OB Exam One 6.3.19

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A woman who gave birth to her infant 1 week ago calls the clinic to report pain with urination and increased frequency. What response by the nurse is appropriate?

"After birth it is easier to develop an infection in the urinary system; we need to see you today." The urinary system is more susceptible to infection during the postpartum period. The woman needs to be checked to rule out a urinary infection. The other responses are incorrect because they do not acknowledge her in an appropriate manner.

A client who recently gave birth to her third child expresses a desire to have her older two come to the hospital for a visit. What should the nurse say in response to this request?

"As long as they are well, absolutely. Why don't we give you a dose of pain medication beforehand so that you will enjoy the visit?" Separation from children is often as painful for a mother as it is for her children. A chance to visit the hospital and see the new baby and their mother reduces feelings that their mother cares more about the new baby than about them. It can help to not only relieve some of the impact of separation but also to make the baby a part of the family. Assess to be certain siblings are free of contagious diseases such as upper respiratory tract illnesses or recent exposure to chickenpox before they visit. Then, have them wash their hands and, if they choose, hold or touch the newborn with parental assistance. Allowing the siblings to walk with the baby out in the hall unsupervised would be unsafe.

A nurse is working with the parents of a newborn. The parents have a 2-year-old boy at home. Which statement would the nurse include when teaching these parents?

"Ask your 2-year-old to pick out a special toy for his sister." The parents should encourage the sibling to participate in some of the decisions about the baby, such as names or toys. Typically siblings experience some regression with the birth of a new baby. The parents should talk to the sibling during relaxed family times. The parents should arrange for the sibling to come to the hospital to see the newborn.

A client who gave birth 5 days ago reports profuse sweating during the night. What should the nurse recommend to the client in this regard?

"Be sure to change your pajamas to prevent you from chilling." The nurse should encourage the client to change her pajamas to prevent chilling and reassure the client that it is normal to have postpartal diaphoresis. Drinking cold fluids at night will not prevent postpartum diaphoresis.

After teaching a group of pregnant women about the skin changes that will occur after the birth of their newborn, the nurse understands there is a need for additional teaching when one of the women makes which statement?

"I can't wait for these stretch marks to disappear after I give birth." Stretch marks gradually fade to silvery lines but do not disappear completely. As estrogen and progesterone levels decrease, the darkened pigmentation on the abdomen, face, and nipples gradually fades.

When assessing a new father's adaptation to his new role, which statement would indicate that he is in the reality stage?

"I didn't realize all that went into being a dad. I wasn't prepared for this." The statement about not feeling prepared reflects the realization that the man's expectations were not realistic. Many wish to be more involved but do not feel prepared to do so, and this is characteristic of the second stage, reality. The statement that it will be fun to have a baby around but life will not change too much indicates a preconceived idea about what home life will be like with a newborn; this is characteristic of the first stage, expectations. The statement about things not changing reflects the first stage of expectations, where the partner is unaware of the changes that may occur after the birth of the newborn. The statement about learning new skills and enjoying being involved indicate a conscious decision to be at the center of the newborn's life; this is characteristic of the third stage, transition to mastery.

A nurse is making an initial call on a new mother who gave birth to her third baby five days ago. The woman says,"I just feel so down this time. Not at all like when I had my other babies. And this one just doesn't sleep. I feel so inadequate." What is the best response to this new mother?

"It sounds like you have the 'baby blues.' They are common after having a baby when you are not getting enough sleep, are busy with your other children, and are still a bit uncomfortable from the birth. They will most likely go away in a day or two." A combination of factors likely contributes to the baby blues. Psychological adjustment along with a physiologic decrease in estrogen and progesterone appear to be the greatest contributors. Additional contributing factors include too much activity, fatigue, disturbed sleep patterns, and discomfort.

A new mother is concerned because it is 24 hours after birth and her breasts have still not become engorged with breast milk. How should the nurse respond to this concern?

"It takes about 3 days after birth for milk to begin forming." The formation of breast milk (lactation) begins in a postpartal woman regardless of her plans for feeding. For the first 2 days after birth, an average woman notices little change in her breasts from the way they were during pregnancy as, since midway through pregnancy, she has been secreting colostrum, a thin, watery, prelactation secretion. On the third day post birth, her breasts become full and feel tense or tender as milk forms within breast ducts and replaces colostrum. There is no need to recommend formula feeding to the mother. Mastitis is inflammation of the lactiferous (milk-producing) glands of the breast; there is no indication that the client has this condition. Lactational amenorrhea is the absence of menstrual flow that occurs in many women during the lactation period.

A client who gave birth vaginally 16 hours ago states she does not need to void at this time. The nurse reviews the documentation and finds that the client has not voided for 7 hours. Which response by the nurse is indicated?

"It's not uncommon after birth for you to have a full bladder even though you can't sense the fullness." After a vaginal birth, the client should be encouraged to void every 4 to 6 hours. As a result of anesthesia and trauma, the client may be unable to sense the filling bladder. It is premature to catheterize the client without allowing her to attempt to void first. There is no need to contact the primary care provider at this time, because the client is demonstrating common adaptations in the early postpartum period. Allowing the client's bladder to fill for another 2 to 3 hours might cause overdistention.

A client gave birth vaginally 2 days prior and wishes to prevent getting pregnant again. She asks the nurse when she will need to begin birth control measures. How should the nurse respond?

"Ovulation may return as soon as 3 weeks after birth." Ovulation may start at soon as 3 weeks after birth. The client needs to be aware and use a form of birth control. She needs to be cleared by her provider prior to intercourse if she has a vaginal birth, but in the event that she has intercourse, needs to be prepared for the possibility of pregnancy. Ovulation can occur without the return of the menstrual cycle, and ovulation does return sooner than six months after birth.

Two days after giving birth, a client is to receive Rho(D) immune globulin. The client asks the nurse why this is necessary. The most appropriate response from the nurse is:

"Rho(D) immune globulin suppresses antibody formation in a woman with Rh-negative blood who gave birth to a baby with Rh-positive blood." Rho(D) immune globulin is indicated to suppress antibody formation in women with Rh-negative blood who gave birth to babies with Rh-positive blood. Rho(D) immune globulin is also given to women with Rh-negative blood after miscarriage/pregnancy termination, abdominal trauma, ectopic pregnancy, and amniocentesis.

Which instruction should the nurse provide to a breastfeeding woman experiencing breast engorgement?

"Take a warm shower just before feeding your infant." Standing in a warm shower or applying warm compresses immediately before feedings will help soften the breasts and nipples to allow the newborn to latch on more easily and will enhance the let-down reflex. Wearing a tight supportive bra all day is appropriate for the woman who is not breastfeeding. Frequent emptying of the breasts helps to resolve engorgement, so the mother should be encouraged to feed the newborn, which would involve touching her breasts and nipples. The breastfeeding woman should apply cold compresses but not ice to her breasts between feedings to reduce swelling.

A client who had a vaginal delivery 2 days ago asks the nurse when she will be able to breathe normally again. Which response by the nurse is accurate?

"Within 1 to 3 weeks, your diaphragm should return to normal and your breathing will feel like it did before your pregnancy." The abdominal organs, including the diaphragm, typically return to prepregnancy state within 1 to 3 weeks after birth. Discomforts such as shortness of breath and rib aches lessen, and tidal volume and vital capacity return to normal values.

A woman who gave birth to a healthy newborn 2 months ago comes to the clinic and reports discomfort during sexual intercourse. Which suggestion by the nurse would be most appropriate?

"You might try using a water-soluble lubricant to ease the discomfort." Coital discomfort and localized dryness usually plague most postpartum women until menstruation returns. Water-soluble lubricants can reduce discomfort during intercourse. Although it may take some time for the woman's body to return to its prepregnant state, telling the woman this does not address her concern. Telling her that dyspareunia is normal and that it takes time to resolve also ignores her concern. Kegel exercises are helpful for improving pelvic floor tone but would have no effect on vaginal dryness.

A client has been discharged from the hospital after a cesarean birth. Which instruction should the nurse include in the discharge teaching?

"You should be seen by your healthcare provider if you have blurred vision." The client needs to notify the healthcare provider for blurred vision as this can indicate preeclampsia in the postpartum period. The client should also notify the healthcare provider for a temperature great than 100.4° F (38° C) or if a peri-pad is saturated in less than 1 hour. The nurse should ensure that the follow-up appointment is fixed for within 2 weeks after hospital discharge.

A client who gave birth to a baby 36 hours ago informs the nurse that she has been passing unusually large volumes of urine very often. How should the nurse explain this to the client?

"Your body usually retains extra fluids during pregnancy, so this is one way it rids itself of the excess fluid." Postpartum diuresis is due to the buildup and retention of extra fluids during pregnancy. Bruising and swelling of the perineum, swelling of tissues surrounding the urinary meatus, and decreased bladder tone due to anesthesia cause urinary retention

what number range is given if the fetus is descending downward meeting goal of birth

+1 to +4

what number range is given if the fetus is not descending past the ischial spines

-1 to -4

What are some premonitory signs of labor

-Cervical changes -Lightening -Increased energy level -Bloody show -Braxton hicks contractions -Spontaneous rupture of membranes

What cervical changes could you expect to see in a patient with premonitory signs of labor?

-Cervical softening -possibly cervical dilation with descent of the presenting part into pelvis (could occur 1 month or 1 hour prior *secondary to effects of prostaglandins and pressure from braxton hicks*

what is the most favorable/common fetal position

-LOA --left occiput anterior

Increased prostaglandins leads to what at the end of pregnancy?

-additional contractions -cervical softening -gap junction induction -myometrial sensitization (leading to a progressive cervical dilation)

second stage of labor: what is the open-glottis method

-air is released during pushing to prevent the buildup of intrathoracic pressure -supports mothers involuntary bearing down efforts

what is the most common fetal attitude

-all joints flexed -fetal back rounded -chin is on the chest -thighs are flexed on the abdomen -legs are flexed at the knees -most favorable for vaginal birth - presenting the smallest fetal skull diameters to the pelvis

what is the concern with the rupture of membranes

-barrier to infection is gone and an ascending infection is possible -danger of cord prolapse if engagement has not occurred

third stage of labor

-begins with birth of newborn -ends with separation & birth of placenta

second stage of labor

-begins with complete cervical dilation and effacement -ends with the birth of newborn -involves moving the fetus -cardinal movements of labor occur during the early phase of passive descent -contractions occur every 2-3 mins -contractions last 60-90 sec -contractions strong by palpation -feels more in control, less irritable & agitated -directed by spontaneous pushing and directed pushing -spontaneous pushing: natural -directed pushing: possible negative repercussions

fourth stage of labor

-begins with completion of the expulsion of the placenta and membranes -ends with the initial physiologic adjustment and stabilization of the mother (1-4 hours after birth) -feels sense of peace and excitement -wide awake -very talkative -fundus should be firm and well contracted --typically located at midline between umbilicus & symphysis --slowly rises to the level of the umbilicus during first hour after birth -lochia is red, mixed with small clots, and of moderate flow -if mother had episiotomy, should be intact, edges well approximated and clean, no redness or eden present -monitor closely to prevent --hemorrhage --bladder distension --venous thrombosis -bladder hypotonic --limited sensation -VS, amount & consistency if vaginal discharge (lochia), and uterine funds are usually monitored every 15 mins for at least 1 hour

first stage of labor: latent or early phase

-begins with the start of regular contractions -ends when rapid cervical dilation begins -cervical effacement occurs -cervix dilates from 0-3 cm -contractions usually occur every 5-10 mins -contractions last 30-45 secs -mild by palpation --similar to menstrual cramps -effacement 0%-40%

What might a women notice when her uterus lowers in premonitory labor?

-breathe easier -increased pelvic pressure, cramping, low back pain, increase of vaginal discharge and frequent urination, edema may also occur in lower extremities

during clinical examination what are the possible effacement levels

-cervical canal 2 cm in length would be described as 0% effaced -cervical canal 1 cm in length would be described as 50% effaced -cervical canal 0 cm in length would be described as 100% effaced

what are the premonitory signs of labor

-cervical changes -lightening -increased energy level -bloody show -braxton hicks contractions -spontaneous rupture of membranes

first stage of labor: active phase

-cervical dilation begins to occur more rapidly -dilates from 4-7 cm -40%-80% effacement -contractions become more frequent, every 2-5 mins -contractions increase in duration, moderate to strong by palpation -relaxation & paced breathing begins

what cervical changes occur before labor begins

-cervical softening -possible cervical dilation with descent of the presenting parts into pelvis -can occur 1 month to 1 hour before actual labor begins -cervix changes from elongated structure to a shortened thinned segment

what do the soft tissues of the passageway consist of

-cervix -pelvic floor muscles -vagina

what factors influence a positive birth experience

-clear information on procedures -support, not being alone -sense of mastery, self-confidence -trust in staff caring for her -positive reaction to the pregnancy -personal control over breathing -preparation for the childbirth experience

what is cephalohematoma

-collection of blood beneath the scalp

what is gynecoid pelvis

-considered the true female pelvis -vaginal delivery most favorable with this type of pelvis because inlet is round and outlet is roomy - allow early and complete fetal internal rotation during labor

what are the distinctions between true vs false labor

-contraction timing -contraction strength -contraction discomfort -change in contraction activity -stay or go

What are the signs of false labor?

-contraction timing: irregular, not occurring close together. -contraction strength: frequently weak, not getting stronger with time or alternating. -contraction discomfort: usually felt in the front of the abdomen -any change in activity: may stop or slow down with walking or making a position change -stay or go: drink fluids and walk to see if there is any change- stay home

What are signs of true labor?

-contraction timing: regular, coming closer together usually 4-6 min apart, lasting 30-60 seconds -contraction strength: become stronger with time, vaginal pressure is usually felt -contraction discomfort: starts in the back and radiates around toward front of abdomen -any change in activity: contractions continue no matter what positional change is made -stay or go?: stay home until contractions are 5 min apart, last 45-60 seconds, and are strong enough so that convo during one is not possible, then go to hospital or birthing center.

what is true labor

-contractions occurring at regular intervals that increase in frequency, duration, and intensity -brings about progressive cervical dilation and effacement

what is fetal position

-describes the relationship of a given point on the presenting part of the fetus to a designated point of the maternal pelvis

cardinal movements of labor: descent

-downward movement of the fetal head until it is within the pelvic inlet

second stage of labor: pelvic phase

-early phase -fetal head is negotiating the pelvis, rotating, and advancing in descent

What happens to progesterone and estrogen in the last trimester of pregnancy? What is the result of this?

-estrogen levels increase progesterone levels decrease. -leads to an increase in the number of myoetrium gap junctions. These facilitate proteins that connect cell membranes and facilitate coordination of uterine contractions and myometrial stretching.

what occurs during the last trimester

-estrogen levels increase and progesterone levels decrease

what are typical descriptions of the cervical os

-external cervical os closed: 0 cm dilated -external cervical os half open: 5 cm dilated -external cervical os fully open: 10 cm dilated

what enters the maternal pelvis first in breech presentation

-fetal buttocks -feet

what makes up the passenger

-fetal head -fetal attitude -fetal lie -fetal presentation -fetal position -fetal station -fetal engagement

second stage of labor: perineal phase

-fetal head is lower in the pelvis and is descending the perineum -strong urge to push -also called the phase of active pushing

what is caput succedaneum

-fluid collected on the scalp

what are the types of breech positions

-frank breech --buttocks first, legs extended to the face -full or complete breech --crossed-legged -footling or incomplete breech --one or both legs presenting

cephalic presentation

-head first -flexed position in which the chin is resting on the chest, the optimal or smallest fetal skull dimensions for vaginal birth are demonstrated

cardinal movements of labor: internal rotation

-head rotates about 45 degrees anteriorly to the midline under the symphysis

what causes nesting

-increase in epinephrine release caused by decrease in progesterone

what are the maternal physiologic responses to labor

-increased heart rate by 10-20 bpm -increased cardiac output by 12% - 31% during first stage of labor and by 50% during second stage of labor -increased blood pressure (during contractions) by up to 35 mm/Hg -increased white blood cell count 25,000-30,000 result of tissue trauma -increased respiratory rate & oxygen consumption r/t increased metabolism -decreased gastric motility and food absorption -increased risk for N/V -decreased gastric emptying and gastic pH -increased risk for vomiting with aspiration -slight temperature elevation -increased muscle activity -muscle cramps/ aches -r/t stressed musculoskeletal system -increased BMR -stress of labor -decreased blood glucose levels -stress of labor

what are voluntary muscle contractions related to

-increased intra-abdominal pressure

what are common complaints during lightening

-increased pelvic pressure -cramping -low back pain -increased vaginal discharge -frequent urination -edema of the lower extremities (due to increased stasis of pooling blood)

what are the 3 phases of contractions

-increment (build up of the contraction) -acme (peak or highest intensity) -decrement (descent or relaxation of the uterine muscle fibers)

what is the role of oxytocin

-induces labor -starts contractions -moves milk with breast feeding

what is late preterm

-infant born between 34-36 completed weeks of gestation

what is the secondary stimulus powering labor

-intra abdominal pressure (voluntary muscle contractions) as she pushes and bears down during second stage of labor

whats the difference between true labor contractions and braxton hicks contractions

-irregular -decreased by walking, voiding, eating, increasing fluid intake, changing postion -true labor usually felt in the lower back -usually last about 30 seconds can last as long as 2 minutes

what does false labor mean

-irregular uterine contractions are felt, but the cervix is not affected

first stage of labor: transition phase

-last phase -dilation slows, progressing from 8-10 cm -effacement from 80%-100% -shortest phase -contractions hard by palpation -contractions more painful -contractions every 1-2 min -contractions last longer, 60-90 secs -maternal features -N/V -trembling extremities -restless movement -backache -increased apprehension -irritability -increased bloody show -inability to relax -diaphoresis -feelings of loss of control -overwhelmed

what is the role of prostaglandins

-lead to additional contractions -cervical softening -gap junction induction -myometrial sensitization -leads to progressive cervical dilation

second stage of labor: why is holding their breath to the count of 10, inhaling, and pushing again not recommended during a contraction

