation.

An infant having no difficulty adjusting to extrauterine life but who should be assessed again at 5 minutes after birth. A score of 10 at 1 minute of life indicates excellent transition to extrauterine life; however, the assessment needs to be repeated at 5 minutes of life. An infant in need of resuscitation has a very low Apgar score. Apgar scores do not predict neurologic outcome but are useful for describing the newborn's transition to extrauterine environment.

A nursing student is reviewing concepts related to infant feeding. Which statement should the nurse identify as being correct concerning tandem feeding? Supplementing breastfeeding with bottle feeding to maintain adequate weight gain. Breastfeeding an infant and an older sibling during the same period. Using both breasts to nurse the baby. Adequate nutritional stores for the mother and infant.

Breastfeeding an infant and an older sibling during the same period. In tandem feeding, a mother nurses both an infant and an older child during the same period.

A nurse is reviewing the concept of breastfeeding. Which statement should the nurse identify as being accurate as it relates to the effect of breastfeeding on the family or society at large? Breastfeeding benefits the environment. Breastfeeding requires fewer supplies and less cumbersome equipment. Breastfeeding costs employers in terms of time lost from work. Breastfeeding saves families money.

Breastfeeding costs employers in terms of time lost from work. Less time is lost from work by breastfeeding mothers, in part because infants are healthier than bottle-fed infants. Breastfeeding is convenient because it does not require cleaning or transporting bottles and other equipment, and it saves families money because the cost of formula far exceeds the cost of extra food for the lactating mother. Also, breastfeeding uses a renewable resource; it does not need fossil fuels, advertising, shipping, or disposal.

A nurse is discussing with an obese client potential long-term consequences of infant feeding practices. Which method should the nurse identify to the client as having a decreased risk for the development of childhood obesity for the infant? Lower-calorie infant formula. An on-demand feeding schedule. Breastfeeding. Smaller, more frequent feedings.

Breastfeeding. Breastfeeding is the best prevention strategy for decreasing childhood and adolescent obesity. Breastfeeding also helps the woman return to her prepregnant weight sooner.All breastfed infants should be fed on demand. Use of lower-calorie formula is an inappropriate strategy that does not meet the infant's nutritional needs. Breastfeeding is the most appropriate choice for infant feeding. Smaller feedings are not necessary. Infants should continue to be fed every 2 to 3 hours in the newborn period.

A nurse is observing a premature infant's breathing pattern who is exhibiting a compensatory rapid respirations. How would the nurse intepret this finding? Trying to maintain a neutral thermal environment. Suffering from sleep or wakeful apnea. Breathing in a respiratory pattern common to premature infants. Experiencing severe swings in blood pressure.

Breathing in a respiratory pattern common to premature infants. The pattern of 5 to 10 seconds of respiratory pauses followed by 10 to 15 seconds of rapid respiration is called periodic breathing, which is common to premature infants. It may require nursing intervention such as oxygen and/or ventilation. Apnea is a cessation of respirations for 20 seconds or longer. An infant who presents with fluctuation in systemic blood pressure may have experienced a central nervous system injury. An infant attempting to maintain body temperature is likely to present with hypoglycemia, shivering, and mottled color.

A nurse must administer erythromycin ophthalmic ointment to a newborn after birth. Which action shoud the nurse include when administering the medication? Cleanse eyes from inner to outer canthus before administration if necessary. Flush eyes 10 minutes after instillation to reduce irritation. Apply directly over the cornea. Instill within 15 minutes of birth for maximum effectiveness.

Cleanse eyes from inner to outer canthus before administration if necessary. The newborn's eyes should be cleansed if necessary before the administration of erythromycin ointment. Instillation of the ointment can be delayed for up to 2 hours to facilitate eye-to-eye contact between the newborn and parents, an activity that fosters bonding and attachment, especially for fathers. Erythromycin ointment should be applied into the conjunctival sac to avoid accidental injury to the eye. The eyes should not be flushed after instillation.

A mother expresses fear about changing her infant's diaper after he is circumcised. What should the nurse teach the mother about providing caring for the infant upon discharge? Cleanse the penis gently with water and put petroleum jelly around the glans after each diaper change. Apply constant, firm pressure by squeezing the penis with the fingers for at least 5 minutes if bleeding occurs. Cleanse the penis with prepackaged diaper wipes every 3 to 4 hours. Wash off the yellow exudate that forms on the glans at least once every day to prevent infection.

Cleanse the penis gently with water and put petroleum jelly around the glans after each diaper change. Gentle cleansing with warm water, not wipes, and application of petroleum jelly at each diaper change are appropriate care for an infant who has had a circumcision. If bleeding occurs, gentle pressure should be applied to the site of the bleeding with a sterile gauze square. Yellow exudate covers the glans penis in 24 hours after the circumcision. This is part of normal healing and not an infective process. The exudate should not be removed.

A nurse is caring for a postpartum client experiencing hemorrhagic shock. Which indicator would lead the nurse to suspect that the client is getting worse? Client statement that she sees "stars" Restoration of blood pressure levels to normal range Capillary refill brisk Client complaint of headache and increased reaction time to questioning

Client complaint of headache and increased reaction time to questioning Client complaint of a headache accompanied by an increased reaction (response) time indicates that cerebral hypoxia is getting worse. Return of blood pressure to normal range would indicate resolving symptoms. Brisk capillary refill is a normal finding. The client may see "stars" early on in decreased blood flow states.