-leads to hemodynamic changes in the mother -interfere with oxygen exchange between mother and fetus -associated with pelvic floor damage -the longer the push, the more damage

what does the third letter in fetal position denote

-location of the presenting part in relation to the anterior (A) portion of the maternal pelvis or the posterior (P) portion of the maternal pelvis -if presenting part is directed to the side of the maternal pelvis, the presentation is transverse (T)

first stage of labor

-longest stage -begins with the first true contraction and ends with full dilation of the cervix -cervical dilation is gauged subjectively by vaginal exam and is expressed in cm -fetal membranes usually rupture during the first stage -pain is a result of the dilation of the cervix and lower uterine segment and the dissension (stretching) during contractions

how can the use of any upright or lateral position during labor compare with a supine or lithotomy position

-may reduce length of the first stage of labor -may reduce the duration of the second stage of labor -may reduce the number of assisted deliveries -may reduce episiotomies and perineal tears -may contribute to fewer abnormal fetal heart rate patterns -may increase comfort/reduce requests for pain meds -may enhance a sense of control by the mother -may alter the shape and size of the pelvis, which assists in descent -may assist gravity to move the fetus downwatd

how are uterine contractions described during early pregnancy

-mild -lasting about 30 seconds -occur about every 5-7 mins

what is bloody show

-mucous plug that fills the cervical canal is expelled as a result of cervical softening and increased pressure of the presenting part -cervical capillaries release small amount of blood mixed with mucus -pink tinged secretions

what are the landmark fetal presenting parts

-occipital bone (O) [vertex presentation] -chin (mentum (M)) [face presentation] -buttocks (sacrum (S)) [breech presentation] -scapula (acromion process (A)) [shoulder presentation] -dorsal (fetal back (D)) [shoulder presentation]

cardinal movements of labor: external rotation (restitution)

-occiput moves about 45 degrees back to its original left or right position (restitution) -external rotation of the fetal head allows the shoulders to rotate internally to fit the maternal pelvis

cardinal movements of labor: extension

-occurs after internal rotation is complete -head emerges through extension under the symphysis pubis along with the shoulders

cardinal movements of labor: flexion

-occurs as the vertex meets resistance from the cervix, the walls of the pelvis, or the pelvic floor -chin is brought in contact with the fetal thorax and the presenting diameter is changed from occipitofrontal to suboccipitobgrematic, which achieves smallest fetal skull diameter presenting to the the maternal pelvic dimensions

cardinal movements of labor: engagement

-occurs when the greatest transverse diameter of the head in vertex passes through the pelvic inlet (usually 0 station)

cardinal movements of labor: expulsion

-of the rest of the body occurs smoothly after the birth of the head and there anterior and posterior shoulders

what are the fetal physiologic responses to labor

-periodic FHR accelerations and slight decelerations -decrease in circulation and perfusion -increase in arterial carbon dioxide pressure -decrease in fetal breathing movements -decrease in fetal oxygen pressure -decrease in partial pressure of oxygen

third stage of labor: placental expulsion

-placenta expelled within 2-3o mins after separation of placenta from uterine wall, caused by continued uterine contractions -uterus massaged briefly after placenta is expelled --until firm so that uterine blood vessels constrict --minimizing possibility of hemorrhage -normal blood loss 500 mL for vaginal delivery -normal blood loss 1000 mL for c-section -placenta can be manually extracted -risk for postpartum hemorrhage if any pieces stay attached to uterine wall

what conditions are associated with shoulder dystocia

-placenta previa -prematurity -high parity -premature rupture of membranes -multiple gestation -fetal anomalies

what are cardinal movements of labor

-positional changes the fetus goes through as it travels through the passageway

what is the breech position associated with

-prematurity -placenta previa -multiparity -uterine abnormalities -congenital anomalies

how is descent brought on

-pressure of the amniotic fluid -direct pressure of the funds on the fetus's buttocks or head -contractions of the abdominal muscles -extension and straightening of the fetal body

second stage of labor: what is laboring down

-promotion of passive descent -alternative strategy for second stage management in women with epidurals -fetus descends and is born without coached maternal pushing

second stage of labor: behaviors demonstrated by laboring women

-pushing at the onset of the urge to bear down -using their own pattern and technique of bearing down in response to sensations they experience -using open glottis bearing down with contractions -pushing with variations in strength and duration -pushing down with progressive intensity -using multiple positions to increase progress and comfort

what is fetal presentation

-refers to the body part of the fetus that enters the pelvic inlet first --the presenting part

what is fetal attitude

-refers to the posturing (flexion or extension) of the joints and the relationship of fetal parts to one another

what is fetal lie

-refers to the relationship of the long axis (spine) of the fetus to the long axis (spine) of the mother -longitudinal --most common --long axis of the fetus is parallel to that of the mother -transverse --perpendicular to long axis --cannot be delivered vaginally

what is fetal station

-refers to the relationship of the presenting part to the level of the maternal pelvic ischial spine

what is fetal engagement

-signifies the entrance of the largest diameter of the fetal presenting part (usually fetal head) into the smallest diameter of the maternal pelvis

anterior fontanelle

-soft spot -open for 12-18 months

what are the differences with squatting or kneeling during childbirth

-squatting --enlarges the pelvic inlet and outlet diameters -kneeling --removes pressure on the maternal vena cava and helps to rotate the fetus from a posterior position to an anterior one to facilitate birth

what happens with the spontaneous rupture of membranes

-sudden gush or steady leakage of amniotic fluid

what is nesting

-sudden increase in energy before labor -usually occurs 24-48 hours before onset of labor

what is used to induce or augment labor by stimulating uterine contractions

-synthetic oxytocin (Pitocin)

why is the ischial spine the natural measuring point for the birth progress

-the ischial spines are the narrowest part of the pelvis

what is dilation dependent on

-the pressure of the presenting part and the contraction and retraction of the uterus

what is the passageway

-the route through which the fetus must travel to be born vaginally

what are uterine contractions responsible for

-thinning & dilating the cervix

what is effacement

-thinning of the cervix

what are braxton hicks contractions

-tightening or pulling sensation of the top of the uterus -occur primarily in the abdomen and groin -help in ripening and softening the cervix

why would a woman be given prostaglandins

-to induce labor

second stage of labor: crowning

-top of the baby's head no longer regresses between contractions

posterior fontanelle

-triangular -closes within 8-12 weeks

what is known about the fetal head

-two frontal bones -two parietal bones -occipital bone -3 bones are not fused -largest and least compressible structure -sutures -allow for overlapping and changes in shape (molding) -help identify position of fetal head -fontanels -there are 2 (anterior/posterior) -intersections of sutures -help in identifying position of fetal head and in molding -molding: overlapping of cranial bones

what is the primary stimulus powering labor

-uterine contractions --cause complete dilation and effacement of the cervix during the first stage of labor

what factors influence the onset of labor

-uterine stretch -progesterone withdrawal -increased oxytocin sensitivity -increased release of prostaglandins

what changes occur with the uterus during lightening (fetal descent into pelvis)

-uterus lowers and moves into a more anterior position

third stage of labor: signs of separation of the placenta

-uterus rises upward -umbilical cord lengthens -sudden trickle of blood is released from vaginal opening -uterus changes its shape to globular

second stage of labor: what is linked to negative maternal fetal hemodynamics and outcomes

-valsalva (holding breath) -bearing down -supine maternal positions

what is another name for cephalic presentation

-vertex presentation

when is an amniotomy done

-when the fetal head is at -2 station or lower, with the cervix dilated to at least 3 cm

what is lightening

-when the fetal presenting part begins to descend into the maternal pelvis -when the baby "drops"

what does the ZERO station mean in relation to fetal station

-when the presenting part is at the level of the maternal ischial spines

The neonatal nurse researches the neonatal mortality rate in the United States. Which of the following accurately describes this measurement of child health? Select all that apply. A) Neonatal mortality is the number of infant deaths occurring in the first 28 days of life per 1,000 live births. B) The infant mortality rate refers to the number of deaths occurring in the first 6 months of life. C) Neonatal mortality is documented as the number of deaths in relation to 1,000 live births. D) The infant mortality rate is used as an index of the general health of a country. E) In 2010, the U.S. infant mortality rate for White infants was greater than that for Black infants per 1,000 live births

. Ans: A,C, D, Feedback: Neonatal mortality is the number of infant deaths occurring in the first 28 days of life per 1,000 live births. The infant mortality rate refers to the number of deaths occurring in the first 12 months of life and is documented as the number of deaths in relation to 1,000 live births. The infant mortality rate is used as an index of the general health of a country; generally, this statistic is one of the most significant measures of children's health. In 2010, the infant mortality rate in the United States was 6.14 for White infants and 11.61 for Black infants per 1,000 live births. In 2005, the infant mortality rate in the United States was 6.86 per 1,000 live births.

The nurse is assigned to a client on postpartum day 1. Prior to assessing her uterus, where should the nurse anticipate she will locate the fundus?

1 cm below the umbilicus The fundus of the uterus should be at the umbilicus after birth. Every day after birth it should decrease 1 cm until it is descended below the pubic bone.

what are the 3 main fetal presentations

1. cephalic (head first) 2.breech (pelvis first) 3.shoulder (scapula first)

what are the four stages of labor

1. dilation 2. expulsive 3. placental 4. restorative

third stage of labor: spontaneous birth of placenta

1. fetal side (shiny grey side) presenting first --schultz's mechanism (shiny schultz) 2. maternal side (red raw side) presenting first --Duncan's mechanism (dirty duncan)

uterine contractions are monitored and assessed according to which 3 parameters

1. frequency- how often the contractions occur and is measured from the beginning of one contraction to the beginning of the next contraction 2. duration- h0w long a contraction lasts and is measured from the beginning of one contraction to the end of that same contraction 3. intensity- strength of the contraction determined by manual palpation or measured by an internal intrauterine pressure catheter.

the first stage is divided into 3 phases

1. latent or early phase 2. active phase 3. transition phase

what are the 3 variations in vertex presentation

1. military 2. brow 3. face

what are the 5 P's, aka the 5 critical factors affecting labor and birth

1. passageway (birth canal) 2. passenger (fetus & placenta) 3. powers (contractions) 4. postion (maternal) 5. psychological response

second stage of labor: 2 phases

1. pelvic 2. perineal

what are the 5 additional factors affecting the labor process

1. philosophy (low tech, high touch) 2. partners (support caregivers) 3. patience (natural timing) 4. patient preparation (childbirth knowledge base) 5. pain management (comfort measures)

third stage of labor: 2 phases

1. placental separation 2. placental expulsion

A nurse is caring for a postpartum client who has a temperature. Which temperature protocols would the nurse use to indicate a possible infection?

100.5º F (38.1º C) at 48 hours postbirth and remains the same the third day postpartum A temperature that is greater than 100.4º F (38º C) on 2 postpartum days after the first 24 hours puts the client at risk for a postpartum infection. A fever in the first 24 hours of birth is considered normal and could be caused by dehydration and analgesia.

Which finding would the nurse describe as "light" or "small" lochia?

4-inch stain or a 1 to 25 ml loss Typically the amount of lochia is described as follows: scant: a 1- to 2-inch lochia stain on the pad or a 10 ml loss; light or small: 4-inch stain or a 10 to 25 ml loss; moderate: 4- to 6-inch stain with an estimated loss of 25 to 50 ml; large or heavy: a pad is saturated within 1 hour after changing it.

The nurse is monitoring a postpartum client who says she's concerned because she feels mildly depressed. The nurse recognizes that she's most likely experiencing "postpartum blues," and reassures the client that this symptom is experienced by approximately what percentage of women?

85%

A client experienced prolonged labor with prolonged premature rupture of membranes. The nurse would be alert for which of the following in the mother and the newborn? A) Infection B) Hemorrhage C) Trauma D) Hypovolemia

A multipara client develops thrombophlebitis after delivery. Which of the following would alert the nurse to the need for immediate intervention? A)Dyspnea, diaphoresis, hypotension, and chest pain B) Dyspnea, bradycardia, hypertension, and confusion C) Weakness, anorexia, change in level of consciousness, and coma D)Pallor, tachycardia, seizures, and jaundice

A nurse suspects that a postpartum client is experiencing postpartum psychosis. Which of the following would most likely lead the nurse to suspect this condition? A) Delirium B) Feelings of anxiety C) Sadness D) Insomnia

A postpartum client is experiencing subinvolution. When reviewing the woman's labor and birth history, which of the following would the nurse identify as being least significant to this condition? A) Early ambulation B) Prolonged labor C) Large fetus D) Use of anesthetics

A postpartum woman who is breast-feeding tells the nurse that she is experiencing nipple pain. Which of the following would be least appropriate for the nurse to suggest? A) Use of a mild analgesic about 1 hour before breast-feeding B) Application of expressed breast milk to the nipples C) Application of glycerin-based gel to the nipples D) Reinstruction about proper latching-on technique

A primipara client gave birth vaginally to a healthy newborn girl 48 hours ago. The nurse palpates the clients fundus, expecting it to be at which location? A)Two finger-breadths above the umbilicus B) At the level of the umbilicus C) Two finger-breadths below the umbilicus D)Four finger-breadths below the umbilicus

A woman who delivered a healthy newborn several hours ago asks the nurse, Why am I perspiring so much? The nurse integrates knowledge that a decrease in which hormone plays a role in this occurrence? A) Estrogen B) hCG C) hPL D) Progesterone

A woman who is 12 hours postpartum had a pulse rate around 80 beats per minute during pregnancy. Now, the nurse finds a pulse of 60 beats per minute. Which of these actions should the nurse take? A)Document the finding, as it is a normal finding at this time. B) Contact the physician, as it indicates early DIC. C) Contact the physician, as it is a first sign of postpartum eclampsia. D)Obtain an order for a CBC, as it suggests postpartum anemia.

Assessment of a postpartum client reveals a firm uterus with bright-red bleeding and a localized bluish bulging area just under the skin at the perineum. The woman also is complaining of significant pelvic pain and is experiencing problems with voiding. The nurse suspects which of the following? A) Hematoma B) Laceration C) Bladder distention D) Uterine atony

The nurse interprets which of the following as evidence that a client is in the taking-in phase? A) Client states, He has my eyes and nose. B) Client shows interest in caring for the newborn. C) Client performs self-care independently. D) Client confidently cares for the newborn.

The nurse is assisting a postpartum woman out of bed to the bathroom for a sitz bath. Which of the following would be a priority? A) Placing the call light within her reach B) Teaching her how the sitz bath works C) Telling her to use the sitz bath for 30 minutes D) Cleaning the perineum with the peri-bottle

The nurse is making a follow-up home visit to a woman who is 12 days postpartum. Which of the following would the nurse expect to find when assessing the clients fundus? A)Cannot be palpated B) 2 cm below the umbilicus C) 6 cm below the umbilicus D)10 cm below the umbilicus

When assessing the postpartum woman, the nurse uses indicators other than pulse rate and blood pressure for postpartum hemorrhage based on the knowledge that: A) These measurements may not change until after the blood loss is large B) The bodys compensatory mechanisms activate and prevent any changes C) They relate more to change in condition than to the amount of blood lost D) Maternal anxiety adversely affects these vital signs

When developing the plan of care for the parents of a newborn, the nurse identifies interventions to promote bonding and attachment based on the rationale that bonding and attachment are most supported by which measure? A) Early parentinfant contact following birth B) Expert medical care for the labor and birth C) Good nutrition and prenatal care during pregnancy D) Grandparent involvement in infant care after birth

Blue

A client states, "I think my waters broke! I felt this gush of fluid between my legs." The nurse tests the fluid with Nitrazine paper and confirms membrane rupture if the paper turns:

Check the fetal heart rate

A client's membranes spontaneously ruptured, as evidenced by a gush of clear fluid with a contraction. Which of the following would the nurse do next?

Meperidine

A group of nursing students are reviewing the various medications used for pain relief during labor. The students demonstrate understanding of the information when they identify which agent as the most commonly used opioid?

Muscles of perineal body

A nurse is assessing a woman after birth and notes a second-degree laceration. The nurse interprets this as indicating that the tear extends through which of the following?

Checking for the cord around the neck

A nurse is assisting with the delivery of a newborn. The fetal head has just emerged. Which of the following would be done next?

Fundal height measurement, Membrane status, Contraction pattern

A nurse is completing the assessment of a woman admitted to the labor and birth suite. Which of the following would the nurse expect to include as part of the physical assessment? (Se

"We can get up and walk around after receiving combined spinal-epidural analgesia."

A nurse is describing the different types of regional analgesia and anesthesia for labor to a group of pregnant women. Which statement by the group indicates that the teaching was successful?

"This technique redirects energy fields that lead to pain."

A nurse is explaining the use of therapeutic touch as a pain relief measure during labor. Which of the following would the nurse include in the explanation?

Sudden gush of dark blood from the vagina

A nurse is providing care to a woman during the third stage of labor. Which of the following would alert the nurse that the placenta is separating?

Variable decelerations

A nurse is reviewing the fetal heart rate pattern and observes abrupt decreases in FHR below the baseline, appearing as a U-shape. The nurse interprets these changes as reflecting which of the following?

Finger pads

A nurse palpates a woman's fundus to determine contraction intensity. Which of the following would be most appropriate for the nurse to use for palpation?

Avoidance of scalp electrodes for fetal monitoring, Refraining from obtaining fetal scalp blood for pH testing, Adminstering zidovudine at the onset of labor.

A pregnant woman admitted to the labor and birth suite undergoes rapid HIV testing and is found to be HIV-positive. Which of the following would the nurse expect to include when developing a plan of care for this women?

Encouraging the woman to push when she has a strong desire to do so

A woman has just entered the second stage of labor. The nurse would focus care on which of the following?

"The temperature of the water should be at least 105° F."

A woman in labor has chosen to use hydrotherapy as a method of pain relief. Which statement by the woman would lead the nurse to suspect that the woman needs additional teaching?

Cervical dilation of 2 cm or more

A woman in labor is to receive continuous internal electronic fetal monitoring. The nurse reviews the woman's medical record to ensure which of the following as being required?

Respiratory depression

A woman in labor received an opioid close to the time of birth. The nurse would assess the newborn for which of the following?

Naloxone

A woman in labor who received an opioid for pain relief develops respiratory depression. The nurse would expect which agent to be administered?

-2 station

A woman is admitted to the labor and birthing suite. Vaginal examination reveals that the presenting part is approximately 2 cm above the ischial spines. The nurse documents this finding as:

Possible infection

A woman's amniotic fluid is noted to be cloudy. The nurse interprets this finding as which of the following?

A nurse is educating a client about a care plan. Which of the following would the nurse use to assess the client's learning ability?

A) "Did you graduate from high school; how many years of schooling did you have?" B) "Do you have someone in your family who would understand this information?" C) "Many people have trouble remembering information; is this a problem for you?" D) "Would you prefer that the doctor give you more detailed medical information?" Ans: C Feedback: It's appropriate to ask the client if he or she will have trouble remembering the information. Many clients have this problem. It removes any judgment or stereotypes regarding one's education level, understanding, or learning skills. Avoid giving information that uses a lot of medical language or jargon and use a simple, conversational style.

A primipara client who is bottle feeding her baby begins to experience breast engorgement on her third postpartum day. Which instruction would be most appropriate to aid in relieving her discomfort?

A) "Express some milk from your breasts every so often to relieve the distention." B) "Remove your bra to relieve the pressure on your sensitive nipples and breasts." C) "Apply ice packs to your breasts to reduce the amount of milk being produced." D) "Take several warm showers daily to stimulate the milk let-down reflex." Ans: C For the woman with breast engorgement who is bottle feeding her newborn, encourage the use of ice packs to decrease pain and swelling. Expressing milk from the breasts and taking warm showers would be appropriate for the woman who was breast-feeding. Wearing a supportive bra 24 hours a day also is helpful for the woman with engorgement who is bottle feeding.

A pregnant client tells her nurse that she is interested in arranging a home birth. After educating the client on the advantages and disadvantages, which statement would indicate that the client understood the information?

A) "I like having the privacy, but it might be too expensive for me to set up in my home." B) "I want to have more control, but I am concerned if an emergency would arise." C) "It is the safest method for giving birth because there are no interferences." D) "The midwife is trained to resolve any emergency, and she can bring any pain meds." Ans: B Feedback: Home births have many advantages, such as having more control over the birth, being the least expensive option, creating a good relationship with a midwife, minimizing interferences, and having more flexibility in the comfort of your home. However, the limited availability of pain medication and danger to the mother and baby if an emergency arises are two of the main disadvantages. Thus, it is not considered the safest method for delivery

After teaching a postpartum woman about breast-feeding, the nurse determines that the teaching was successful when the woman states which of the following?

A) "I should notice a decrease in abdominal cramping during breast-feeding." B) "I should wash my hands before starting to breast-feed." C) "The baby can be awake or sleepy when I start to feed him." D) "The baby's mouth will open up once I put him to my breast." Ans: B To promote successful breast-feeding, the mother should wash her hands before breast feeding, and make sure that the baby is awake and alert and showing hunger signs. In addition, the mother should lightly tickle the infant's upper lip with her nipple to stimulate the infant to open the mouth wide and then bring the infant rapidly to the breast with a wide-open mouth. The mother also needs to know that her afterpains will increase during breast-feeding.

During class, a nursing student asks, "I read an article that was talking about integrative medicine. What is that?" Which response by the instructor would be most appropriate?

A) "It refers to the use of complementary and alternative medicine in place of traditional therapies for a condition." B) "It means that complementary and alternative medicine is used together with conventional therapies to reduce pain or discomfort." C) "It means that mainstream medical therapies and complementary and alternative therapies are combined based on scientific evidence for being effective." D) "It refers to situations in which a client and his or her family prefer to use an unproven method of treatment over a proven one." Ans: C Feedback: Integrative medicine combines mainstream medical therapies and CAM therapies for which there is some scientific evidence of safety and effectiveness (NCCAM, 2011). These include acupuncture, reflexology, therapeutic touch, meditation, yoga, herbal therapies, nutritional supplements, homeopathy, naturopathic medicine, and many more used for the promotion of health and well-being. Complementary medicine is used together with conventional medicine, such as using aromatherapy to reduce discomfort after surgery or to reduce pain during a procedure or during early labor. Alternative medicine is used in place of conventional medicine, such as eating a special natural diet to control nausea and vomiting or to treat cancer instead of undergoing surgery, chemotherapy, or radiation that has been recommended by a conventional doctor.

After reviewing information about postpartum blues, a group of students demonstrate understanding when they state which of the following about this condition?

A) "Postpartum blues is a long-term emotional disturbance." B) "Sleep usually helps to resolve the blues." C) "The mother loses contact with reality." D) "Extended psychotherapy is needed for treatment." Ans: A Postpartum blues are transient emotional disturbances beginning in the first week after childbirth and are characterized by anxiety, irritability, insomnia, crying, loss of appetite, and sadness (Hanley, 2010). These symptoms typically begin 3 to 4 days after childbirth and resolve by day 8 (Mattson & Smith, 2011). These mood swings may be confusing to new mothers but usually are self-limiting. The blues typically resolves with restorative sleep. Postpartum blues are thought to affect up to 75% of all new mothers; this condition is the mildest form of emotional disturbance associated with childbearing (March of Dimes, 2011). The mother maintains contact with reality consistently and symptoms tend to resolve spontaneously without therapy within 1 to 2 weeks.

Which statement would alert the nurse to the potential for impaired bonding between mother and newborn?

A) "You have your daddy's eyes." B) "He looks like a frog to me." C) "Where did you get all that hair?" D) "He seems to sleep a lot." Ans: B Negative comments may indicate impaired bonding. Pointing out commonalities such as "daddy's eyes" and expressing pride such as "all that hair" are positive attachment behaviors. The statement about sleeping a lot indicates that the mother is assigning meaning to the newborn's actions, another positive attachment behavior.

A postpartum woman who is bottle-feeding her newborn asks the nurse, "About how much should my newborn drink at each feeding?" The nurse responds by saying that to feel satisfied, the newborn needs which amount at each feeding?

A) 1 to 2 ounces B) 2 to 4 ounces C) 4 to 6 ounces D) 6 to 8 ounces Ans: B Feedback: Newborns need about 108 cal/kg or approximately 650 cal/day (Dudek, 2010). Therefore, explain to parents that a newborn will need to 2 to 4 ounces to feel satisfied at each feeding.

A nursing instructor is describing trends in maternal and newborn health care and the rise in community-based care for childbearing women. The instructor addresses the length of stay for vaginal births during the past decade, citing that which of the following denotes the average stay?

A) 24-48 hours or less B) 72-96 hours or less C) 48-72 hours or less D) 96-120 hours or less Ans: A Feedback: Hospital stays for vaginal births have averaged 24-48 hours or less during the past decade, and 72-96 hours or less for cesarean births.

When caring for childbearing families from cultures different from one's own, which of the following must the nurse accomplish first?

A) Adapting to the practices of the family's culture B) Determining similarities between both cultures C) Assessing personal feelings about that culture D) Learning as much as possible about that culture Ans: C Feedback: The first step is to develop cultural awareness, engaging in self-exploration beyond one's own culture, seeing patients from different cultures, and examining personal biases and prejudices toward other cultures. Once this occurs, the nurse can learn as much about the culture as possible and become familiar with similarities and differences between his or her own culture and the family's culture. The nurse would adapt nursing care to address the practices of the family's culture to provide culturally competent care.

A nurse is working as part of a committee to establish policies to promote bonding and attachment. Which practice would be least effective in achieving this goal?

A) Allowing unlimited visiting hours on maternity units B) Offering round-the-clock nursery care for all infants C) Promoting rooming-in D) Encouraging infant contact immediately after birth Ans: B Factors that can affect attachment include separation of the infant and parents for long times during the day, such as if the infant was being cared for in the nursery throughout the day. Unlimited visiting hours, rooming-in, and infant contact immediately after birth promote bonding and attachment.

A pregnant woman asks the nurse about giving birth in a birthing center. She says, "I'm thinking about using one but I'm not sure." Which of the following would the nurse need to integrate into the explanation about this birth setting? Select all that apply.

A) An alternative for women who are uncomfortable with a home birth B) The longer length of stay needed when compared to hospital births C) Focus on supporting women through labor instead of managing labor D) View of labor and birth as a normal process requiring no intervention E) Care provided primarily by obstetricians with midwives as backup care Ans: A, C, D Feedback: Birthing centers are an alternative for women who are uncomfortable with a home birth but do not want a hospital birth. A birthing center offers a home-like setting but with close proximity to a hospital in case of complications. Typically the normal discharge time in birthing centers ranges from 4 to 24 hours, shorter than that for a hospital birth. Labor and birth are viewed as a normal process and midwives, not obstetricians, support the woman through labor rather than manage labor. Most centers use a noninterventional view of labor and birth.

A 3-year-old boy with encephalitis is scheduled for a lumbar puncture. Which of the following actions by the nurse would demonstrate atraumatic care?

A) Applying an anesthetic cream before the lumbar puncture B) Having his anxious mother stay in the waiting room C) Explaining, using medical terms, what will happen D) Starting the child's intravenous infusion in his room Ans: A Feedback: Using an anesthetic cream prior to the lumbar puncture reduces the pain associated with the procedure and is an example of atraumatic care. The presence of a parent during procedures is supportive for the child and should be encouraged because it can reduce stress. The explanation of what will happen should be given on the child's level. The IV should not be started in the child's hospital room, which should remain a "safe" area.

The nurse is providing home care for a 6-year-old girl with multiple medical challenges. Which of the following activities would be considered the tertiary level of prevention?

A) Arranging for a physical therapy session B) Teaching the parents to administer albuterol C) Reminding the parents to give the full course of antibiotics D) Giving the DTaP vaccination at proper intervals Ans: A Feedback: The tertiary level of prevention involves restorative, rehabilitative, or quality-of-life care, such as arranging for a physical therapy session. Teaching the parents to administer albuterol and reminding them to give the full course of antibiotics as prescribed are part of the secondary level of prevention, which focuses on diagnosis and treatment of illness. Giving a DTaP vaccination at proper intervals is an example of the primary level of prevention, which centers on health promotion and illness prevention.

The nurse is educating the parents of a 7-year-old girl who has just been diagnosed with epilepsy. Which of the following teaching techniques would be most appropriate?

A) Assessing the parents' knowledge of anticonvulsant medications B) Demonstrating proper seizure safety procedures C) Discussing the surgical procedures for epilepsy D) Giving the parents information in small amounts at a time Ans: D Feedback: Parents, when given a life-altering diagnosis, need time to absorb information and to ask questions. Therefore, giving the parents information in small amounts at a time is best. The child has just been diagnosed with epilepsy, and surgical intervention is not used unless seizures persist despite medication therapy. Therefore, discussing surgery would be inappropriate at this time. Assessing the parents' knowledge of anticonvulsant medications identifies a knowledge gap and need to learn, but it would be unreasonable to think that they would understand the medications because the diagnosis had just been made. Demonstrating proper seizure safety procedures is an effective way to present information later on, once the family begins to understand the condition.

The nurse administers RhoGAM to an Rh-negative client after delivery of an Rh-positive newborn based on the understanding that this drug will prevent her from:

A) Becoming Rh positive B) Developing Rh sensitivity C) Developing AB antigens in her blood D) Becoming pregnant with an Rh-positive fetus Ans: B The woman who is Rh-negative and whose infant is Rh-positive should be given Rh immune globulin (RhoGAM) within 72 hours after childbirth to prevent sensitization.

The nurse would recommend the use of which supplement as a primary prevention strategy to prevent neural tube defects in pregnant women?

A) Calcium B) Folic acid C) Vitamin C D) Iron Ans: B Feedback: Prevention of neural tube defects in the offspring of pregnant women via the use of folic acid is an example of a primary prevention strategy. Calcium, vitamin C, and iron have no effect on the prevention of neural tube defects.

When integrating the principles of family-centered care for a pregnant woman and her family, the nurse would integrate understanding of which of the following?

A) Childbirth is viewed as a medical event. B) Families are unable to make informed choices. C) Childbirth results in changes in relationships. D) Families require little information to make appropriate decisions. Ans: C Feedback: Family-centered care is based on the following principles. Childbirth affects the entire family and relationships will change. Childbirth is viewed as a normal, healthy event in the life of the family. Families are capable of making decisions about their own care if given adequate information and professional support.

The nurse is providing care to an ill child and his family. Which of the following activities would deviate from the basic principles of case management?

A) Collaborating with the family throughout the care path B) Focusing on both the client's and the family's needs C) Coordinating care provided by the interdisciplinary team D) Ensuring quality care regardless of the cost Ans: D Feedback: Ensuring quality care regardless of the cost is not part of case management, but providing cost-effective, high-quality care is. Collaborating with the family throughout the care path, coordinating care provided by the interdisciplinary team, and focusing on client and family needs are key components of case management that increase family satisfaction.

A nursing instructor is presenting a class for a group of students about community-based nursing interventions. The instructor determines that additional teaching is needed when the students identify which of the following as a role of the community-based nurse?

A) Conducting childbirth education classes B) Counseling a pregnant teen with anemia C) Consulting with a parent of a child who is vomiting D) Performing epidemiologic investigations Ans: D Feedback: Community health nurses, not community-based nurses, perform epidemiologic investigations to help analyze and develop health policy and community health initiatives. Community-based nurses are involved in teaching, such as childbirth education classes; counseling, such as with a pregnant teenager; and consulting with clients.

When assuming the role of discharge planner for a child requiring ventilator support at home, the nurse would do which of the following?

A) Confer with the school nurse or teacher. B) Teach new self-care skills to the child. C) Determine if there is a need for backup power. D) Discuss coverage with the family's insurance company. Ans: C Feedback: Discharge planning involves the development and implementation of a comprehensive plan for the safe discharge of a client from a health care facility and for continuing safe and effective care in the community and at home. Thus as a discharge planner, the nurse should establish if there is a need for backup power to ensure the safety of the child. Conferring with a school nurse or teacher and dealing with insurance companies are case management activities. Teaching self-care skills is an activity associated with the nurse's role as an educator.

The nurse who is scheduled to work in a clinic in a Hispanic neighborhood takes time to research Hispanic cultural norms to better provide culturally competent care to people at work. This behavior is an example of which of the following cultural components?

A) Cultural awareness B) Cultural knowledge C) Cultural skills D) Cultural encounter Ans: B Feedback: Cultural knowledge is the acquisition of information about other cultures from a variety of sources. Cultural awareness is an exploration of one's own culture and how values, beliefs, and behaviors have influenced personal life. Cultural skills and practices provide for the incorporation of knowledge of cultural background, including specific practices for health, and a cultural encounter is participation in and interaction with persons of diverse cultural backgrounds.

A group of nurses is engaged in developing cultural competence. The students demonstrate achievement of this goal after developing which of the following?

A) Cultural knowledge B) Cultural skills C) Cultural encounter D) Cultural awareness Ans: C Feedback: The steps to developing cultural competence are cultural awareness, cultural knowledge, cultural skills, and, last, cultural encounter.

A woman who is 12 hours postpartum had a pulse rate around 80 beats per minute during pregnancy. Now, the nurse finds a pulse of 60 beats per minute. Which of these actions should the nurse take?

A) Document the finding, as it is a normal finding at this time. B) Contact the physician, as it indicates early DIC. C) Contact the physician, as it is a first sign of postpartum eclampsia. D) Obtain an order for a CBC, as it suggests postpartum anemia. Ans: A Pulse rates of 40 to 80 beats per minute (bmp) are normal during the first week after birth. This pulse rate is called puerperal bradycardia. During pregnancy, the heavy gravid uterus causes a decreased flow of venous blood to the heart. After giving birth, there is an increase in intravascular volume. The cardiac output is most likely caused by an increased stroke volume from the venous return now. The elevated stroke volume leads to a decreased heart rate.

A) Early parent-infant contact following birth B) Expert medical care for the labor and birth C) Good nutrition and prenatal care during pregnancy D) Grandparent involvement in infant care after birth Ans: A Optimal bonding requires a period of close contact between the parents and newborn within the first few minutes to a few hours after birth. Expert medical care, nutrition and prenatal care, and grandparent involvement are not associated with the promotion of bonding.

The parents of an 8-year-old with cancer are telling the nurse their problems and successes when caring for their child. In response, the nurse arranges for social services to meet with the parents to help them obtain financial assistance for the equipment and supplies. The nurse is acting in which role?

A) Educator B) Advocate C) Case manager D) Direct care provider Ans: B Feedback: The nurse is acting as an advocate, representing the client and family to a third party, by ensuring that the family has the resources and services to provide care for their child. The nurse acts as a direct care provider through assessment, observation of physical care, and the actual provision of physical care. The role of educator would require the nurse to give rather than receive information. Case management involves coordinating elements of a nursing plan of care.

A nurse is developing cultural competence. Which of the following indicates that the nurse is in the process of developing cultural knowledge? Select all that apply.

A) Examining personal sociocultural heritage B) Reviewing personal biases and prejudices C) Seeking resources to further understanding of other cultures D) Becoming familiar with other culturally diverse lifestyles E) Performing a competent cultural assessment F) Advocating for social justice to eliminate disparities Ans: C, D Feedback: When developing cultural knowledge, the nurse would seek resources to increase understanding of different sociocultural groups and become familiar with culturally/ethnically diverse groups, worldviews, beliefs, practices, lifestyles, and problem-solving styles. Examining one's personal sociocultural heritage and personal biases and prejudices are components involved with developing cultural awareness. Performing a competent cultural assessment and advocating for social justice are components involved with developing cultural skills.

A postpartum client has a fourth-degree perineal laceration. The nurse would expect which of the following medications to be ordered?

A) Ferrous sulfate (Feosol) B) Methylergonovine (Methergine) C) Docusate (Colace) D) Bromocriptine (Parlodel) Ans: C A stool softener such as docusate (Colace) may promote bowel elimination in a woman with a fourth-degree laceration, who may fear that bowel movements will be painful. Ferrous sulfate would be used to treat anemia. However, it is associated with constipation and would increase the discomfort when the woman has a bowel movement. Methylergonovine would be used to prevent or treat postpartum hemorrhage. Bromocriptine is used to treat hyperprolactinemia.