Between gestational weeks 18 and 32, the nurse should measure fundal height using a disposable metric tape measure, noting the distance from the symphysis pubis to the top of the fundus. The result in cm is a rough estimate of gestational age. Counterpressure Effleurage Therapeutic touch Breathing techniques

Counterpressure Counterpressure is steady pressure a support person applies to the sacral area of the patient's back. This is especially helpful for patients who have pain and internal pressure in the lower back because the fetal head is in a posterior position. The coach or the nurse uses the heel of the hand or a fist to achieve adequate counterpressure.

The nurse is assessing the respiratory system of a newborn. Which statement should the nurse be aware of with regard to the respiratory development of the newborn? Crying increases the distribution of air in the lungs. Seesaw respirations are no cause for concern in the first hour after birth. Newborns must expel the fluid at uterine life from the respiratory system within a few minutes of birth. Newborns are instinctive mouth breathers.

Crying increases the distribution of air in the lungs. Respirations in the newborn can be stimulated by mechanical factors such as changes in intrathoracic pressure resulting from the compression of the chest during vaginal birth. With birth, the pressure on the chest is released, helping draw air into the lungs. The positive pressure created by crying helps keep the alveoli open and increases distribution of air throughout the lungs. Newborns continue to expel fluid for the first hour of life. They are natural nose breathers and may not have the mouth-breathing response to nasal blockage for 3 weeks. Seesaw respirations instead of normal abdominal respirations are not normal and should be reported.

The nurse is providing discharge instructions related to the baby's respiratory system. Which statement should the nurse not include as part of discharge teaching? Don't let the infant sleep on his or her back. Avoid loose bedding, waterbeds, and beanbag chairs. Prevent exposure to people with upper respiratory tract infections. Keep the infant away from secondhand smoke.

Don't let the infant sleep on his or her back. The infant should be laid down to sleep on his or her back for better breathing and to prevent sudden infant death syndrome. Infants are vulnerable to respiratory infections, so infected people must be kept away. Secondhand smoke can damage lungs. Infants can suffocate in loose bedding, and furniture that can trap them.

The birth weight of a breastfed newborn was 8 lb, 4 oz. On the third day the newborn's weight is 7 lb, 12 oz. Which action should the nurse take based on this finding? Notify the physician because the newborn is being poorly nourished. Encourage the mother to continue breastfeeding because it is effective in meeting the newborn's nutrient and fluid needs. Suggest that the mother switch to bottle feeding because breastfeeding is ineffective in meeting newborn needs for fluid and nutrients. Refer the mother to a lactation consultant to improve her breastfeeding technique.

Encourage the mother to continue breastfeeding because it is effective in meeting the newborn's nutrient and fluid needs. Weight loss of 8 oz falls within the 5% to 10% expected weight loss from birth weight during the first few days of life, which for this newborn would be 6.6 to 13.2 oz. The infant is not undernourished, and the physician does not need to be notified. Breastfeeding is effective, and bottle feeding does not need to be initiated at this time.

A nurse administers Vitamin K to the newborn post delivery. The nurse understands that the reason for this medication to be given is? Reduce bilirubin levels. Enhance the ability of blood to clot. Stimulate the formation of surfactant. Increase the production of red blood cells.

Enhance the ability of blood to clot. Newborns have a deficiency of vitamin K until intestinal bacteria that produce it are formed. Vitamin K is required for the production of certain clotting factors. Vitamin K does not reduce bilirubin levels, increase the production of red blood cells, or stimulate the formation of surfactant.

Following a vaginal delivery, the client tells the nurse that she intends to breastfeed her infant but she is very concerned about returning to her prepregnancy weight. On the basis of this interaction, the nurse would advise the client that: (Select all that apply.) Select all that apply. She should join Weight Watchers as soon as possible to ensure adequate weight loss. Even though more calories are needed for lactation, typically women who breastfeed lose weight more rapidly than women who bottle feed in the postpartum period. If breastfeeding, she should regulate her fluid consumption in response to her thirst level. If she decreases her calorie intake by 100-200 calories a day she will lose weight more quickly. Weight loss diets are not recommended for women who breastfeed.

Even though more calories are needed for lactation, typically women who breastfeed lose weight more rapidly than women who bottle feed in the postpartum period. If breastfeeding, she should regulate her fluid consumption in response to her thirst level. Weight loss diets are not recommended for women who breastfeed. Weight loss diet plans are not recommended for women who are breastfeeding because they can lead to depletion of reserves and nutrient stores and decreased milk production. Breastfeeding mothers need to increase their caloric intake by 400-500 calories/day to ensure adequate nutritional stores and milk production. Breastfeeding women lose weight faster postpartum than women who bottle feed their infants. Regulating fluid consumption in response to her thirst level will ensure that a breastfeeding woman has adequate hydration without overhydration.

A woman gave birth to a 7-lb, 3-oz boy 2 hours ago. The nurse determines that the woman's bladder is distended because her fundus is now 3 cm above the umbilicus and to the right of the midline. What does the nurse identify as being the most serious complication based on this finding? Urinary tract infection. A ruptured bladder. Excessive uterine bleeding. Bladder wall atony.

Excessive uterine bleeding. Excessive bleeding can occur immediately after birth if the bladder becomes distended because it pushes the uterus up and to the side and prevents it from contracting firmly. A urinary tract infection may result from overdistention of the bladder, but it is not the most serious consequence. A ruptured bladder may result from a severely overdistended bladder. However, vaginal bleeding most likely would occur before the bladder reaches this level of overdistention. Bladder distention may result from bladder wall atony. The most serious concern associated with bladder distention is excessive uterine bleeding.

The nurse helps a breastfeeding mother change the diaper of her 16-hour-old newborn after the first bowel movement. The mother expresses concern because the large amount of thick, sticky stool is very dark green, almost black. She asks the nurse whether something is wrong. Which of the following would be the best response offered by the nurse? Telling the mother not to worry because all breastfed babies have this type of stool. Asking the mother what she ate for her last meal. Suggesting to the mother that she ask her pediatrician to explain normal newborn stooling patterns to her. Explaining to the mother that this stool is called meconium and is expected for the first few bowel movements of all newborns.