The nurse is caring for a 14-year-old girl with multiple health problems. Which of the following activities would best reflect evidence-based practice by the nurse?

A) Following blood pressure monitoring recommendations B) Determining how often vital signs are monitored C) Using hospital protocol for ordering diagnostic tests D) Deciding on the medication dose Ans: A Feedback: Using hospital protocol for ordering a diagnostic test, determining how often vital signs are monitored, and deciding on the medication dose would be the physician's responsibility. However, following blood pressure monitoring recommendations would be part of evidence-based practice reflected in the nursing care delivered.

A nurse is observing a postpartum woman and her partner interact with their newborn. The nurse determines that the parents are developing parental attachment with their newborn when they demonstrate which of the following? (Select all that apply.)

A) Frequently ask for the newborn to be taken from the room B) Identify common features between themselves and the newborn C) Refer to the newborn as having a monkey-face D) Make direct eye contact with the newborn E) Refrain from checking out the newborn's features Ans: B, D Positive behaviors that indicate attachment include identifying common features and making direct eye contact with the newborn. Asking for the newborn to be taken out of the room, referring to the newborn as having a monkey-face and refraining from checking out the newborn's features are negative attachment behaviors.

A nurse is reviewing the medical record of a postpartum client. The nurse identifies that the woman is at risk for a postpartum infection based on which of the following? (Select all that apply.)

A) History of diabetes B) Labor of 12 hours C) Rupture of membranes for 16 hours D) Hemoglobin level 10 mg/dL E) Placenta requiring manual extraction Ans: A, D, E Risk factors for postpartum infection include history of diabetes, labor over 24 hours, hemoglobin less than 10.5 mg/dL, prolonged rupture of membranes (more than 24 hours), and manual extraction of the placenta.

The nurse is making a home visit to a client who had a cesarean birth 3 days ago. Assessment reveals that she is complaining of intermittent pain, rating it as 8 on a scale of 1 to 10. She states, "I'm pretty tired. And with this pain, I haven't been drinking and eating like I should. The medication helps a bit but not much. My mom has been helping with the baby." Her incision is clean, dry, and intact. Which nursing diagnosis would the nurse identify as the priority for this client?

A) Impaired skin integrity related to cesarean birth incision B) Fatigue related to effects of surgery and caretaking activities C) Imbalanced nutrition, less than body requirements, related to poor fluid and food intake D) Acute pain related to incision and cesarean birth Ans: D Feedback: The client reports a pain rating of 8 out of 10 and states that the medication is helping only a bit. She also mentions that the pain is interfering with her ability to eat and drink. Therefore, the priority nursing diagnosis is acute pain related to incision and cesarean birth. Her incision is clean, dry, and intact, so impaired skin integrity is not the problem. She is fatigued, but her complaints of pain supersede her fatigue. Although her nutritional intake is reduced, it is due to the pain.

After teaching a group of students about the changes in health care delivery and funding, which of the following, if identified by the group as a current trend seen in the maternal and child health care settings, would indicate that the teaching was successful?

A) Increase in ambulatory care B) Decrease in family poverty level C) Increase in hospitalization of children D) Decrease in managed care Ans: A Feedback: The health care system has moved from reactive treatment strategies in hospitals to a proactive approach in the community, resulting in an increased emphasis on health promotion and illness prevention in the community through the use of community-based settings such as ambulatory care. Poverty levels have not decreased and the hospitalization of children has not increased. Case management also is a primary focus of care.

When explaining community-based nursing versus nursing in the acute care setting to a group of nursing students, the nurse describes the challenges associated with community-based nursing. Which of the following would the nurse include?

A) Increased time available for education B) Improved access to resources C) Decision making in isolation D) Greater environmental structure Ans: C Feedback: Community-based nurses often have to make decisions in isolation. This is in contrast to the acute care setting, where other health care professionals are readily available. Nursing care and procedures in the community also are becoming more complex and time-consuming, leaving limited time for education. Nurses working in the community have fewer resources available and the environment is less structured and controlled when compared to the acute care setting.

A nurse is completing a postpartum assessment. Which finding would alert the nurse to a potential problem?

A) Lochia rubra with a fleshy odor B) Respiratory rate of 16 breaths per minute C) Temperature of 101° F D) Pain rating of 2 on a scale from 0 to 10 Ans: C : Typically, the new mother's temperature during the first 24 hours postpartum is within the normal range. Some women experience a slight fever, up to 38º C (100.4º F), during the first 24 hours. A temperature above 38º C (100.4º F) at any time or an abnormal temperature after the first 24 hours may indicate infection and must be reported. Foul-smelling lochia or lochia with an unexpected change in color or amount, shortness of breath, or respiratory rate below 16 or above 20 breaths per minute would also be a cause for concern. The goal of pain management is to have the woman's pain scale rating maintained between 0 to 2 points at all times, especially after breast-feeding.

A) Mother placing the newborn next to bare breast. B) Mother making eye-to-eye contact with the newborn C) Mother gently stroking the newborn's face D) Mother holding the newborn upright at the shoulder Ans: B The en face position is characterized by the mother interacting with the newborn through eye-to-eye contact while holding the newborn.

Which of the following factors in a client's history would alert the nurse to an increased risk for postpartum hemorrhage?

A) Multiparity, age of mother, operative delivery B) Size of placenta, small baby, operative delivery C) Uterine atony, placenta previa, operative procedures D) Prematurity, infection, length of labor Ans: C Risk factors for postpartum hemorrhage include a precipitous labor less than 3 hours, uterine atony, placenta previa or abruption, labor induction or augmentation, operative procedures such as vacuum extraction, forceps, or cesarean birth, retained placental fragments, prolonged third stage of labor greater than 30 minutes, multiparity, and uterine overdistention such as from a large infant, twins, or hydramnios.

To decrease the pain associated with an episiotomy immediately after birth, which action by the nurse would be most appropriate?

A) Offer warm blankets. B) Encourage the woman to void. C) Apply an ice pack to the site. D) Offer a warm sitz bath. Ans: C An ice pack is the first measure used after a vaginal birth to provide perineal comfort from edema, an episiotomy, or lacerations. Warm blankets would be helpful for the chills that the woman may experience. Encouraging her to void promotes urinary elimination and uterine involution. A warm sitz bath is effective after the first 24 hours.

The nurse is assisting a postpartum woman out of bed to the bathroom for a sitz bath. Which of the following would be a priority?

A) Placing the call light within her reach B) Teaching her how the sitz bath works C) Telling her to use the sitz bath for 30 minutes D) Cleaning the perineum with the peri-bottle Ans: A Tremendous hemodynamic changes are taking place within the woman, and safety must be a priority. Therefore, the nurse makes sure that the emergency call light is within her reach should she become dizzy or lightheaded. Teaching her how to use the sitz bath, including using it for 15 to 20 minutes, is appropriate but can be done once the woman's safety is ensured. The woman should clean her perineum with a peri-bottle before using the sitz bath, but this can be done once the woman's safety needs are met.

A postpartum woman is having difficulty voiding for the first time after giving birth. Which of the following would be least effective in helping to stimulate voiding?

A) Pouring warm water over her perineal area B) Having her hear the sound of water running nearby C) Placing her hand in a basin of cool water D) Standing her in the shower with the warm water on Ans: C Helpful measures to stimulate voiding include placing her hand in a basin of warm water, pouring warm water over her perineal area, hearing the sound of running water nearby, blowing bubbles through a straw, standing in the shower with the warm water turned on, and drinking fluids.

A) Presence of lochia serosa B) Frequent scant voiding C) Fundus firm, below umbilicus D) Milk filling in both breasts Ans: B Infrequent or insufficient voiding may be a sign of infection and is not a normal finding on the second postpartum day. Lochia serosa, a firm fundus below the umbilicus, and milk filling the breasts are expected findings.

After teaching a group of students about risk factors associated with postpartum hemorrhage, the instructor determines that the teaching was successful when the students identify which of the following as a risk factor? (Select all that apply.)

A) Prolonged labor B) Placenta previa C) Null parity D) Hydramnios E) Labor augmentation Ans: B, D, E Risk factors for postpartum hemorrhage include precipitous labor less than 3 hours, placenta previa or abruption, multiparity, uterine overdistention such as with a large infant, twins, or hydramnios, and labor induction or augmentation. Prolonged labor over 24 hours is a risk factor for postpartum infection.

Which action would the nurse include in a primary prevention program in the community to help reduce the incidence of HIV infection?

A) Provide treatment for clients who test positive for HIV. B) Monitor viral load counts periodically. C) Educate clients about how to practice safe sex. D) Offer testing for clients who practice unsafe sex. Ans: C Feedback: Primary prevention involves preventing disease before it occurs. Therefore, educating clients about safe-sex practices would be an example of a primary prevention strategy. Providing treatment for clients who test positive for HIV, monitoring viral loads periodically, and offering testing for clients who practice unprotected sex are examples of secondary preventive strategies, which focus on early detection and treatment of adverse health conditions.

After teaching parents about their newborn, the nurse determines that the teaching was successful when they identify the development of a close emotional attraction to a newborn by parents during the first 30 to 60 minutes after birth as which of the following?

A) Reciprocity B) Engrossment C) Bonding D) Attachment Ans: C The development of a close emotional attraction to the newborn by parents during the first 30 to 60 minutes after birth describes bonding. Reciprocity is the process by which the infant's capabilities and behavioral characteristics elicit a parental response. Engrossment refers to the intense interest during early contact with a newborn. Attachment refers to the process of developing strong ties of affection between an infant and significant other.

A) Resumption of sexual intercourse about two weeks after delivery B) Possible experience of fluctuations in sexual interest C) Use of a water-based lubricant to ease vaginal discomfort D) Use of combined hormonal contraceptives for the first three weeks E) Possibility of increased breast sensitivity during sexual activity Ans: B, C, E Typically, sexual intercourse can be resumed once bright-red bleeding has stopped and the perineum is healed from an episiotomy or lacerations. This is usually by the third to the sixth week postpartum. Fluctuations in sexual interest are normal. In addition, breast-feeding women may notice a let-down reflex during orgasm and find that breasts are very sensitive when touched by the partner. Precoital vaginal lubrication may be impaired during the postpartum period, especially in women who are breast-feeding. Use of water-based gel lubricants (KY jelly, Astroglide) can help. The Centers for Disease Control and Prevention recommend that postpartum women not use combined hormonal contraceptives during the first 21 days after childbirth because of the high risk for venous thromboembolism (VTE) during this period.

The nurse is assessing a postpartum client's lochia and finds that there is about a 4-inch stain on the perineal pad. The nurse documents this finding as which of the following?

A) Scant B) Light C) Moderate D) Large Ans: B The amount of lochia is described as light or small for an approximately 4-inch stain. Scant refers to a 1- to 2-inch stain of lochia; moderate refers to a 4- to 6-inch stain; and large or heavy refers to a pad that is saturated within 1 hour after changing.

A nursing student is reviewing information about documenting client care and education in the medical record and the purposes that it serves. The student demonstrates a need for additional study when the student identifies which of the following as a reason for documentation?

A) Serves as a communication tool for the interdisciplinary team B) Demonstrates education the family has received if legal matters arise C) Permits others access to allow refusal of medical insurance coverage D) Verifies meeting client education standards set by the Joint Commission Ans: C Feedback: Medical records are not in place for others to view for the sole purpose of denying medical coverage. Documenting client care and education (medical records) serves four main purposes. The client's medical record serves as a communication tool that the entire interdisciplinary team can use to keep track of what the client and family have learned. Next, it serves to testify to the education the family has received if legal matters arise. Third, it verifies standards set by JCAHO and other accrediting bodies that hold health care providers accountable for client education activities. Last, it informs third-party payers of goods and services provided for reimbursement purposes.

The nurse is caring for a 2-week-old girl with a metabolic disorder. Which of the following activities would deviate from the characteristics of family-centered care?

A) Softening unpleasant information or prognoses B) Evaluating and changing the nursing plan of care C) Collaborating with the child and family as equals D) Showing respect for the family's beliefs and wishes Ans: A Feedback: Family-centered care requires that the nurse provide open and honest information to the child and family. It is inappropriate to soften unpleasant information or prognoses. Evaluating and changing the nursing plan of care to fit the needs of the child and family, collaborating with them as equals, and showing respect for their beliefs and wishes are guidelines for family-centered care.

A) Superficial structures above the muscle B) Through the perineal muscles C) Through the anal sphincter muscle D) Through the anterior rectal wall Ans: C A third-degree laceration extends through the anal sphincter muscle. A first-degree laceration involves only the skin and superficial structures above the muscle. A second-degree laceration extends through the perineal muscles. A fourth-degree laceration continues through the anterior rectal wall.

A nurse is preparing a teaching plan for a woman who is pregnant for the first time. Which of the following would the nurse incorporate into the teaching plan to foster the client's learning? Select all that apply.

A) Teach "survival skills" first. B) Use simple, nonmedical language. C) Refrain from using a hands-on approach. D) Avoid repeating information. E) Use visual materials such as photos and videos. Ans: A, B, E Feedback: To foster learning, the nurse should slow down and repeat information often; speak in a conversational style using plain, nonmedical language; prioritize information, teaching "survival skills" first; use visuals; and use an interactive, "hands-on" approach.

After teaching a group of students about the different levels of prevention, the instructor determines a need for additional teaching when the students identify which of the following as an activity at the tertiary prevention level in community-based health care?

A) Teaching women to take folic acid supplements to prevent neural tube defects B) Working with women who are victims of domestic violence C) Working with clients at an HIV clinic to provide nutritional and CAM therapies D) Teaching hypertensive clients to monitor blood pressure Ans: A Feedback: Primary prevention involves preventing a disease or condition before it occurs, such as teaching women about the importance of taking folic acid supplements to prevent neural tube defects. Secondary prevention is the early detection of disease or conditions. Working with women who are victims of domestic violence, clients at an HIV clinic, or hypertensive clients are all examples of tertiary prevention, which is designed to reduce or limit the progression of a permanent, irreversible disease or disability.

The nurse is caring for a 4-year-old boy with Ewing's sarcoma who is scheduled for a CT scan tomorrow. Which of the following best reflects therapeutic communication?

A) Telling him he will get a shot when he wakes up tomorrow morning B) Telling him how cool he looks in his baseball cap and pajamas C) Using family-familiar words and soft words when possible D) Describing what it is like to get a CT scan using words he understands Ans: D Feedback: Describing what it is like to get a CT scan using age-appropriate words is the best example of therapeutic communication. It is goal-directed, focused, and purposeful communication. Using family-familiar words and soft words is a good teaching technique. Telling him how cool he looks in his baseball cap and pajamas is not goal-directed communication. Telling the child he will get a shot when he wakes up could keep him awake all night.

A nurse is considering a change in employment from the acute care setting to community-based nursing. The nurse is focusing her job search on ambulatory care settings. Which of the following would the nurse most likely find as a possible setting? Select all that apply.

A) Urgent care center B) Hospice care C) Immunization clinic D) Physician's office E) Day surgery center F) Nursing home Ans: A, D, E Feedback: Ambulatory care settings include physician's offices, day surgery centers, and freestanding urgent care centers. Hospice may be a part of home health care services or long-term care. Immunization clinics are examples of health department services. Nursing homes are examples of long-term care settings.

A postpartum woman who is breast-feeding tells the nurse that she is experiencing nipple pain. Which of the following would be least appropriate for the nurse to suggest?

A) Use of a mild analgesic about 1 hour before breast-feeding B) Application of expressed breast milk to the nipples C) Application of glycerin-based gel to the nipples D) Reinstruction about proper latching-on technique Ans: A Nipple pain is difficult to treat, although a wide variety of topical creams, ointments, and gels are available to do so. This group includes beeswax, glycerin-based products, petrolatum, lanolin, and hydrogel products. Many women find these products comforting. Beeswax, glycerin-based products, and petrolatum all need to be removed before breast-feeding. These products should be avoided in order to limit infant exposure because the process of removal may increase nipple irritation. Mild analgesics such as acetaminophen or ibuprofen are considered relatively safe for breast-feeding mothers. Applying expressed breast milk to nipples and allowing it to dry has been suggested to reduce nipple pain. Usually the pain is due to incorrect latch-on and/or removal of the nursing infant from the breast. Early assistance with breast-feeding to ensure correct positioning can help prevent nipple trauma. In addition, applying expressed milk to nipples and allowing it to dry has been suggested to result in less nipple pain for many women.

While a nurse is obtaining a health history, the client tells the nurse that she practices aromatherapy. The nurse interprets this as which of the following?

A) Use of essential oils to stimulate the sense of smell to balance the mind and body B) Application of pressure to specific points to allow self-healing C) Use of deep massage of areas on the foot or hand to rebalance body parts D) Participation in chanting and praying to promote healing Ans: A Feedback: Aromatherapy involves the use of essential oils to stimulate the sense of smell to balance the mind, body, and spirit. Acupressure involves the application of pressure to specific points to restore balance and allow self-healing to take over. Reflexology is the use of deep massage on identified points of the foot or hand to scan and rebalance body parts that correspond to each point. Spiritual healing involves praying, chanting, presence, laying on of hands, rituals, and meditation to assist in healing.

A postpartum woman is diagnosed with metritis. The nurse interprets this as an infection involving which of the following? (Select all that apply.) A) Endometrium B) Decidua C) Myometrium D) Broad ligament E) Ovaries F) Fallopian tubes

A, B, C

A group of students are reviewing risk factors associated with postpartum hemorrhage. The students demonstrate understanding of the information when they identify which of the following as associated with uterine tone? (Select all that apply.) A) Rapid labor B) Retained blood clots C) Hydramnios D) Operative birth E) Fetal malpostion

A, C

The nurse is developing a discharge teaching plan for a postpartum woman who has developed a postpartum infection. Which of the following would the nurse most likely include in this teaching plan? (Select all that apply.) A) Taking the prescribed antibiotic until it is finished B) Checking temperature once a week C) Washing hands before and after perineal care D) Handling perineal pads by the edges E) Directing peribottle to flow from back to front

A, C, D

Assessment of a postpartum woman experiencing postpartum hemorrhage reveals mild shock. Which of the following would the nurse expect to assess? (Select all that apply.) A) Diaphoresis B) Tachycardia C) Oliguria D) Cool extremities E) Confusion

A, D

A nurse is reviewing the medical record of a postpartum client. The nurse identifies that the woman is at risk for a postpartum infection based on which of the following? (Select all that apply.) A) History of diabetes B) Labor of 12 hours C) Rupture of membranes for 16 hours D) Hemoglobin level 10 mg/dL E) Placenta requiring manual extraction

A, D, E

A home health care nurse is assessing a postpartum woman who was discharged 2 days ago. The woman tells the nurse that she has a low-grade fever and feels lousy. Which of the following findings would lead the nurse to suspect metritis? (Select all that apply.) A) Lower abdominal tenderness B) Urgency C) Flank pain D) Breast tenderness E) Anorexia

A, E

A new mother is changing the diaper of her 12-hour-old newborn and asks why the stool is black and sticky. Which response by the nurse would be most appropriate?

A. "I'll take a sample and check it for possible bleeding." B. "This is unusual, and I need to report this to your pediatrician. " C. "You probably took iron during your pregnancy and that is what causes this type of stool." D. "This is meconium stool and is normal for a newborn."- correct

A nurse is describing the advantages and disadvantages of circumcision to a group of expectant parents. Which statement by the parents indicates effective teaching?

A. "Sexually transmitted infections are more common in circumcised males." B. "Urinary tract infections are more easily treated in circumcised males." C. "The rate of penile cancer is less for circumcised males."- correct D. "Circumcision is a risk factor for acquiring HIV infection."

A woman who gave birth 24 hours ago tells the nurse, "I've been urinating so much over the past several hours." Which response by the nurse would be most appropriate?

A. "The anesthesia that you received is wearing off and your bladder is working again." B. "You must have an infection, so let me get a urine specimen." C. "Your body is undergoing many changes that cause your bladder to fill quickly."- correct D. "Your uterus is not contracting as quickly as it should."

A postpartum client who is bottle feeding her newborn asks, "When should my period return?" Which response by the nurse would be most appropriate?

A. "You don't have to worry about that now. It'll be quite a while." B. "It varies, but you can estimate it returning in about 7 to 9 weeks."- correct C. "You won't have to worry about it returning for at least 3 months." D. "It's difficult to say, but it will probably return in about 2 to 3 weeks."

A postpartum woman who has experienced diastasis recti asks the nurse about what to expect related to this condition. Which response by the nurse would be most appropriate?

A. "You'll notice that this will fade to silvery lines." B. "Expect the color to lighten somewhat." C. "Exercise will help to improve the muscles."- correct D. "You'll notice that your shoe size will increase."

A client who is breast-feeding her newborn tells the nurse, "I notice that when I feed him, I feel fairly strong contraction-like pain. Labor is over. Why am I having contractions now?" Which response by the nurse would be most appropriate?

A. "Your body is responding to the events of labor, just like after a tough workout." B. "Let me check your vaginal discharge just to make sure everything is fine." C. "The baby's sucking releases a hormone that causes the uterus to contract."- correct D. "Your uterus is still shrinking in size; that's why you're feeling this pain."

A. 4 to 6 ounces B. 6 to 8 ounces C. 2 to 4 ounces- correct D. 1 to 2 ounces

The nurse is assessing the respirations of several newborns. The nurse would notify the health care provider for the newborn with which respiratory rate at rest?

A. 68 breaths per minute- correct B. 46 breaths per minute C. 38 breaths per minute D. 54 breaths per minute

Which method would be most effective in evaluating the parents' understanding about their newborn's care?

A. Allow the parents to state the steps of the care. B. Routinely assess the newborn for cleanliness. C. Observe the parents performing the procedures.- correct D. Demonstrate all infant care procedures.

While making rounds in the nursery, the nurse sees a 6-hour-old baby girl gagging and turning bluish. What would the nurse do first?

A. Aspirate the oral and nasal pharynx with a bulb syringe.

A nurse is assessing a newborn's reflexes. The nurse strokes the lateral sole of the newborn's foot from the heel to the ball of the foot to elicit which reflex?

A. Babinski

After the birth of a newborn, which action would the nurse do first to assist in thermoregulation?

A. Check the newborn's temperature. B. Dry the newborn thoroughly.- correct C. Put a hat on the newborn's head. D. Wrap the newborn in a blanket.

A nurse is observing a new mother interacting with her newborn. Which statement would alert the nurse to the potential for impaired bonding between mother and newborn?

A. He looks like a frog to me

A nurse is teaching a new mother about her newborn's immune status. The nurse determines that the teaching was successful when the mother states which immunoglobulin as having crossed the placenta?

A. IgG

Just after delivery, a newborn's axillary temperature is 94° F (34.4° C). What action would be most appropriate?

A. Observe the newborn every hour. B. Assess the newborn's gestational age. C. Notify the primary care provider if the temperature goes lower. D. Rewarm the newborn gradually.- correct

Method would be most effective in evaluating the parents' understanding about their newborn's care?

A. Observe the parents performing the procedures.- correct B. Demonstrate all infant care procedures. C. Allow the parents to state the steps of the care. D. Routinely assess the newborn for cleanliness.

A woman who is 12 hours postpartum had a pulse rate around 80 beats per minute during pregnancy. Now, the nurse finds a pulse of 66 beats per minute. Which of these actions should the nurse take?

A. Obtain an order for a CBC, as it suggests postpartum anemia. B. Document the finding, as it is a normal finding at this time.- correct C. Contact the primary care provider, as it indicates early DIC. D. Contact the primary care provider, as it is a first sign of postpartum eclampsia.

The nurse administers vitamin K intramuscularly to the newborn based on which rationale?

A. Promote blood clotting.

A nurse is teaching a postpartum client how to do muscle-clenching exercises for the perineum. The client asks the nurse, "Why do I need to do these exercises?" Which reason would the nurse most likely incorporate into the response?

A. alleviates perineal pain B. improves pelvic floor tone- correct C. promotes uterine involution D. reduces lochia

A nurse is preparing a couple and their newborn for discharge. Which instructions would be most appropriate for the nurse include in discharge teaching?

A. allowing the infant to cry for at least an hour before picking him or her up B. encouraging daily outings to the shopping mall with the newborn C. demonstrating comfort measures to quiet a crying infant- correct D. introducing solid foods immediately to increase sleep cycle

After teaching parents about their newborn, the nurse determines that the teaching was successful when they identify which concept as reflecting the enduring nature of their relationship involving placing the infant at the center of their lives and finding their own way to assume the parental identity?

A. commitment- correct B. bonding C. attachment D. reciprocity

The nurse dries the neonate thoroughly and promptly changes wet linens. The nurse does so to minimize heat loss via which mechanism?

A. conduction B. radiation C. evaporation- correct D. convection

Prior to discharging a 24-hour-old newborn, the nurse assesses her respiratory status. What would the nurse expect to assess?

A. crackles on auscultation B. respiratory rate 45, irregular- correct C. costal breathing pattern D. nasal flaring, rate 65

When assessing a newborn 1 hour after birth, the nurse measures an axillary temperature of 95.8° F (35.4° C), an apical pulse of 114 beats/minute, and a respiratory rate of 60 breaths/minute. The nurse would identify which area as the priority?

A. deficient fluid volume B. risk for infection C. hypothermia- correct D. impaired parenting

A nurse is observing the interaction between a new father and his newborn. The nurse determines that engrossment has yet to occur based on which behavior?

A. demonstrates pleasure when touching or holding the newborn B. is able to distinguish his newborn from others in the nursery C. shows feelings of pride with the birth of the newborn D. identifies imperfections in the newborn's appearance- correct

A nurse is making a home visit to a postpartum woman who delivered a healthy newborn 4 days ago. The woman's breasts are swollen, hard, and tender to the touch. The nurse documents this finding as:

A. engorgement.- correct B. involution. C. mastitis. D. engrossment.

A nurse is reviewing information about maternal and paternal adaptations to the birth of a newborn. The nurse observes the parents interacting with their newborn physically and emotionally. The nurse documents this as:

A. engrossment. B. puerperium. C. lactation. D. attachment.- attachment

A woman who delivered a healthy newborn several hours ago asks the nurse, "Why am I perspiring so much?" The nurse integrates knowledge that a decrease in which hormone plays a role in this occurrence?

A. estrogen

A newborn is scheduled to undergo a screening test for phenylketonuria (PKU). The nurse prepares to obtain the blood sample from the newborn's:

A. finger. B. scalp vein. C. umbilical vein. D. heel.- correct

A primipara client gave birth vaginally to a healthy newborn girl 12 hours ago. The nurse palpates the client's fundus. Which finding would the nurse identify as expected?

A. four fingerbreadths below the umbilicus B. two fingerbreadths above the umbilicus C. at the level of the umbilicus- correct D. two fingerbreadths below the umbilicus

A. frequently ask for the newborn to be taken from the room B. identify common features between themselves and the newborn- correct C. refer to the newborn as having a monkey-face D. refrain from checking out the newborn's features E. make direct eye contact with the newborn- correct

A. grandparent involvement in infant care after birth B. good nutrition and prenatal care during pregnancy C. early parent-infant contact following birth- correct D. expert medical care for the labor and birth

When caring for a mother who has had a cesarean birth, the nurse would expect the client's lochia to be:

A. greater than after a vaginal delivery. B. saturated with clots and mucus. C. less than after a vaginal delivery.- correct D. about the same as after a vaginal delivery.

A. hPL B. estrogen- correct C. progesterone D. hCG

When assessing a postpartum woman, the nurse suspects the woman is experiencing a problem based on which finding?

A. increased levels of clotting factors B. elevated white blood cell count C. acute decrease in hematocrit- correct D. pulse rate of 60 beats/minute

A nurse is assessing a newborn who is about 41/2 hours old. The nurse would expect this newborn to exhibit which behavior? Select all that apply.

A. interest in environmental stimuli D. passage of meconium

A newborn is experiencing cold stress. Which findings would the nurse expect to assess? Select all that apply.

A. jaundice C. hypoglycemia E. respiratory distress

The nurse is inspecting the external genitalia of a male newborn. Which finding would alert the nurse to a possible problem?

A. large scrotum B. absence of engorgement C. limited rugae- correct D. palpable testes in scrotal sac

The nurse is auscultating a newborn's heart and places the stethoscope at the point of maximal impulse at which location?

A. lateral to the midclavicular line at the fourth intercostal space- correct B. just superior to the nipple, at the midsternum C. directly adjacent to the sternum at the second intercostals space D. at the fifth intercostal space to the left of the sternum

When describing the neurologic development of a newborn to his parents, the nurse would explain that it occurs in which fashion?

A. lateral-to-medial B. outward-to-inward C. distal-caudal D. head-to-toe- correct

A. milk filling in both breasts B. frequent scant voidings- correct C. fundus firm, below umbilicus D. presence of lochia serosa

The nurse assesses a 1-day-old newborn. Which finding would the nurse interpret as suggesting an issue with oxygenation?

A. nasal flaring- correct B. respiratory rate of 54 breaths/minute C. abdominal breathing D. acrocyanosis

A nurse is preparing a presentation about changes in the various body systems during the postpartum period and their effects for a group of new mothers. The nurse explains which event as influencing a postpartum woman's ability to void? Select all that apply.

A. need for an episiotomy B. decreased bladder tone from regional anesthesia- correct C. generalized swelling of the perineum- correct D. use of oxytocin to augment labor- correct E. use of an opioid anesthetic during labor

A client expresses concern that her 2-hour-old newborn is sleepy and difficult to awaken. The nurse explains that this behavior indicates:

A. normal progression of behavior.

Assessment of a newborn reveals uneven gluteal (buttocks) skin creases and a "clunk" when Ortolani maneuver is performed. What would the nurse suspect?

A. overriding of the pelvic bone B. normal newborn variation C. slipping of the periosteal joint D. developmental hip dysplasia- correct

A nurse is assessing a newborn. Which finding would alert the nurse to the possibility of respiratory distress in a newborn?

A. periodic breathing B. symmetrical chest movements C. respirations of 40 breaths/minute D. sternal retractions- correct

The nurse is assisting a postpartum woman out of bed to the bathroom for a sitz bath. Which action would be a priority?

A. placing the call light within her reach

After teaching a group of nurses during in-service program about risk factors associated with postpartum hemorrhage, the nurse determines that the teaching was successful when the group identifies which risk factors? Select all that apply.

A. prolonged labor B. labor augmentation- correct C. hydramnios- correct D. null parity E. placenta previa- correct

A nurse is working as part of a committee to establish policies to promote bonding and attachment. Which practice would be least effective in achieving this goal?

A. promoting rooming-in B. allowing unlimited visiting hours on maternity units C. encouraging infant contact immediately after birth D. offering round-the-clock nursery care for all infant- correct

A nurse is assessing a postpartum woman. Which finding would lead the nurse to suspect that a postpartum woman is having a problem?

A. pulse rate of 110 beats/minute- correct B. slightly increased hematocrit C. increased levels of clotting factors D. elevated white blood cell count

The partner of a woman who has given birth to a healthy newborn says to the nurse, "I want to be involved, but I'm not sure that I'm able to care for such a little baby." The nurse interprets this as indicating which stage?

A. reality- correct B. taking-hold C. transition to mastery D. expectations

A nurse is assessing a postpartum woman's adjustment to her maternal role. Which event would the nurse expect to occur first?

A. reestablishing relationships with others B. assuming a passive role in meeting her own needs- correct C. becoming preoccupied with the present D. demonstrating increasing confidence in care of the newborn

As part of an education program for a group of pregnant women, the nurse teaches them about the changes that occur in the respiratory system during the postpartum period. The women demonstrate understanding of the information when they identify which occurrence as a postpartum adaptation?

A. relief of rib aching- correct B. decrease in respiratory rate C. diaphragmatic elevation D. continued shortness of breath

When explaining how a newborn adapts to extrauterine life, the nurse would describe which body systems as undergoing the most rapid changes?

A. respiratory and cardiovascular- correct B. gastrointestinal and hepatic C. neurological and integumentary D. urinary and hematologic

A nurse is reviewing the medical record of a postpartum client. The nurse identifies that the woman is at risk for a postpartum infection based on which information? Select all that apply.

A. rupture of membranes for 16 hours B. history of diabetes- correct C. placenta requiring manual extraction- correct D. labor of 12 hours E. hemoglobin level 10 mg/dL- correct

A postpartum client comes to the clinic for her 6-week postpartum check-up. When assessing the client's cervix, the nurse would expect the external cervical os to appear:

A. shapeless. B. slit-like.- correct C. circular. D. triangular.

Which factor in a client's history would alert the nurse to an increased risk for postpartum hemorrhage?

A. size of placenta, small baby, operative delivery B. uterine atony, placenta previa, operative procedures- correct C. multiparity, age of mother, operative delivery D. prematurity, infection, length of labor

A nurse is assessing a postpartum woman. Which finding would lead the nurse to suspect that a postpartum woman is having a problem?

A. slightly increased hematocrit B. elevated white blood cell count C. pulse rate of 110 beats/minute- correct D. increased levels of clotting factors

A postpartum client is experiencing subinvolution. When reviewing the woman's labor and birth history, which contributor would the nurse identify as being a significant to this condition?

A. use of anesthetics- correct B. early ambulation C. breast-feeding D. short duration of labor

A nurse is developing a teaching plan for a postpartum woman who is breast-feeding about sexuality and contraception. Which information would the nurse most likely include? Select all that apply.

A. use of combined hormonal contraceptives for the first three weeks B. resumption of sexual intercourse about two weeks after delivery C. possibility of increased breast sensitivity during sexual activity- correct D. use of a water-based lubricant to ease vaginal discomfort- correct E. possible experience of fluctuations in sexual interest-correct

The nurse is providing an in-service education program to a group of home health care nurses who provide care to postpartum women. After teaching the group about the process of involution, the nurse determines that additional teaching is needed when the group identifies which process as being involved?

A. vasodilation- correct B. epithelial regeneration C. muscle fiber contraction D. catabolism

A nurse teaches a postpartum woman about her risk for thromboembolism. The nurse determines that additional teaching is required when the woman identifies which as a factor that increases her risk?

A. vessel damage B. increase in red blood cell production- correct C. immobility D. increase in clotting factors

A nurse is reviewing the laboratory test results of a newborn. Which result would the nurse identify as a cause for concern?

A. white blood cells 20,000/mm3- correct B. hemoglobin 19 g/dL C. hematocrit 52% CorrectD. platelets 75,000/uL

A nurse is preparing a presentation about ways to minimize heat loss in the newborn. Which measure would the nurse include to prevent heat loss through convection?

A. working inside an isolette as much as possible.

3. Which assessment finding could indicate hemorrhage in the postpartum patient? a. Elevated pulse rate b. Elevated blood pressure c.Firm fundus at the midline d.Saturation of two perineal pads in 4 hours

ANS: A An increasing pulse rate is an early sign of excessive blood loss. If the blood volume were diminishing, the blood pressure would decrease. A firm fundus indicates that the uterus is contracting and compressing the open blood vessels at the placental site. Saturation of one pad within the first hour is the maximum normal amount of lochial flow. Two pads within 4 hours is within normal limits.

25.The client in labor experiences a spontaneous rupture of membranes. What information related to this event must the nurse include in the client's record? a.Fetal heart rate b.Pain level c.Test results ensuring that the fluid is not urine d.The client's understanding of the event

ANS: A Charting related to membrane rupture includes the time, FHR, and character and amount of the fluid. Pain is not associated with this event. When it is obvious that the fluid is amniotic fluid, which is anticipated during labor, it is not necessary to verify this by testing. The client's understanding of the event would only need to be documented if it presents a problem.

2. Which comfort measure should a nurse use to assist a laboring woman to relax? a. Recommend frequent position changes. b.Palpate her filling bladder every 15 minutes. c.Offer warm wet cloths to use on the client's face and neck. d.Keep the room lights lit so the client and her coach can see everything.

ANS: A Frequent maternal position changes reduce the discomfort from constant pressure and promote fetal descent. A full bladder intensifies labor pain. The bladder should be emptied every 2 hours. Women in labor get hot and perspire. Cool cloths are much better. Soft indirect lighting is more soothing than irritating bright lights.