Explaining to the mother that this stool is called meconium and is expected for the first few bowel movements of all newborns. The majority of healthy term infants pass meconium during the first 12 to 24 hours after birth. Meconium is composed of amniotic fluid, intestinal secretions, shed mucosal cells, and possibly blood, resulting in the dark green to black color. At this early age this type of stool is typical of both bottle- and breastfed newborns. The mother's nutritional intake is not responsible for the appearance of a meconium stool. The nurse is fully capable of and responsible for teaching a new mother about the characteristics of her newborn, including expected stool patterns.

A nurse observes a postpartum client to have excessive blood loss. Which cause should the nurse identify as being the most common cause for this finding? Unrepaired lacerations of the vagina or cervix. Vaginal or vulvar hematomas. Failure of the uterine muscle to contract firmly. Retained placental fragments.

Failure of the uterine muscle to contract firmly. Although vaginal or vulvar hematomas, unrepaired lacerations, and retained placental fragments are possible causes of excessive blood loss, uterine muscle failure (uterine atony) is the most common cause. Uterine atony can best be thwarted by maintaining good uterine tone and preventing bladder distention.

Which of the following findings would raise concern for the nurse who is monitoring a postpartum client who had a spontaneous vaginal delivery (SVD) of a 10-lb baby boy? Fundus midline and firm with spurts of bright red blood upon fundal massage Lochia rubra with minimal clots expressed on fundal massage Fundus midline and firm with nonpalpable bladder Client report of mild to moderate cramping and request for pain medication

Fundus midline and firm with spurts of bright red blood upon fundal massage Even though the fundus is firm and midline, the fact that spurts of blood are evident on fundal massage may indicate that a tear is present. Further investigation is required as this is considered nonlochial bleeding. Lochia rubra with minimal clots expressed on fundal massage would be considered a normal finding, given that the client had an SVD of a large infant. Fundus midline and firm with nonpalpable bladder would be considered a normal finding. A report of mild to moderate cramping with a request for pain medication would be considered a normal finding in the postpartum period; the cramping is due to uterine contractions as the uterus returns to its normal prepregnancy status.

A nurse is reviewing the concept of injuries occuring to the infant's plexus during labor and birth. Which statement would the nurse identify as being accurate? -Breastfeeding is not recommended for infants with facial nerve paralysis until the condition resolves. -Parents of children with brachial palsy are taught to pick up the child from under the axillae. -Erb palsy is damage to the lower plexus. -If the nerves are stretched with no avulsion, they should recover completely in 3 to 6 months.

If the nerves are stretched with no avulsion, they should recover completely in 3 to 6 months. If the ganglia are disconnected completely from the spinal cord, the damage is permanent. Erb palsy is damage to the upper plexus and is less serious than brachial palsy. Parents of children with brachial palsy are taught to avoid picking up the child under the axillae or by pulling on the arms. Breastfeeding is not contraindicated in facial nerve paralysis, but both mother and infant will need help from the nurse at the start.

While caring for the newborn, the nurse must be alert for any signs of cold stress. Which finding should the nurse anticpate? Increased respiratory rate Decreased activity level Hyperglycemia Shivering

Increased respiratory rate In an infant who is cold, the respiratory rate rises in response to the increased need for oxygen. Signs of cold stress include increased activity level and crying (increased basal metabolic rate [BMR] and heat production). A cold infant is at risk for hypoglycemia as the glucose stores are depleted. Newborns are unable to shiver as a means to increase heat production.

A nurse is reviewing concepts of small-for-gestational age (SGA) infants and intrauterine growth restriction (IUGR). Which statement would the nurse identify as being accurate? Symmetric IUGR occurs in the later stages of pregnancy. In the first trimester, diseases or abnormalities result in asymmetric IUGR. Infants with asymmetric IUGR have the potential for normal growth and development. In asymmetric IUGR, weight is slightly more than SGA, whereas length and head circumference are somewhat less than SGA.

Infants with asymmetric IUGR have the potential for normal growth and development. The infant with asymmetric IUGR has the potential for normal growth and development.IUGR is either symmetric or asymmetric. The symmetric form occurs in the first trimester, as a result of disease or abnormalities; SGA infants have reduced brain capacity. The asymmetric form occurs in the later stages of pregnancy. Weight is less than the 10th percentile, but the head circumference is greater than the 10th percentile (within normal limits).

A nurse is reviewing possible etiologies for hyperbilirubinemia in the newborn. Which findings would the nurse expect to lead to increased bilirubin levels in the newborn? (Select all that apply.) Select all that apply. Cord clamped immediately following delivery of newborn Initiation of newborn feedings delayed following birth Twin-to-twin transfusion syndrome Hyperglycemia Meconium passed after 24 hours

Initiation of newborn feedings delayed following birth Twin-to-twin transfusion syndrome Meconium passed after 24 hours Delay in passage of meconium or in newborn feedings could lead to increased bilirubin levels because of increased enterohepatic circulation. Twin-to-twin transfusion syndrome could lead to increased bilirubin levels as a result of an increased amount of hemoglobin. An increase in bilirubin levels would be seen if cord clamping were delayed following birth. Hypoglycemia could lead to increased bilirubin levels because of alterations in hepatic function and perfusion.

A nurse examining a newborn infant notes that the infant is jaundiced. Which observation would lead the nurse to continue to monitor but not to intervene and contact the physician? Infant is being bottle fed and within the first 24 hours of life. Jaundice appeared on the third day of life. Jaundice appeared within the first 24 hours of life. Preterm infant who is 12 hours old.