4.Which is an essential part of nursing care for a laboring client? a. Helping the woman manage the pain b.Eliminating the pain associated with labor c.Feeling comfortable with the predictable nature of intrapartal care d.Sharing personal experiences regarding labor and birth to decrease her anxiety

ANS: A Helping a client manage the pain is an essential part of nursing care because pain is an expected part of normal labor and cannot be fully relieved. Labor pain cannot be fully relieved. The labor nurse should always be assessing for unpredictable occurrences. Decreasing anxiety is important, but managing pain is a top priority.

17.The nurse thoroughly dries the infant immediately after birth primarily to: a.reduce heat loss from evaporation. b.stimulate crying and lung expansion. c.increase blood supply to the hands and feet. d.remove maternal blood from the skin surface.

ANS: A Infants are wet with amniotic fluid and blood at birth, which accelerates evaporative heat loss. Rubbing the infant does stimulate crying but is not the main reason for drying the infant. The main purpose of drying the infant is to prevent heat loss. Drying the infant after birth does not remove all of the maternal blood.

9.The nurse auscultates the fetal heart rate and determines a rate of 152 bpm. Which nursing intervention is appropriate? a.Inform the mother that the rate is normal. b.Reassess the fetal heart rate in 5 minutes because the rate is too high. c.Report the fetal heart rate to the physician or nurse-midwife immediately. d.Tell the mother that she is going to have a boy because the heart rate is fast.

ANS: A The FHR is within the normal range, so no other action is indicated at this time. The FHR is within the expected range; reassessment should occur, but not in 5 minutes. The FHR is within the expected range; no further action is necessary at this point. The gender of the baby cannot be determined by the FHR.

32.The nurse is preparing to initiate intravenous (IV) access on a patient in the active phase of labor. Which size IV cannula is best for this patient? a.18-gauge b.20-gauge c.22-gauge d.24-gauge

ANS: A The larger the number, the smaller the diameter of the cannula. The nurse should select the largest bore cannula possible. IV access is initiated for hydration prior to epidural placement and for use in an emergency. Both require the rapid administration of fluid, which is most easily accomplished with a large bore cannula.

16.If a woman's fundus is soft 30 minutes after birth, the nurse's first response should be to: a.massage the fundus. b.take the blood pressure. c.notify the physician or nurse-midwife. d.place the woman in Trendelenburg position.

ANS: A The nurse's first response should be to massage the fundus to stimulate contraction of the uterus to compress open blood vessels at the placental site, limiting blood loss. The blood pressure is an important assessment to determine the extent of blood loss but is not the top priority. Notification should occur after all nursing measures have been attempted with no favorable results. The Trendelenburg position is contraindicated for this woman at this point. This position would not allow for appropriate vaginal drainage of lochia. The lochia remaining in the uterus would clot and produce further bleeding.

22.When using the second Leopold's maneuver in fetal assessment, the nurse would palpate (the): a.both sides of the maternal abdomen. b.lower abdomen above the symphysis pubis. c.both upper quadrants of the maternal abdomen . d.lower abdomen for flexion of the presenting part.

ANS: A The second Leopold's maneuver involves determining the location of the fetal back and is performed by palpating both sides of the maternal abdomen. Palpating the lower abdomen above the symphysis pubis is the third maneuver. Palpating the upper quadrants of the maternal abdomen is the first maneuver. Palpating the lower abdomen for flexion of the presenting part is the fourth maneuver.

13.During labor a vaginal examination should be performed only when necessary because of the risk of: a. infection. b. fetal injury. c. discomfort. d. perineal trauma.

ANS: A Vaginal examinations increase the risk of infection by carrying vaginal microorganisms upward toward the uterus. Properly performed vaginal examinations should not cause fetal injury. Vaginal examinations may be uncomfortable for some women in labor, but that is not the main reason for limiting them. A properly performed vaginal examination should not cause perineal trauma.

37.A laboring client is 10 cm dilated but does not feel the urge to push. The nurse understands that according to laboring down, the advantages of waiting until an urge to push are which of the following? (Select all that apply.) a.Less maternal fatigue b.Less birth canal injuries c.Decreased pushing time d.Faster descent of the fetus e.An increase in frequency of contractions

ANS: A, B, C Delayed pushing has been shown to result in less maternal fatigue and decreased pushing time. Pushing vigorously sooner than the onset of the reflexive urge may contribute to birth canal injury because her vaginal tissues are stretched more forcefully and rapidly than if she pushed spontaneously and in response to her body's signals. A brief slowing of contractions often occurs at the beginning of the second stage.

40.Which interventions are required following an amniotomy procedure? (Select all that apply.) a.Notation related to amount of fluid expelled b.Color and consistency of fluid c.Fetal heart rate d.Maternal blood pressure e.Maternal heart rate

ANS: A, B, C Following amniotomy (AROM), observation and documentation of the amount of fluid, color and consistency, and fetal heart rate should be done. Maternal assessments related to blood pressure and heart rate are not required.

42.The nurse is caring for a client in the fourth stage of labor. Which assessment findings should the nurse identify as a potential complication? (Select all that apply.) a.Soft boggy uterus b.Maternal temperature of 99° F c.High uterine fundus displaced to the right d.Intense vaginal pain unrelieved by analgesics e.Half of a lochia pad saturated in the first hour after birth

ANS: A, C, D Assessment findings that may indicate a potential complication in the fourth stage include a soft boggy uterus, high uterine fundus displaced to the right, and intense vaginal pain unrelieved by analgesics. The maternal temperature may be slightly elevated after birth because of the inflammation to tissues, and half of a lochia pad saturated in the first hour after birth is within expected amounts.

41.The nurse is monitoring a client in the active stage of labor. Which conditions associated with fetal compromise should the nurse monitor? (Select all that apply.) a.Maternal hypotension b.Fetal heart rate of 140 to 150 bpm c.Meconium-stained amniotic fluid d.Maternal fever—38° C/100.4° F or higher e.Complete uterine relaxation of more than 30 seconds between contractions

ANS: A, C, D Conditions associated with fetal compromise include maternal hypotension (may divert blood flow away from the placenta to ensure adequate perfusion of the maternal brain and heart), meconium-stained (greenish) amniotic fluid, and maternal fever (38° C (100.4° F) or higher). Fetal heart rate of 110 to 160 bpm for a term fetus is normal. Complete uterine relaxation is a normal finding.

12.Which nursing assessment indicates that a woman who is in the second stage of labor is almost ready to give birth? a.Bloody mucous discharge increases. b.The vulva bulges and encircles the fetal head. c.The membranes rupture during a contraction. d.The fetal head is felt at 0 station during the vaginal examination.

ANS: B A bulging vulva that encircles the fetal head describes crowning, which occurs shortly before birth. Bloody show occurs throughout the labor process and is not an indication of an imminent birth. Rupture of membranes can occur at any time during the labor process and does not indicate an imminent birth. Birth of the head occurs when the station is +4. A 0 station indicates engagement.

20.Which of the following behaviors would be applicable to a nursing diagnosis of risk for injury in a client who is in labor? a.Length of second-stage labor is 2 hours. b.Client has received an epidural for pain control during the labor process. c.Client is using breathing techniques during contractions to maximize pain relief. d.Client is receiving parenteral fluids during the course of labor to maintain hydration.

ANS: B A client who has received medication during labor is at risk for injury as a result of altered sensorium, so this presentation is applicable to the diagnosis. A length of 2 hours for the second stage of labor is within the range of normal. Breathing techniques help maintain control over the labor process. Fluids administered during the labor process are used to prevent potential fluid volume deficit.

35.The labor nurse is reviewing the cardinal maneuvers with a group of nursing students. Which maneuver will immediately follow the birth of the baby's head? a.Expulsion b.Restitution c.Internal rotation d.External rotation

ANS: B After the head emerges, it realigns with the shoulders (restitution). External rotation occurs as the fetal shoulders rotate internally, aligning their transverse diameter with the anteroposterior diameter of the pelvic outlet. Expulsion occurs when the baby is completely delivered. Internal rotation occurs prior to birth of the head.

7.A woman who is gravida 3, para 2, enters the intrapartum unit. The most important nursing assessments are: a.contraction pattern, amount of discomfort, and pregnancy history. b.fetal heart rate, maternal vital signs, and the woman's nearness to birth. c.last food intake, when labor began, and cultural practices the couple desires. d.identification of ruptured membranes, the woman's gravida and para, and her support person.

ANS: B All options describe relevant intrapartum nursing assessments, but the focus assessment has priority. If the maternal and fetal conditions are normal and birth is not imminent, other assessments can be performed in an unhurried manner. Contraction pattern, amount of discomfort, and pregnancy history are important nursing assessments but do not take priority if the birth is imminent. Last food intake, when labor began, and cultural practices the couple desires is an assessment that can occur later in the admission process, if time permits. Identification of ruptured membranes, the woman's gravida and para, and her support person are assessments that can occur later in the admission process if time permits.

28.The nurse assesses the amniotic fluid. Which characteristic presents the lowest risk of fetal complications? a.Bloody b.Clear with bits of vernix caseosa c.Green and thick d.Yellow and cloudy with foul odor

ANS: B Amniotic fluid should be clear and may include bits of vernix caseosa, the creamy white fetal skin lubricant. Green fluid indicates that the fetus passed meconium before birth. The newborn may need extra respiratory suctioning at birth if the fluid is heavily stained with meconium. Cloudy, yellowish, strong-smelling, or foul-smelling fluid suggests infection. Bloody fluid may indicate partial placental separation.

21.A gravida 1, para 0, 38 weeks' gestation is in the transition phase of labor with SROM and is very anxious. Vaginal exam, 8 cm, 100% effaced, −1 station vertex presentation. She wants the nurse to keep checking her by performing repeated vaginal exams because she is sure that she is progressing rapidly. What is the best response that the nurse can provide to this client at this time? a.Performing more frequent vaginal exams will not make the labor go any quicker. b.Even though she is in transition, frequent vaginal exams must be limited because of the potential for infection. c.Tell the client that she will check every 30 minutes. d.Medicate the client as needed for anxiety so that the labor can progress.

ANS: B Data reveals a primipara in labor who is in transition (8 to 10 cm) with ruptured membranes. At this point, vaginal exams should be limited until the client feels further pressure and/or has increased bloody show, indicating fetal descent. Telling the client that performing more frequent vaginal exams will not make the labor go any quicker would not be therapeutic because this does not address client's anxiety. Telling the client that the nurse will continue checking every 30 minutes without adequate clinical indication is not the standard of care. Medicating the client is not an appropriate intervention at this time because effective communication will help alleviate stress, and the use of medications during transition may affect maternal and/or fetal well-being during birth.

11.The nurse is caring for a low-risk client in the active phase of labor. At which interval should the nurse assess the fetal heart rate? a.Every 15 minutes b.Every 30 minutes c.Every 45 minutes d.Every 1 hour

ANS: B For the fetus at low risk for complications, guidelines for frequency of assessments are at least every 30 minutes during the active phase of labor. 15-minute assessments would be appropriate for a fetus at high risk. 45-minute assessments during the active phase of labor are not frequent enough to monitor for complications. 1-hour assessments during the active phase of labor are not frequent enough to monitor for complications.

26.At 5 minutes after birth, the nurse assesses that the neonate's heart rate is 96 bpm, respirations are spontaneous, with a strong cry, body posture is flexed with vigorous movement, reflexes are brisk, and there is cyanosis of the hands and feet. What Apgar score will the nurse assign? a.7 b.8 c.9 d.10

ANS: B The neonate is assigned a score of 1 for heart rate and color and a score of 2 for respiratory effort, muscle tone, and reflex response, for a combined total of 8.

33.The nurse notes a concerning fetal heart rate pattern for a patient in active labor. The health care provider has prescribed the placement of a Foley catheter. What priority nursing action will the nurse implement when placing the catheter? a.Place the catheter as quickly as possible. b.Place a small pillow under the patient's left hip. c.Omit the use of a cleansing agent, such as Betadine. d.Set up the catheter tray before positioning the patient.

ANS: B To promote placental function, the nurse can place a small pillow or rolled blanket under the patient's left hip to shift the weight of the uterus off the aorta and inferior vena cava. Catheter placement is a sterile procedure, with very prescribed steps. Placing the catheter quickly might lead to skipping a step and place the patient at risk for infection. Use of a cleansing agent, such as Hibiclens or Betadine, is included in the catheter placement procedure to ensure a sterile area for placement. Setting up the catheter tray before positioning the patient is the standard of care.

23.A nursing priority during admission of a laboring client who has not had prenatal care is: a.obtaining admission labs. b.identifying labor risk factors. c.discussing her birth plan choices. d.explaining importance of prenatal care.

ANS: B When a client has not had prenatal care, the nurse must determine through interviewing and examination the presence of any pregnancy or labor risk factors, obtain admission labs, and discuss birth plan choices. Explaining the importance of prenatal care can be accomplished after the patient's history has been completed.

39.When taking care of a client in labor who is not considered to be at risk, which assessments should be included in the plan of care? (Select all that apply.) a.Check the DTR each shift. b.Monitor and record vital signs frequently during the course of labor. c.Document the FHR pattern, noting baseline and response to contraction patterns. d.Indicate on the EFM tracing when maternal position changes are done. e.Provide food, as tolerated, during the course of labor.

ANS: B, C, D Nursing care of the normal laboring client would include monitoring and documentation of vital signs as part of the labor assessment, documentation the FHR, checking patterns to look for assurance of fetal well-being by evaluating baseline and the fetal response to contraction patterns, and noting any position changes on the monitor tracing to evaluate the fetal response. Providing dietary offerings during the course of labor is not part of the nursing care plan because the introduction of food may lead to nausea and vomiting in response to the labor process and might affect the mode of birth.

38.Which interventions should be performed in the birth room to facilitate thermoregulation of the newborn? (Select all that apply.) a.Place the infant covered with blankets in the radiant warmer. b.Dry the infant off with sterile towels. c.Place stockinette cap on infant's head. d.Bathe the newborn within 30 minutes of birth. e.Remove wet linen as needed.

ANS: B, C, E Following birth, the newborn is at risk for hypothermia. Therefore, nursing interventions are aimed at maintaining warmth. Drying the infant off, in addition to maintaining warmth, helps stimulate crying and lung expansion, which helps in the transition period following birth. Placing a cap on the infant's head helps prevent heat loss. Removal of wet linens helps minimize further heat loss caused by exposure. Newborns should not be covered while in a radiant warmer with blankets because this will impede birth of heat transfer. Bathing a newborn should be delayed for at least a few hours so that the newborn temperature can stabilize during the transition period.

5.A client at 40 weeks' gestation should be instructed to go to a hospital or birth center for evaluation when she experiences: a.fetal movement. b.irregular contractions for 1 hour. c.a trickle of fluid from the vagina. d.thick pink or dark red vaginal mucus.

ANS: C A trickle of fluid from the vagina may indicate rupture of the membranes, requiring evaluation for infection or cord compression. The lack of fetal movement needs further assessment. Irregular contractions are a sign of false labor and do not require further assessment. Bloody show may occur before the onset of true labor. It does not require professional assessment unless the bleeding is pronounced.

31.The health care provider has asked the nurse to prepare for an amniotomy. What is the nurse's priority action with this procedure? a.Perform Leopold's maneuvers. b.Determine the color of the amniotic fluid. c.Assess the fetal heart rate immediately after the procedure. d.Prepare the patient for a change in her pain level after the procedure.

ANS: C An amniotomy is the artificial rupture of the membranes performed with an AmniHook inserted through the cervix. The FHR is assessed for at least 1 minute when the membranes rupture. The umbilical cord could be displaced in a large fluid gush, resulting in compression and interruption of blood flow through the cord. Leopold's maneuvers should be performed before the amniotomy, which will give an indication of fetal position and station. Color of the fluid can indicate fetal status; however, circulatory assessment is the priority. If the patient is in active labor, a decrease in the amount of amniotic fluid will result in increased intensity of contractions. There is no information in the stem to indicate that the patient is in labor.

1. The nurse is preparing to perform Leopold's maneuvers. Why are Leopold's maneuvers used by practitioners? a. To determine the status of the membranes b. To determine cervical dilation and effacement c. To determine the best location to assess the fetal heart rate d. To determine whether the fetus is in the posterior position

ANS: C Leopold's maneuvers are often performed before assessing the fetal heart rate (FHR). These maneuvers help identify the best location to obtain the FHR. A Nitrazine or ferning test can be performed to determine the status of the fetal membranes. Dilation and effacement are best determined by vaginal examination. Assessment of fetal position is more accurate with vaginal examination.

18.The nurse notes that a client who has given birth 1 hour ago is touching her infant with her fingertips and talking to him softly in high-pitched tones. Based on this observation, which action should the nurse take? a.Request a social service consult for psychosocial support. b.Observe for other signs that the mother may not be accepting of the infant. c.Document this evidence of normal early maternal-infant attachment behavior. d.Determine whether the mother is too fatigued to interact normally with her infant.

ANS: C Normal early maternal-infant behaviors are tentative and include fingertip touch, eye contact, and using a high-pitched voice when talking to the infant. There is no indication at this point that a social service consult is necessary. The signs are of normal attachment behavior. These are signs of normal attachment behavior; no other assessment is necessary at this point. The mother may be fatigued but is interacting with the infant in an expected manner.

30.A woman arrives to the labor and birth unit at term. She is greeted by a staff nurse and a nursing student. The student reviews the initial intake assessment with the staff nurse. Which action will the staff nurse have to correct? a.Obtain a fetal heart rate. b.Determine the estimated due date. c.Auscultate anterior and posterior breath sounds. d.Ask the client when she last had something to eat.

ANS: C On admission to the labor and birth unit, a focused assessment is performed. This includes the following: names of mother and support person(s); name of her physician or nurse-midwife if she had prenatal care; number of pregnancies and prior births, including whether the birth was vaginal or cesarean; status of membranes; expected date of birth; problems during this or other pregnancies; allergies to medications, foods, or other substances; time and type of last oral intake; maternal vital signs and FHR; and pain—location, intensity, factors that intensify or relieve, duration, whether constant or intermittent, and whether the pain is acceptable to the woman. Generally, women of childbearing years are healthy and auscultation of lung sounds can be delayed until the initial intake assessment has been completed.

15.At 1 minute after birth, the nurse assesses the newborn to assign an Apgar score. The apical heart rate is 110 bpm, and the infant is crying vigorously with the limbs flexed. The infant's trunk is pink, but the hands and feet are blue. The Apgar score for this infant is: a.7. b.8. c.9. d.10.

ANS: C The Apgar score is 9 because 1 point is deducted from the total score of 10 for the infant's blue hands and feet. The baby received 2 points for each of the categories except color. Because the infant's hands and feet were blue, this category is given a grade of 1. The baby received 2 points for each of the categories except color. Because the infant's hands and feet were blue, this category is given a grade of 1. The infant had 1 point deducted because of the blue color of the hands and feet.

36.The nurse is performing Leopold's maneuvers on a client. Which figure depicts the Leopold's maneuver that determines whether the fetal presenting part is engaged in the maternal pelvis. Refer to Figures a to d. a. b. c. d.

ANS: C The maneuver that determines whether the presenting part is engaged (widest diameter at or below a zero station) in the maternal pelvis is done by palpating the suprapubic area. Next, an attempt is made to grasp the presenting part gently between the thumb and fingers. If the presenting part is not engaged, the grasping movement of the fingers moves it upward in the uterus. If the presenting part is engaged, the fetus will not move upward in the uterus. Palpating the uterine fundus distinguishes between a cephalic and breech presentation. Holding the left hand steady on one side of the uterus while palpating the opposite side of the uterus determines on which side of the uterus is the fetal back and on which side are the fetal arms and legs. Placing your hands on each side of the uterus with fingers pointed toward the inlet determines whether the head is flexed (vertex) or extended (face).

29.The nurse assists the midwife during a vaginal examination of the client in labor. What does the nurse recognize as the primary reason that a vaginal exam is done at this time? a.To apply internal monitoring electrodes b.To assess for Goodell's sign c.To determine cervical dilation and effacement d.To determine strength of contractions

ANS: C The primary purpose of a vaginal exam during labor is to determine cervical dilation and effacement and fetal descent. Goodell's sign is assessed in early pregnancy, not during labor. Although application of monitoring electrodes is done by entering the vagina, it is not the primary purpose of a vaginal exam. Vaginal exams are not done to determine the strength of contractions.

19.Which nursing diagnosis would take priority in the care of a primipara client with no visible support person in attendance who has entered the second stage of labor after a first stage of labor lasting 4 hours? a.Fluid volume deficit (FVD) related to fluid loss during labor and birth process b.Fatigue related to length of labor requiring increased energy expenditure c.Acute pain related to increased intensity of contractions d.Anxiety related to imminent birth process

ANS: D A primipara is experiencing the birthing event for the first time and may experience anxiety because of fear of the unknown. It would be important to recognize this because the client is alone in the labor-birth room and will need additional support and reassurance. Although FVD may occur as a result of fluid loss, prospective management of labor clients includes the use of parenteral fluid therapy; the client should be monitored for FVD and, if symptoms warrant, receive intervention. Because the client has been in labor for 4 hours, this is not considered to be a prolonged labor pattern for a primipara client. Although the client may be tired, this nursing diagnosis would not be a priority unless there were other symptoms manifested. Because the client is entering the second stage of labor, she will be allowed to push with contractions. Thus, in terms of pain management, medication will not be administered at this time because of imminent birth.

27.The gynecologist performs an amniotomy. What will the nurse's role include immediately following the procedure? a.Assessing for ballottement b.Conducting a pH and/or fern test c.Labeling of specimens for chromosomal analysis d.Recording the character and amount of amniotic fluid

ANS: D An amniotomy is a procedure in which the amniotic sac is deliberately ruptured. It is important to note and record the character and amount of amniotic fluid following this procedure. Assessing for ballottement is not indicated. Conducting a pH or fern test is not needed because an amniotomy releases amniotic fluid. An amniocentesis, not an amniotomy, is used to collect a specimen for chromosomal analysis.

24.The nurse has given the newborn an Apgar score of 5. She should then: a.begin ventilation and compressions. b.do nothing except place the infant under a radiant warmer. c.observe the infant and recheck the score after 10 minutes. d.gently stimulate by rubbing the infant's back while administering O2.

ANS: D An infant who receives a score of 4 to 6 requires only additional oxygen and gentle stimulation. An infant who receive a score of 3 or less requires ventilation and compressions. An infant who scores less than 7 requires more intervention than placement under a radiant warmer. Observing and rechecking the infant will not improve newborn's transition to extrauterine life.

6.Which client at term should go to the hospital or birth center the soonest after labor begins? a.Gravida 2, para 1, who lives 10 minutes away b.Gravida 1, para 0, who lives 40 minutes away c.Gravida 2, para 1, whose first labor lasted 16 hours d.Gravida 3, para 2, whose longest previous labor was 4 hours

ANS: D Multiparous women usually have shorter labors than do nulliparous women. The woman described in option D is multiparous with a history of rapid labors, increasing the likelihood that her infant might be born in uncontrolled circumstances. A gravida 2 would be expected to have a longer labor than the gravida in option C. The fact that she lives close to the hospital allows her to stay home for a longer period of time. A gravida 1 will be expected to have the longest labor. The gravida 2 would be expected to have a longer labor than the gravida 3, especially because her first labor was 16 hours.

34.The nurse examines a primipara's cervix at 8-9/100%/+2; it is tight against the fetal head. The patient reports a strong urge to bear down. What is the nurse's priority action? a.Palpate her bladder for fullness. b.Assess the frequency and duration of her contractions. c.Determine who will stay with the patient for the birth. d.Encourage the patient to exhale in short breaths with contractions.

ANS: D Teach the woman to exhale in short breaths if pushing is likely to injure her cervix or cause cervical edema. Pushing against a cervix that does not easily yield to pressure from the presenting part may result in cervical edema, which can block labor progress or cause cervical lacerations. A full bladder may impede the progress of labor. Although this is an important nursing action, it does not address the patient's urge to push. This patient is in the transition phase of the first stage of labor. Her contractions will be every 2 to 3 minutes and last 60 to 90 seconds. Determining the frequency and duration of the contractions does not add to the known assessment data for this patient. Determining who will attend the birth, although nice to know, does not address her urge to push.

8.A primigravida at 39 weeks of gestation is observed for 2 hours in the intrapartum unit. The fetal heart rate has been normal. Contractions are 5 to 9 minutes apart, 20 to 30 seconds in duration, and of mild intensity. Cervical dilation is 1 to 2 cm and uneffaced (unchanged from admission). Membranes are intact. The nurse should expect the client to be: a.discharged home with a sedative. b.admitted for extended observation. c.admitted and prepared for a cesarean birth. d.discharged home to await the onset of true labor.

ANS: D The situation describes a client with normal assessments who is probably in false labor and will probably not deliver rapidly once true labor begins. The client will probably be discharged, but there is no indication that a sedative is needed. These are all indications of false labor; there is no indication that further assessment or observations are indicated. These are all indications of false labor without fetal distress. There is no indication that a cesarean birth is indicated.

14.A 25-year-old primigravida client is in the first stage of labor. She and her husband have been holding hands and breathing together through each contraction. Suddenly, the client pushes her husband's hand away and shouts, "Don't touch me!" This behavior is most likely: a.abnormal labor. b.a sign that she needs analgesia. c.normal and related to hyperventilation. d.common during the transition phase of labor.

ANS: D The transition phase of labor is often associated with an abrupt change in behavior, including increased anxiety and irritability. This change of behavior is an expected occurrence during the transition phase. If she is in the transitional phase of labor, analgesia may not be appropriate if the birth is near. Hyperventilation will produce signs of respiratory alkalosis.

10.Which should the nurse recognize as being associated with fetal compromise? a.Active fetal movements b.Fetal heart rate in the 140s c.Contractions lasting 90 seconds d.Meconium-stained amniotic fluid

ANS: D When fetal oxygen is compromised, relaxation of the rectal sphincter allows passage of meconium into the amniotic fluid. Active fetal movement is an expected occurrence. The expected FHR range is 120 to 160 bpm. The fetus should be able to tolerate contractions lasting 90 seconds if the resting phase is sufficient to allow for a return of adequate blood flow.

A nurse is caring for a female client in the postpartum phase. The client reports "afterpains." Which intervention should the nurse complete first?

Administer pain medications. "Afterpains" should be expected in postpartum clients. These are commonly treated with pain analgesics. The client should not stop breastfeeding. Assessing vital signs and helping the client to void are not the priority interventions for this client.

"Unfortunately, I'm going to have to stay quite still in bed while it is in place."

After describing continuous internal electronic fetal monitoring to a laboring woman and her partner, which of the following would indicate the need for additional teaching?

Sinusoidal pattern, Recurrent variable decelerations, Fetal bradycardia

After teaching a group of students about fetal heart rate patterns, the instructor determines the need for additional teaching when the students identify which of the following as indicating normal fetal acid-base status?

19. The nurse is reviewing the monitoring strip of a woman in labor who is experiencing a contraction. The nurse notes the time the contraction takes from its onset to reach its highest intensity. The nurse interprets this time as which of the following? A) Increment B) Acme C) Peak D) Decrement

Ans: A Feedback: Each contraction has three phases: increment or the buildup of the contraction; acme or the peak or highest intensity; and the decrement or relaxation of the uterine muscle fibers. The time from the onset to the highest intensity corresponds to the increment.

13. Assessment of a fetus identifies the buttocks as the presenting part, with the legs extended upward. The nurse identifies this as which type of breech presentation? A) Frank B) Full C) Complete D) Footling

Ans: A Feedback: In a frank breech, the buttocks present first, with both legs extended up toward the face. In a full or complete breech, the fetus sits cross-legged above the cervix. In a footling breech, one or both legs are presenting.

24. During a follow-up prenatal visit, a pregnant woman asks the nurse, "How long do you think I will be in labor?" Which response by the nurse would be most appropriate? A) "It's difficult to predict how your labor will progress, but we'll be there for you the entire time." B) "Since this is your first pregnancy, you can estimate it will be about 10 hours." C) "It will depend on how big the baby is when you go into labor." D) "Time isn't important; your health and the baby's health are key."

Ans: A Feedback: It is difficult to predict how a labor will progress and therefore equally difficult to determine how long a woman's labor will last. There is no way to estimate the likely strength and frequency of uterine contractions, the extent to which the cervix will soften and dilate, and how much the fetal head will mold to fit the birth canal. We cannot know beforehand whether the complex fetal rotations needed for an efficient labor will take place properly. All of these factors are unknowns when a woman starts labor. Telling the woman an approximate time would be inappropriate because there is no way to determine the length of labor. It is highly individualized. Although fetal size and maternal and fetal health are important considerations, these responses do not address the woman's concern.

2. Which of the following would indicate to the nurse that the placenta is separating? A) Uterus becomes globular B) Fetal head is at vaginal opening C) Umbilical cord shortens D) Mucous plug is expelled

Ans: A Feedback: Placental separation is indicated by the uterus changing shape to globular and upward rising of the uterus. Additional signs include a sudden trickle of blood from the vaginal opening, and lengthening (not shortening) of the umbilical cord. The fetal head at the vaginal opening is termed crowning and occurs before birth of the head. Expulsion of the mucous plug is a premonitory sign of labor.

25. A nurse is describing how the fetus moves through the birth canal. Which of the following would the nurse identify as being most important in allowing the fetal head to move through the pelvis? A) Sutures B) Fontanelles C) Frontal bones D) Biparietal diameter

Ans: A Feedback: Sutures are important because they allow the cranial bones to overlap in order for the head to adjust in shape (elongate) when pressure is exerted on it by uterine contractions or the maternal bony pelvis. Fontanelles are the intersections formed by the sutures. The frontal bones, along with the parietal and occipital bones are bones of the cranium that are soft and pliable. The biparietal diameter is an important diameter that can affect the birth process.

7. The fetus of a nulliparous woman is in a shoulder presentation. The nurse would most likely prepare the client for which type of birth? A) Cesarean B) Vaginal C) Forceps-assisted D) Vacuum extraction

Ans: A Feedback: The fetus is in a transverse lie with the shoulder as the presenting part, necessitating a cesarean birth. Vaginal birth, forceps-assisted, and vacuum extraction births are not appropriate.

8. Assessment of a woman in labor reveals cervical dilation of 3 cm, cervical effacement of 30%, and contractions occurring every 7 to 8 minutes, lasting about 40 seconds. The nurse determines that this client is in: A) Latent phase of the first stage B) Active phase of the first stage C) Transition phase of the first stage D) Perineal phase of the second stage

Ans: A Feedback: The latent phase of the first stage of labor involves cervical dilation of 0 to 3 cm, cervical effacement of 0% to 40%, and contractions every 5 to 10 minutes lasting 30 to 45 seconds. The active phase is characterized by cervical dilation of 4 to 7 cm, effacement of 40% to 80%, and contractions occurring every 2 to 5 minutes lasting 45 to 60 seconds. The transition phase is characterized by cervical dilation of 8 to 10 cm, effacement of 80% to 100%, and contractions occurring every 1 to 2 minutes lasting 60 to 90 seconds. The perineal phase of the second stage occurs with complete cervical dilation and effacement, contractions occurring every 2 to 3 minutes and lasting 60 to 90 seconds, and a tremendous urge to push by the mother.

The nurse caring for families in crisis assesses the affective function of an immigrant family consisting of a father, mother, and two school-age children. Based on Friedman's structural functional theory, which of the following would the nurse identify as defining the family component? A) Meeting the love and belonging needs of each member B) Teaching children how to function and assume adult roles in society C) Ensuring the family has necessary resources with appropriate allocation D) Involving the provision of physical care to keep the family healthy

Ans: A Feedback: According to Friedman's structural functional theory, the affective function involves meeting the love and belonging needs of each member. Teaching children how to function and assume adult roles in society is the socialization and social placement function. Ensuring the family has necessary resources with appropriate allocation is related to the economic function, and involving the provision of physical care to keep the family healthy involves the health care function.

A mother confides to the nurse that she is thinking of divorce. Which suggestion by the nurse would be most helpful in minimizing the effects of the divorce on the couple's son? A) "Tell him together, using appropriate terms." B) "Reassure him that no one loves him more than you." C) "Do special things with him to make up for the divorce." D) "Share your feelings about your spouse with the child."

Ans: A Feedback: Both parents should tell the child about the divorce together, using appropriate terms. The other responses are unacceptable behaviors for the mother, such as competing with the spouse and using the child as a confidant.

After interviewing the mother of an 8-year-old girl with a broken arm, the nurse identifies the mother as the nurturer in the family. When developing the teaching plan for the girl and her mother, the nurse integrates knowledge of this role and focuses the teaching on which of the following? A) Teaching proper care procedures B) Dealing with insurance coverage C) Determining success of treatment D) Transmitting information to family members

Ans: A Feedback: The mother is the nurturer and thus the primary caregiver, so she would be the best family member to learn proper care procedures. Dealing with insurance coverage is the responsibility of the family's financial manager, transmitting information to family members is the gatekeeper's duty, and determining the success of treatment would likely fall to the family decision maker.

The school nurse is trying to get consent to care for an 11-year-old boy with diabetic ketoacidosis. His parents are out of town on vacation and the child is staying with a neighbor. Which action would be the priority? A) Getting telephone consent, with two people listening to the verbal consent B) Providing emergency care without parental consent C) Contacting the child's aunt or uncle to obtain consent D) Advocating for parens patriae to proceed with care for the child

Ans: A Feedback: The priority action would be to contact the neighbor for an emergency number to reach the parents and get their verbal consent, with two witnesses listening simultaneously. If the nurse cannot reach the parents and there is no relative or other person with written authorization to act on the parent's behalf, then the physician may initiate emergency care without the parent's consent. Parens patriae would be reserved for situations in which the parents are neglectful, irresponsible, or incompetent, for example, if the parents refuse treatment and the health care team feels the treatment is reasonable and warranted.

The nurse is counseling a young couple who in 2 months are having their third baby. The nurse uses Von Bertalanffy's (1968) general system theory applied to families to analyze the family structure. Which of the following best describes the main emphasis of this theory and its application to family dynamics? A) It emphasizes the family as a system with interdependent, interacting parts that endure over time to ensure the survival, continuity, and growth of its components. B) It emphasizes the social system of family, such as the organization or structure of the family and how the structure relates to the function. C) It emphasizes the developmental stages that all families go through, beginning with marriage; the longitudinal career of the family is also known as the family life cycle. D) It addresses the way families respond to stress and how the family copes with the stress as a group and how each individual member copes.

Ans: A Feedback: Von Bertalanffy emphasizes the family as a system with interdependent, interacting parts that endure over time to ensure the survival, continuity, and growth of its components. Friedman emphasizes the social system of family, such as the organization or structure of the family and how the structure relates to the function. Duvall emphasizes the developmental stages that all families go through, beginning with marriage; the longitudinal career of the family is also known as the family life cycle. The family stress theory addresses the way families respond to stress and how the family copes with the stress as a group and how each individual member copes.

15. After teaching a group of students about the factors affecting the labor process, the instructor determines that the teaching was successful when the group identifies which of the following as a component of the true pelvis? (Select all that apply.) A) Pelvic inlet B) Cervix C) Mid pelvis D) Pelvic outlet E) Vagina F) Pelvic floor muscles

Ans: A, C, D Feedback: The true pelvis is made up of three planes: the pelvic inlet, mid pelvis, and pelvic outlet. The cervix, vagina, and pelvic floor muscles are the soft tissues of the passageway.

The nurse working in a free community clinic knows that access to health care is affected negatively by lack of health insurance. Which of the following accurately describe the effect of lack of insurance on family health? Select all that apply. A) Parents with uninsured children often delay care and are less likely to take their children to a doctor or dentist for preventive care. B) The percentage of children without health insurance is beginning to decrease slightly from previous years. C) Currently, the states have improved enrollment in Medicaid and the State Children's Health Insurance Program (SCHIP). D) Despite state efforts to ensure all children, nearly two-thirds of children eligible for these public programs are not enrolled. E) In most states, men and women of the same health status and age are charged similar rates for the same individual health insurance policy.