Jaundice appeared on the third day of life. Physiologic jaundice can be seen in a large percentage of newborns, 60% of term and 80% of preterm, but typically resolves without immediate intervention. The critical factor here is the time of appearance, being within the first 24 hours of life. Jaundice appearing at this time is considered pathological and requires further investigation. The timing in C combined with prematurity also requires further investigation.

A nurse has provided client teaching to a breastfeeding mother. Which action if observed by the nurse would indicate the need for further instruction? Puts her finger into newborn's mouth before removing breast. Leans forward to bring breast toward the baby. Holds breast with four fingers along bottom and thumb at top. Stimulates the rooting reflex and then inserts nipple and areola into newborn's open mouth.

Leans forward to bring breast toward the baby. To maintain a comfortable, relaxed position, the mother should bring the baby to the breast, not the breast to the baby. The mother would need further demonstration and teaching to correct the ineffective action. The other actions described are correct.

As part of the postpartum assessment, the nurse examines the breasts of a primiparous breastfeeding woman 1 day postpartum. What should the nurse identify as an expected finding? Little if any change. Leakage of milk at let-down. Swollen, warm and tender on palpation. A few blisters and a bruise on each areola.

Little if any change. Breasts are essentially unchanged for the first 24 hours after birth. Colostrum is present and may leak from the nipples. Leakage of milk occurs after the milk comes in 72 to 96 hours after birth. Engorgement occurs at day 3 or 4 postpartum. A few blisters and a bruise indicate problems with the breastfeeding techniques being used.

The nurse examines a woman 1 hour after birth. The woman's fundus is boggy, midline, and 1 cm below the umbilicus. Her lochial flow is profuse, with two plum-sized clots. What is the nurse's intial action? Massage her fundus Place her on a bedpan to empty her bladder Administer methylergonovine (Methergine), 0.2 mg IM, which has been ordered prn Call the physician

Massage her fundus A boggy or soft fundus indicates that uterine atony is present. This is confirmed by the profuse lochia and passage of clots. The first action is to massage the fundus until firm.The physician can be called or methylergonovine administered after the fundus massage, especially if the fundus does not become or remain firm with massage. There is no indication of a distended bladder, so having the woman urinate will not alleviate the problem.

On examining a woman who gave birth 5 hours ago, the nurse finds that the woman has completely saturated a perineal pad within 15 minutes. What is the first action to be taken by the nurse? Call the woman's primary health care provider. Begin an IV infusion of Ringer's lactate solution. Assess the woman's vital signs. Massage the woman's fundus.

Massage the woman's fundus. The nurse should assess the uterus for atony. Uterine tone must be established to prevent excessive blood loss. The nurse may begin an IV infusion to restore circulatory volume, but this would not be the first action. Blood pressure is not a reliable indicator of impending shock from impending hemorrhage; assessing vital signs should not be the nurse's first action. The physician should be notified after the nurse completes assessment of the woman.

While evaluating the reflexes of a male newborn, the nurse notes that with a loud noise, the newborn symmetrically abducts and extends his arms, his fingers fan out and form a "C" with the thumb and forefinger, and he has a slight tremor. The nurse documents this finding as a positive: Glabellar (Myerson) reflex response Babinski reflex response Tonic neck reflex response Moro reflex response

Moro reflex response The characteristics displayed by the infant are associated with a positive Moro reflex response. The tonic neck reflex occurs when the infant extends the leg on the side to which the infant's head simultaneously turns. The glabellar reflex is elicited by tapping on the infant's head while the eyes are open; a characteristic response is blinking for the first few taps. The Babinski reflex occurs when the sole of the foot is stroked upward along the lateral aspect of the sole and then across the ball of the foot; a positive response occurs when all the toes hyperextend, with dorsiflexion of the big toe.

A group of nursing students are reviewing the process of bathing for a newborn. Which statement should the nursing students identify as being incorrect? Tub baths may be given before the infant's umbilical cord falls off and the umbilicus is healed. Only plain warm water should be used to preserve the skin's acid mantle. Powders are not recommended because the infant can inhale powder. Newborns should be bathed every day, for the bonding as well as the cleaning.

Newborns should be bathed every day, for the bonding as well as the cleaning. Newborns do not need a bath every day, as it can disrupt the integrity of a newborn's skin. The diaper area and creases under the arms and neck need more attention. Tub baths may be given as soon as an infant's temperature has stabilized. Unscented mild soap is appropriate to use to wash the infant. Powder is not recommended because of the risk of inhalation. Should a parent elect to use baby powder, it should never be sprinkled directly onto the baby's skin. The parent can apply a small amount of powder to his or her own hand and then apply it to the infant.

Nurses are getting ready for bedside reporting at change of shift. What benefit do the nurses identify for this type of change of shift report? Information is transparent so that the nurses and clients are aware of all pertinent data and delivery of care aspects. Clients can ask questions of the nurses during change of shift report so that they can better direct the delivery of their health care. Nurses are able to visualize their client's directly at the time of report leading to better client satisfaction. There is no need for additional information to be exchanged as the client is right there to answer questions and voice concerns.

Nurses are able to visualize their client's directly at the time of report leading to better client satisfaction. Using a bedside report technique helps the nurse directly visualize the client in question so as to improve his/her understanding of each client's clinical situation. The transparency of information is not a benefit of bedside reporting. A bedside report is a change-of-shift report between nurses involved in the delivery of health care to a client and/or group of clients; it is not mediated by client questioning. Also, it is not all inclusive because client care continues and is evolving over the course of the client's hospitalization. Thus, additional information will be needed.

A nurse is assesing a client who is 12 hours postpartum. Which finding would be a source of concern if observed by the nurse? Bradycardia—pulse rate of 55 beats/min Postural hypotension Pain in left calf with dorsiflexion of left foot Temperature of 38° C

Pain in left calf with dorsiflexion of left foot These findings indicate presence of Homans sign, are suggestive of thrombophlebitis, and should be investigated. Postural hypotension is an expected finding related to circulatory changes after birth. A heart rate of 55 beats/min is an expected finding in the initial postpartum period. A temperature of 38° C in the first 24 hours most likely indicates dehydration, which is easily corrected by increasing oral fluid intake.

Which factor would the nurse identify as contributing to depletion of weight and metabolic stores in the high risk newborn? Phototherapy Frequent breast feedings Bathing Core temperature within normal range

Phototherapy The use of phototherapy could lead to insensible heat loss and as a result lead to decreased weight and metabolic stores in the high risk newborn. Frequent breastfeedings and bathing would not have these effects. Maintaining a core temperature would help maintain weight and metabolic stores in the high risk newborn.

A nurse is monitoring an obstetrical client. Which test result would provide evidence to the nurse that there is fetal blood in maternal circulation? Negative Coombs test result Positive Fern test result Positive Coombs test result Positive Kleihauer-Betke test result

Positive Kleihauer-Betke test result A Kleihauer-Betke test determines the presence of fetal blood in maternal circulation.A positive fern test result would indicate the presence of amniotic fluid, noting that membranes had ruptured. A positive Coombs test result would indicate that the mother has Rh antibodies, and a negative result would indicate no presence of Rh antibodies.

A nurse is providing teaching relative to TORCH infections to a group of pregnant women. Which TORCH infection could be contracted by the infant because the mother owned a cat? Toxoplasmosis Parvovirus B19 Varicella-zoster Rubella

Toxoplasmosis Cats that eat birds infected with the Toxoplasma gondii protozoan excrete infective oocysts. Humans (including pregnant women) can become infected if they fail to wash their hands after cleaning a cat's litter box. The infection is passed through the placenta. The varicella-zoster virus is responsible for chickenpox and shingles. Approximately 90% of childbearing women are immune. During pregnancy, infection with parvovirus can result in abortion, fetal anemia, hydrops, intrauterine growth restriction (IUGR), and stillbirth; this virus is spread by vertical transmission, not by felines. Since vaccination for rubella was begun in 1969, cases of congenital rubella infection have been reduced significantly. Vaccination failures, lack of compliance, and the migration of nonimmunized persons result in periodic outbreaks of rubella (German measles).

A nurse is providing instruction to a postpartum client regarding perineal care technique. When evaluating the postpartum woman's perineal care technique, the nurse would recognize the need for further instruction if the woman: Uses soap and warm water to wash the vulva and perineum. Uses the peribottle to rinse upward into her vagina. Washes from symphysis pubis back to the episiotomy. Changes her perineal pad every 2 to 3 hours.

Uses the peribottle to rinse upward into her vagina. The peribottle should be used in a backward direction over the perineum. The flow should never be directed upward into the vagina because debris would be forced upward into the uterus through the still-open cervix. Using soap and warm water to wash the vulva and perineum is an appropriate measure. Washing from the symphysis pubis back to the episiotomy is an appropriate infection control measure. The client should be instructed to change her perineal pad every 2 to 3 hours.

The nurse taught new parents the guidelines to follow regarding the bottle feeding of their newborn who will be using formula from a can of concentrate. Which action if observed by the nurse would indicate that the parents correctly understand the nurse's instruction? Warm formula in a microwave oven for a couple of minutes prior to feeding. Add some honey to sweeten the formula and make it more appealing to a fussy newborn. Adjust the amount of water added according to weight gain pattern of the newborn. Wash the top of can and can opener with soap and water before opening the can.

Wash the top of can and can opener with soap and water before opening the can. Washing the top of the can and can opener with soap and water before opening the can of formula is a good habit for parents to get into to prevent contamination. Directions on the can for dilution should be followed exactly and not adjusted according to weight gain to prevent nutritional and fluid imbalances. Honey is not necessary and could contain botulism spores. The formula should be warmed in a container of hot water because a microwave can easily overheat it.

A nurse is reviewing intrapartum risk factors that would lead to the development of neonatal sepsis. Which of the following would the nurse not consider to be a factor? Meconium aspiration Mechanical ventilation Chorioamnionitis Galactosemia

- Chorioamnionitis Chorioamnionitis would be considered to be an intrapartum risk factor. The other conditions described are neonatal risk factors.

A 3.8-kg infant was delivered vaginally at 39 weeks after a 30-minute second stage. There was a nuchal cord. After birth the infant is noted to have petechiae over the face and upper back. What information should the nurse provide to the parents regarding the presence of petechiae? Should always be further investigated. Are benign if they disappear within 48 hours of birth. Usually occur with forceps delivery. Result from increased blood volume.

Are benign if they disappear within 48 hours of birth. Petechiae, or pinpoint hemorrhagic areas, acquired during birth may extend over the upper portion of the trunk and face. They usually occur with a breech presentation vaginal birth, although in this case they are soft-tissue injury resulting from the nuchal cord at birth. These lesions are benign if they disappear within 2 days of birth and no new lesions appear. Unless they do not dissipate in 2 days, there is no reason to alarm the family. Petechiae may also result from decreased platelet formation.

A nurse is taking care of a postpartum client diagnosed with von Willebrand diseaee who is experiencing a postpartum hemorrhage. Which medication should the nurse anticipate as being used first? Cryoprecipitate Factor VIII and vWf Desmopressin Hemabate

Desmopressin Desmopressin is the primary treatment of choice. This hormone, which can be administered orally, nasally, and intravenously, promotes the release of factor VIII and vWf from storage. Treatment with cryoprecipitate or with plasma products such as factor VIII and vWf is acceptable, but because of the associated risk of possible viruses from donor blood products, other modalities are considered safer. Although the administration of the synthetic prostaglandin in Hemabate is known to promote contraction of the uterus during postpartum hemorrhage, it is not effective for the client who presents with a bleeding disorder.

A nurse is preparing to educate a group of postpartum clients. Which description of postpartum restoration or healing times should the nurse identify as being accurate? Most episiotomies heal within a week. Hemorrhoids usually decrease in size within 2 weeks of childbirth. Rugae reappear within 3 to 4 weeks. The cervix shortens, becomes firm, and returns to form within a month postpartum.

Rugae reappear within 3 to 4 weeks. Rugae are never again as prominent as in a nulliparous woman. Localized dryness may occur until ovarian function resumes. The cervix regains its form within days; the cervical os may take longer. Most episiotomies take 2 to 3 weeks to heal. Hemorrhoids can take up to 6 weeks to decrease in size.

A nurse is reviewing metabolic functions occurring during the postpartum period. Which of the following changes would the nurse identify as being consistent with that timeframe? (Select all that apply.) Select all that apply. Mildly increased T3 and T4 levels for the first several weeks postpartum Increased BMR in the immediate postpartum period Secretion of insulinase Decrease in estrogen and cortisol levels Moderate hyperglycemia

Increased BMR in the immediate postpartum period Secretion of insulinase Decrease in estrogen and cortisol levels BMR remains elevated for the first 2 weeks after birth and then returns to prepregnancy levels. Insulinase enzyme reverses the diabetogenic effects of pregnancy, leading to decreased glucose levels in the postpartum period. Decreases in hormones such as estrogen and cortisol are seen during the postpartum period.Blood sugar levels typically decrease in the postpartum period as a result of the reversal of diabetogenic effects of pregnancy. Thyroid hormones gradually decrease to prepregnant levels in the 4 weeks following delivery.

A nurse providing care to preterm infants should understand that nasogastric and orogastric tubes are used to: Provide oxygen and ventilation. Feed the infants. Help maintain body temperature. Replace surfactants.

Feed the infants. Nasogastric and orogastric tubes are used in gavage feeding, providing breast milk or formula directly to an infant unable to nipple feed. To help maintain body temperature, preterm infants should be placed on warmers. Oxygen, continuous positive airway pressure (CPAP), and a ventilator are used for O2 and ventilation. Surfactants are not replaced by using nasogastric or orogastric tubes.

A group of nursing students are discussing the condition and reconditioning of the urinary system after childbirth. Which statement should the nursing students identify as correct? Fluid loss through perspiration and increased urinary output account for a weight loss of more than 2 kg during the puerperium. Kidney function returns to normal a few days after birth. With adequate emptying of the bladder, bladder tone is usually restored 2 to 3 weeks after childbirth. Diastasis recti abdominis is a common condition that alters the voiding reflex.

Fluid loss through perspiration and increased urinary output account for a weight loss of more than 2 kg during the puerperium. Excess fluid loss through other means occurs as well. Kidney function usually returns to normal in about a month. Diastasis recti abdominis is the separation of muscles in the abdominal wall; it has no effect on the voiding reflex. Bladder tone usually is restored 5 to 7 days after childbirth.

Two hours after giving birth, a primiparous woman becomes anxious and complains of intense perineal pain with a strong urge to have a bowel movement. Her fundus is firm, at the umbilicus, and midline. Her lochia is moderate rubra with no clots. What clinical finding should the nurse expect? Hematoma formation Uterine atony Constipation Bladder distention

Hematoma formation Increasing perineal pressure along with a firm fundus and moderate lochial flow are characteristic of hematoma formation. Bladder distention results in an elevation of the fundus above the umbilicus and deviation to the right or left of midline. Uterine atony results in a boggy fundus. Constipation is unlikely at this time.

A nurse is caring for an infant with suspected sepsis. Which priority intervention would the nurse implement? Electronic monitoring of vital signs Intravenous access Administration of oxygen Recorded intake and output

Intravenous access Establishing intravenous access for the administration of antibiotics would be a priority intervention. The other actions described might be required but are not the priority intervention.

A nurse is working with a postpartm client who is experiencing after birth pains. Which statement should the nurse identify as being accurate with regard to afterbirth pains? Alleviated somewhat when the mother breastfeeds. They are caused by mild, continual contractions for the duration of the postpartum period. More common in first-time mothers. More noticeable in births in which the uterus was overdistended.

More noticeable in births in which the uterus was overdistended. A large baby or multiple babies overdistend the uterus. The cramping that causes afterbirth pains arises from periodic, vigorous contractions and relaxations that persist through the first part of the postpartum period. Afterbirth pains are more common in multiparous women because first-time mothers have better uterine tone. Breastfeeding intensifies afterbirth pain because it stimulates contractions.

A nurse is placing a newborn under a radiant heat warmer for temperature stabilization. Which action should the nurse include during this procedure? Cover the probe with a nonreflective material. Recheck temperature by periodically taking a rectal temperature. Perform all examinations and activities under the warmer. Place the thermistor probe on the left side of the chest.

Perform all examinations and activities under the warmer. During all procedures, heat loss must be avoided or minimized for the newborn. All examinations and activities are performed with the infant under the heat panel. The thermistor probe should be placed on the upper abdomen away from the ribs and should be covered with reflective material. Rectal temperature measurements should be avoided because rectal thermometers can perforate the intestine, and the rectal temperature may remain normal until cold stress is advanced.

A nurse is reviewing the concept of lochia. Which statement should the nurse identify as correct? Will usually decrease with ambulation and breastfeeding. Should smell like normal menstrual flow unless an infection is present. Is similar to a light menstrual period for the first 6 to 12 hours. Is usually greater after cesarean births.

Should smell like normal menstrual flow unless an infection is present. An offensive odor usually indicates an infection. Lochia flow should approximate a heavy menstrual period for the first 2 hours and then steadily decrease. Less lochia is usually seen after cesarean births. It usually increases with ambulation and breastfeeding.

A nurse is examining a newborn male, who is estimated to be 39 weeks of gestation. Which physical finding should the nurse anticipate to be present? Abundant lanugo over his entire body. Ability to move his elbow past his sternum. Testes descended into the scrotum. Extended posture when at rest.

Testes descended into the scrotum. A full-term male infant has both testes descended into his scrotum and rugae appear on the anterior portion. A full-term infant's good muscle tone results in a more flexed posture when at rest. A full-term infant exhibits only a moderate amount of lanugo, usually on the shoulders and back. Preterm infants have an abundance of lanugo over the entire body. The muscle tone of a full-term newborn prevents him from being able to move his elbow past midline.

The nurse should suggest that the patient apply ice packs to her breasts in a pattern of 15 min on and 45 min off to help relieve engorgement by reducing swelling. The newborn feeds at least six times in 24 hr. The newborn has six wet diapers and three stools per day after day 4. The milk supply is plentiful by the newborn's second day. The newborn has returned to his birth weight 6 to 8 days following delivery.

The newborn has six wet diapers and three stools per day after day 4. Although there are variations, an appropriate guideline for determining adequate nourishment in a newborn who is breastfeeding is six to eight wet diapers and at least three stools every 24 hr by the fourth day of life.

A nurse is providing umbilical cord care to a newly delivered infant. What information should the nurse be aware of? The cord clamp is removed at cord separation. The stump can easily become infected. The average cord separation time is 5 to 7 days. A nurse noting bleeding from the vessels of the cord should immediately call for assistance.

The stump can easily become infected. The cord stump is an excellent medium for bacterial growth. If bleeding occurs, the nurse should first check the clamp (or tie) and apply a second one; if the bleeding does not stop, then the nurse calls for assistance. The cord clamp is removed after 24 hours when it is dry. The average cord separation time is 10 to 14 days.

The nurse is assessing a newborn at 5 hours of age and finds a soft mass over the infant's occiput. The soft mass crosses the suture line. The nurse documents this finding as which of the following? Subgaleal hemorrhage Caput succedaneum Cephalhematoma Hydrocephalus

The symphysis pubis and the top of the fundus Between gestational weeks 18 and 32, the nurse should measure fundal height using a disposable metric tape measure, noting the distance from the symphysis pubis to the top of the fundus. The result in cm is a rough estimate of gestational age.

A nurse caring for a newborn should be aware that the sensory system least mature at the time of birth is: Hearing. Taste. Smell. Vision.

Vision. The visual system continues to develop for the first 6 months. As soon as the amniotic fluid drains from the ear (minutes), the infant's hearing is similar to that of an adult. Newborns have a highly developed sense of smell and can distinguish and react to various tastes.

A nurse is caring for a postpartum client who is experiecing profuse postpartum bleeding. What is the priority intervention to be performed by the nurse? -Call the woman's primary health care provider. -Administer the standing order for an oxytocic. -Palpate the uterus and massage it if it is boggy. -Assess maternal blood pressure and pulse for signs of hypovolemic shock.

-Palpate the uterus and massage it if it is boggy. The initial management of excessive postpartum bleeding is firm massage of the uterine fundus to stop the bleeding. This is the most important nursing intervention. Then the primary health care provider should be notified or the nurse can delegate this task to another staff member. Administering an oxytocic and ascertaining vital signs are appropriate after assessment has been made and immediate steps have been taken to control the bleeding.

A nurse is reviewing the occurrence of hematologic problems in preterm infants. Which of the following processes or findings would the nurse identify as leading to an increase in hematologic problems? (Select all that apply.) Select all that apply. Prolonged Prothrombin time (PT)time Decrease in size of red blood cells Decreased capillary fragility Decreased red blood cell survival time Decrease in erythropoiesis

-Prolonged Prothrombin time (PT)time -Decreased red blood cell survival time -Decrease in erythropoiesis Explanation: Prolonged PT reflects an increased tendency to bleed in preterm infants. Decrease in red blood cell survival time is seen in such infants. So is decreased functional ability of erythropoietin, which limits red blood cell synthesis. One sees an increase in the size of red blood cells in preterm infants, which affects their survival time. Increased capillary fragility also occurs in preterm infants.

A nurse is caring is administering a gavage feeding to an infant. What should the nurse document each time? -The infant's suck and swallow coordination -The infant's heart rate and respirations -The infant's response to the feeding -The infant's abdominal circumference after the feeding

-The infant's response to the feeding Explanation: Documentation of a gavage feeding should include the size of the feeding tube, the amount and quality of the residual from the previous feeding, the type and quantity of the fluid instilled, and the infant's response to the procedure. Some older infants may be learning to suck, but the important factor to document is the infant's response to the feeding (including attempts to suck). Abdominal circumference is not measured after a gavage feeding. Vital signs may be obtained prior to feeding, but the infant's response is more important.

A nurse is reviewing best practice for placing an infant to breast following birth. What timeframe should the nurse identify as representing a Baby-friendly hospital mandate? 1 hour 30 minutes 4 hours 2 hours

1 hour Baby-friendly hospitals mandate that the infant be put to breast within the first hour after birth (BFHI, 2010). The ideal time to initiate breastfeeding is within the first 1 to 2 hours after delivery. In many countries this is the norm; however, the BFHI mandates 1 hour. Four hours is much too long to wait to initiate breastfeeding, whether the hospital is baby-friendly or not.

The nurse is observing a postpartum client who has been bleeding excessively during the first hour, saturating multiple pads. Which interventions would the nurse anticipate that the physician would order? (Select all that apply.) Select all that apply. Administer oxygen via nonrebreather mask @ 10 L/minute Insert a secondary intravenous line access Document findings in the health care record Type & screen for 2 units of blood Decrease flow rate for intravenous fluid administration

Administer oxygen via nonrebreather mask @ 10 L/minute Insert a secondary intravenous line access Administration of oxygen @ 10L/minute via nonrebreather mask would be an anticipated order, as would insertion of a secondary line access for administration of fluids, blood, and/or medications. Although documentation of findings in a health care record is required, this is part of the nursing role and does not require an order by the physician. With regard to the presence of hypovolemic shock, intravenous fluids would be increased and maintained. The flow rate would not typically be decreased unless there was another comorbidity leading to potential fluid overload. Type & Screen would not be an anticipated order because no blood would be held for use; rather a Type & Cross order would be anticipated.

The nurse is assessing a newborn and discovers unequal movement or uneven gluteal skinfolds during the Ortolani maneuver. What should be the priority action taken by the nurse? Informs the parents and physician that molding has not taken place. Tells the parents that one leg may be longer than the other, but they will equal out by the time the infant is walking. Alerts the physician that the infant has a dislocated hip. Suggests that if the condition does not change, surgery to correct vision problems might be needed.

Alerts the physician that the infant has a dislocated hip. The Ortolani maneuver is a technique for checking hip integrity. Unequal movement suggests that the hip is dislocated. The physician should be notified. The statement in B is inappropriate and may result in unnecessary anxiety for the new parents. Molding refers to movement of the cranial bones and has nothing to do with the infant's hips.

Although there are variations, an appropriate guideline for determining adequate nourishment in a newborn who is breastfeeding is six to eight wet diapers and at least three stools every 24 hr by the fourth day of life. Blackening of the stump Redness at the base Clear gel at the tip Hardening of the stump

Redness at the base Redness at the base, swelling, purulent drainage, or a foul odor are indications of infection. The nurse should notify the provider immediately about these findings.

A nurse is reviewing the concept of weaning with regard to infant care. Which statement should the nurse identify as correct? Abrupt weaning is easier than gradual weaning. Weaning can be mother or infant initiated. Weaning should proceed from breast to bottle to cup. The feeding of most interest should be eliminated first.

Weaning can be mother or infant initiated. Weaning is initiated by the mother or the infant. With infant-led weaning, the infant moves at his or her own pace in omitting feedings, which leads to a gradual decrease in the mother's milk supply. In mother-led weaning, the mother decides which feedings to drop. Infants can be weaned directly from the breast to a cup. Bottles are usually offered to infants younger than 6 months. If the infant is weaned prior to 1 year of age, iron-fortified formula rather than cow's milk should be offered. The feeding of least interest to the baby or the one through which the infant is likely to sleep should be eliminated first. Every few days thereafter the mother drops another feeding. Gradual weaning over a period of weeks or months is easier for both the mother and the infant than an abrupt weaning.

A nurse is caring for a client who is bottlefeeding but has engorged breasts. What action should the nurse implement?

Wear a snug, supportive bra. A snug, supportive bra limits milk production and reduces discomfort by supporting the tender breasts and limiting their movement. Ice packs, fresh cabbage leaves, and mild analgesics may also relieve discomfort. Cold packs reduce tenderness, whereas warmth would increase circulation, thereby increasing discomfort. Expressing milk results in continued milk production. Plastic liners would keep the nipples and areola moist, leading to excoriation and cracking.

A nurse is preparing to weight a newborn. Which action should the nurse include as part of the procedure? Weigh the newborn at the same time each day for accuracy. Place a sterile scale paper on the scale for infection control. Keep a hand on the newborn's abdomen for safety. Leave its diaper on for comfort.

Weigh the newborn at the same time each day for accuracy. Weighing a newborn at the same time each day allows for the most accurate weight. The baby should be weighed without a diaper or clothes. Clean scale paper is acceptable; it does not need to be sterile. The nurse's hand should be above, not on, the abdomen for safety.

A nurse is assisting a breastfeeding mother with positioning of the baby. Which finding should the nurse be aware of? While supporting the head, the mother should push gently on the occiput. Whatever the position used, the infant is held in direct skin with the mother. Women with perineal pain and swelling prefer the modified cradle position. The cradle position is usually preferred by mothers who had a cesarean birth.

Whatever the position used, the infant is held in direct skin with the mother. The infant inevitably faces the mother, belly to belly and should be in direct skin contact. The football position usually is preferred after cesarean birth. Women with perineal pain and swelling prefer the side-lying position because they can rest while breastfeeding. The mother should never push on the back of the head, because doing so might cause the baby to bite, hyperextend the neck, or develop an aversion to being brought near the breast.

Counterpressure is steady pressure a support person applies to the sacral area of the patient's back. This is especially helpful for patients who have pain and internal pressure in the lower back because the fetal head is in a posterior position. The coach or the nurse uses the heel of the hand or a fist to achieve adequate counterpressure. Applying ice packs Wearing a loose-fitting bra Pumping her breasts Taking a warm shower

apply ice packs The nurse should suggest that the patient apply ice packs to her breasts in a pattern of 15 min on and 45 min off to help relieve engorgement by reducing swelling.