Ans: A, C, D Feedback: Parents with uninsured children often delay care for their children, and are less likely to take their children to a doctor or dentist for preventive care. The percentage of children without health insurance is rising. Despite efforts by the states to improve enrollment in Medicaid and State Children's Health Insurance Program (SCHIP), nearly two-thirds of children eligible for these programs remain uninsured. Additionally, in most states, a man and woman of the same age and health status will be charged different rates for exactly the same individual health insurance policy.

23. A nurse is preparing a presentation for a group of pregnant women about the labor experience. Which of the following would the nurse most likely include when discussing measures to promote coping for a positive labor experience? (Select all that apply.) A) Presence of a support partner B) View of birth as a stressor C) Low anxiety level D) Fear of loss of control E) Participation in a pregnancy exercise program

Ans: A, C, E Feedback: Numerous factors can affect a woman's coping ability during labor and birth. Having the presence and support of a valued partner during labor, engaging in exercise during pregnancy, viewing the birthing experience as a meaningful rather than stressful event, and a low anxiety level can promote a woman's ability to cope. Excessive anxiety may interfere with the labor progress, and fear of labor and loss of control may enhance pain perception, increasing the fear.

18. A nurse is preparing a class for pregnant women about labor and birth. When describing the typical movements that the fetus goes through as it travels through the passageway, which of the following would the nurse most likely include? (Select all that apply.) A) Internal rotation B) Abduction C) Descent D) Pronation E) Flexion

Ans: A, C, E Feedback: The positional changes that occur as the fetus moves through the passageway are called the cardinal movements of labor and include engagement, descent, flexion, internal rotation, extension, external rotation, and expulsion. The fetus does not undergo abduction or pronation.

A nurse is working to develop a health education program for a local community to address breast cancer awareness. Which of the following would the nurse expect to include when describing this problem to the group? Select all that apply. A) White women have higher rates of breast cancer than African American women. B) African American women are more likely to die from breast cancer at any age. C) Survival at any stage is worse among White women. D) Women living in South America have the highest rates of breast cancer. E) Breast cancer is the leading cause of cancer mortality in women.

Ans: A,B Feedback: White women get breast cancer at a higher rate than African American women, but African American women are more likely to get breast cancer before they are 40, and are more likely to die from it at any age. This is likely because the cancer is more advanced when it is found in African American women, and because survival at every cancer stage is worse among African American women. Women living in North America have the highest rate of breast cancer in the world. At this time there are about 2.6 million breast cancer survivors in the United States. It is the most common malignancy in women and second only to lung cancer as a cause of cancer mortality in women.

3. When assessing cervical effacement of a client in labor, the nurse assesses which of the following characteristics? A) Extent of opening to its widest diameter B) Degree of thinning C) Passage of the mucous plug D) Fetal presenting part

Ans: B Feedback: Effacement refers to the degree of thinning of the cervix. Cervical dilation refers to the extent of opening at the widest diameter. Passage of the mucous plug occurs with bloody show is a premonitory sign of labor. The fetal presenting part is determined by vaginal examination and is commonly the head (cephalic), pelvis (breech), or shoulder.

14. A woman in her third trimester comes to the clinic for a prenatal visit. During assessment the woman reports that her breathing has become much easier in the last week but she has noticed increased pelvic pressure, cramping, and lower back pain. The nurse determines that which of the following has most likely occurred? A) Cervical dilation B) Lightening C) Bloody show D) Braxton-Hicks contractions

Ans: B Feedback: Lightening occurs when the fetal presenting part begins to descend into the maternal pelvis. The uterus lowers and moves into the maternal pelvis. The shape of the abdomen changes as a result of the change in the uterus. The woman usually notes that her breathing is much easier. However, she may complain of increased pelvic pressure, cramping, and lower back pain. Although cervical dilation also may be occurring, it does not account for the woman's complaints. Bloody show refers to passage of the mucous plug that fills the cervical canal during pregnancy. It occurs with the onset of labor. Braxton-Hicks contractions increase in strength and frequency and aid in moving the cervix from a posterior position to an anterior position. They also help in ripening and softening the cervix.

4. A woman calls the health care facility stating that she is in labor. The nurse would urge the client to come to the facility if the client reports which of the following? A) Increased energy level with alternating strong and weak contractions B) Moderately strong contractions every 4 minutes, lasting about 1 minute C) Contractions noted in the front of abdomen that stop when she walks D) Pink-tinged vaginal secretions and irregular contractions lasting about 30 seconds

Ans: B Feedback: Moderately strong regular contractions 60 seconds in duration indicate that the client is probably in the active phase of the first stage of labor. Alternating strong and weak contractions, contractions in the front of the abdomen that change with activity, and pink-tinged secretions with irregular contractions suggest false labor.

11. After teaching a group of students about the maternal bony pelvis, which statement by the group indicates that the teaching was successful? A) The bony pelvis plays a lesser role during labor than soft tissue. B) The pelvic outlet is associated with the true pelvis. C) The false pelvis lies below the imaginary linea terminalis. D) The false pelvis is the passageway through which the fetus travels.

Ans: B Feedback: The maternal bony pelvis consists of the true and false portions. The true pelvis is made up of three planes—the inlet, the mid pelvis, and the outlet. The bony pelvis is the more important part of the passageway because it is relatively unyielding. The false pelvis lies above the imaginary linea terminalis. The true pelvis is the bony passageway through which the fetus must travel.

9. A client is admitted to the labor and birthing suite in early labor. On review of her medical record, the nurse determines that the client's pelvic shape as identified in the antepartal progress notes is the most favorable one for a vaginal delivery. Which pelvic shape would the nurse have noted? A) Platypelloid B) Gynecoid C) Android D) Anthropoid

Ans: B Feedback: The most favorable pelvic shape for vaginal delivery is the gynecoid shape. The anthropoid pelvis is favorable for vaginal birth but it is not the most favorable shape. The android pelvis is not considered favorable for a vaginal birth because descent of the fetal head is slow and failure of the fetus to rotate is common. Women with a platypelloid pelvis usually require cesarean birth.

21. When describing the stages of labor to a pregnant woman, which of the following would the nurse identify as the major change occurring during the first stage? A) Regular contractions B) Cervical dilation C) Fetal movement through the birth canal D) Placental separation

Ans: B Feedback: The primary change occurring during the first stage of labor is progressive cervical dilation. Contractions occur during the first and second stages of labor. Fetal movement through the birth canal is the major change during the second stage of labor. Placental separation occurs during the third stage of labor.

10. A woman telephones her health care provider and reports that her "water just broke." Which suggestion by the nurse would be most appropriate? A) "Call us back when you start having contractions." B) "Come to the clinic or emergency department for an evaluation." C) "Drink 3 to 4 glasses of water and lie down." D) "Come in as soon as you feel the urge to push."

Ans: B Feedback: When the amniotic sac ruptures, the barrier to infection is gone and there is the danger of cord prolapse if engagement has not occurred. Therefore, the nurse should suggest that the woman come in for an evaluation. Calling back when contractions start, drinking water, and lying down are inappropriate because of the increased risk for infection and cord prolapse. Telling the client to wait until she feels the urge to push is inappropriate because this occurs during the second stage of labor.

Parents are complaining about the amount of time their 14-year-old girl spends on the Internet. Which of the following would be most important to address with the parents? A) "Limit her use of the Internet to an hour per day." B) "Does she do her homework and socialize in person?" C) "Can you place the computer where you can keep an eye on her?" D) "You need to warn her about protecting her identity."

Ans: B Feedback: Although having the computer in a family area is better than putting it in her room, and warning her about protecting her identity is key, it is important to determine if the child is neglecting responsibilities, schoolwork, household activities, friends, or other forms of personal interaction. Once this is determined, then reasonable time limits for the child's use of the Internet can be established.

A mother of four children is being interviewed by the nurse. She states: "Whatever my husband and I say goes and the kids need to follow our rules without complaining about them." The nurse interprets this as which parenting style? A) Authoritative B) Authoritarian C) Permissive D) Rejecting-neglecting

Ans: B Feedback: Four major parenting styles seen in our society are authoritarian, authoritative, permissive, and rejecting-neglecting. The authoritarian parent expects obedience from the child and discourages the child from questioning the family's rules. The authoritative or democratic parent shows some respect for the child's opinions. Permissive or laissez-faire parents have little control over the behavior of their children. Rejecting or neglecting parents are indifferent or uninvolved.

After teaching a group of nursing students about pregnancy-related mortality, the instructor determines that additional teaching is necessary when the students identify which condition as a leading cause? A) Hemorrhage B) Embolism C) Hypertension D) Infection

Ans: B Feedback: Most pregnancy-related complications are preventable. The leading causes of pregnancy-related mortality are hemorrhage, infection, preeclampsia-eclampsia, obstructed labor, and unsafe abortion. Embolism is not a leading cause.

The nurse is teaching discipline strategies to the parents of a 12-year-old girl. Which of the following topics is an example of positive reinforcement discipline? A) Unplugging the DVD player for the weekend B) Taking a chore away from the child for a week C) Having her clean up the kitchen for a week D) Ignoring her request if she doesn't say "please"

Ans: B Feedback: Taking a chore away from the child for a week is an excellent way to reward her for positive behavior. Unplugging the DVD player and assigning an extra chore are examples of negative reinforcement. Ignoring her until she uses good manners is an example of extinction.

A preschool child is scheduled to undergo a diagnostic test. Which action by the nurse would violate a child's bill of health care rights? A) Arranging for her mother to be with her B) Telling the child the test will not hurt C) Assuring the child that the test will be done quickly D) Introducing the child to the lab technicians

Ans: B Feedback: Telling the child the test will not hurt lacks veracity or truth. It is not a lie, but it does not honor the child's right to be educated honestly about his or her health care. Arranging for the mother to be with the child, assuring the child that the test will be done quickly, and introducing the child to the lab technicians are actions that honor the child's bill of health care rights.

The nurse is working with a group of community leaders to develop a plan to address the special health needs of women. Which of the following conditions would the group address as the major problem? A) Smoking B) Heart disease C) Diabetes D) Cancer

Ans: B Feedback: The group needs to address cardiovascular disease, the number-one cause of death in women regardless of racial or ethnic group. Smoking is related to heart disease and cancer, although heart disease and cancer can occur in any woman regardless of her smoking history. Cancer is the second leading cause of death, with women having a one in three lifetime risk of developing cancer. Diabetes is another important health condition that can affect women, but it is not the major health problem that heart disease is.

The United States ranks 50th in the world for maternal mortality and 41st among industrialized nations for infant mortality rates. When developing programs to assist in decreasing theses rates, which factor would most likely need to be addressed as having the greatest impact? A) Resolving all language and cultural differences B) Ensuring early and adequate prenatal care C) Providing more extensive women's shelters D) Encouraging all women to eat a balanced diet

Ans: B Feedback: The lack of prenatal care during pregnancy is a major factor contributing to a poor outcome. Prenatal care is well known to prevent complications of pregnancy and to support the birth of healthy infants. Infant mortality commonly includes problems occurring at birth or shortly thereafter. Thus, ensuring early and adequate prenatal care would have the greatest impact on decreasing these rates. Resolving all language and cultural differences would be helpful but is unrealistic. Providing more extensive women's shelters would be helpful for women who are victims of abuse. Encouraging all women to eat a balanced diet is helpful but would not decrease infant mortality rates.

The nurse is assessing a toddler for temperament and documents a "difficult" temperament. Which of the following is a trait of this type of personality? Select all that apply. A) Moodiness B) Irritability C) Even-temperedness D) Overly active

Ans: B,D Feedback: Children's temperaments may be categorized into three major groups: easy, difficult, and slow to warm up. Easy children are even-tempered and have regular biological functions, predictable behavior, and a positive attitude toward new experiences. Difficult children are irritable, overactive, and intense; they react to new experiences by withdrawing and are frustrated easily. Children in the slow-to-warm-up category are moody and less active and have more irregular reactions; they react to new experiences with mild but passive resistance and need extra time to adjust to new situations.

1. A woman in her 40th week of pregnancy calls the nurse at the clinic and says she's not sure whether she is in true or false labor. Which statement by the client would lead the nurse to suspect that the woman is experiencing false labor? A) "I'm feeling contractions mostly in my back." B) "My contractions are about 6 minutes apart and regular." C) "The contractions slow down when I walk around." D) "If I try to talk to my partner during a contraction, I can't."

Ans: C Feedback: False labor is characterized by contractions that are irregular and weak, often slowing down with walking or a position change. True labor contractions begin in the back and radiate around toward the front of the abdomen. They are regular and become stronger over time; the woman may find it extremely difficult if not impossible to have a conversation during a contraction.

16. A nurse is documenting fetal lie of a woman in labor. Which term would the nurse most likely use? A) Flexion B) Extension C) Longitudinal D) Cephalic

Ans: C Feedback: Fetal lie refers to the relationships of the long axis (spine) of the fetus to the long axis (spine) of the mother. There are two primary lies: longitudinal and transverse. Flexion and extension are terms used to describe fetal attitude. Cephalic is a term used to describe fetal presentation.

26. Assessment of a pregnant woman reveals that the presenting part of the fetus is at the level of the maternal ischial spines. The nurse documents this as which station? A) -2 B) -1 C) 0 D) +1 .

Ans: C Feedback: Station refers to the relationship of the presenting part to the level of the maternal pelvic ischial spines. Fetal station is measured in centimeters and is referred to as a minus or plus, depending on its location above or below the ischial spines. Zero (0) station is designated when the presenting part is at the level of the maternal ischial spines. When the presenting part is above the ischial spines, the distance is recorded as minus stations. When the presenting part is below the ischial spines, the distance is recorded as plus stations

17. The nurse is reviewing the medical record of a woman in labor and notes that the fetal position is documented as LSA. The nurse interprets this information as indicating which of the following is the presenting part? A) Occiput B) Face C) Buttocks D) Shoulder

Ans: C Feedback: The second letter denotes the presenting part which in this case is "S" or the sacrum or buttocks. The letter "O" would denote the occiput or vertex presentation. The letter "M" would denote the mentum (chin) or face presentation. The letter "A" would denote the acromion or shoulder presentation.

6. A client has not received any medication during her labor. She is having frequent contractions every 1 to 2 minutes and has become irritable with her coach and no longer will allow the nurse to palpate her fundus during contractions. Her cervix is 8 cm dilated and 90% effaced. The nurse interprets these findings as indicating: A) Latent phase of the first stage of labor B) Active phase of the first stage of labor C) Transition phase of the first stage of labor D) Pelvic phase of the second stage of labor

Ans: C Feedback: The transition phase is characterized by cervical dilation of 8 to 10 cm, effacement of 80% to 100%, contractions that are strong, painful, and frequent (every 1 to 2 minutes) and last 60 to 90 seconds, and irritability, apprehension, and feelings of loss of control. The latent phase is characterized by mild contractions every 5 to 10 minutes, cervical dilation of 0 to 3 cm and effacement of 0% to 40%, and excitement and frequent talking by the mother. The active phase is characterized by moderate to strong contractions every 2 to 5 minutes, cervical dilation of 4 to 7 cm and effacement of 40% to 80%, with the mother becoming intense and inwardly focused. The pelvic phase of the second stage of labor is characterized by complete cervical dilation and effacement, with strong contractions every 2 to 3 minutes; the mother focuses on pushing.

5. A woman is in the first stage of labor. The nurse would encourage her to assume which position to facilitate the progress of labor? A) Supine B) Lithotomy C) Upright D) Knee-chest

Ans: C Feedback: The use of any upright position helps to reduce the length of labor. Research validates that nonmoving back-lying positions such as supine and lithotomy positions during labor are not healthy. The knee-chest position would assist in rotating the fetus in a posterior position.

The nurse providing care to a family and an ill child in a hospital setting reflects on the focus of the health care provided in today's society. Which of the following statements best describes the current definition of health? A) Health is described as "an absence of disease." B) Health is measured by monitoring the mortality and morbidity of a group. C) Health is a state of complete physical, mental, and social well-being. D) Technological gains made in health care are shared equally among all children.

Ans: C Feedback: In the past, health was defined simply as the absence of disease; health was measured by monitoring the mortality and morbidity of a group. Over the past century, however, the focus of health has shifted to disease prevention, health promotion, and wellness. The World Health Organization (2012) defines health as "a state of complete physical, mental, and social well-being, and not merely the absence of disease or infirmity." The gains in child health have been huge, but, unfortunately, these gains are not shared equally among all children.

The nurse is teaching discipline strategies to the parents of a 4-year-old boy. Which response by the parents indicates a need for more teaching? A) "We should remove temptations that lead to bad behavior." B) "We need to explain how we expect him to behave." C) "We should tell him we get angry when he's bad." D) "We must praise the child for good behavior."

Ans: C Feedback: Telling the child that the parents get angry when he is bad would be inappropriate. This response indicates the need to restate that it is important to let the child know that it is not him but rather his behavior that is bad. Removing temptations, setting expectations, and praising good behavior are important concepts the parents need to learn.

A group of students is reviewing historical aspects about childbirth. The students demonstrate understanding of the information when they identify the use of twilight sleep as a key event during which time frame? A) 1700s B) 1800s C) 1900s D) 2000s

Ans: C Feedback: Twilight sleep, or the use of a heavy dose of narcotics and amnesiacs, was used on women during childbirth in the United States during the 1900s. Female midwives attended the majority of births during the 1700s. Care shifted to doctors among middle-class women during the 1800s. Certified nurse midwives and childbirth classes characterize the 2000s.

A nurse is preparing a presentation for a local women's group about heart disease and women. Which of the following would the nurse expect to address when discussing measures to promote health? A) Women have similar symptoms as men for a heart attack. B) Heart disease is no longer viewed as a "man's disease." C) Women experiencing a heart attack are at greater risk for dying. D) Heart attacks in women are more easily diagnosed.

Ans: C Feedback: Women who have a heart attack are more likely than men to die. Heart attacks in women are often more difficult to diagnose than in men because of their vague and varied symptoms. Heart disease is still thought of as a "man's disease," and thus a heart attack may not be considered in the differential diagnosis when a woman presents to the emergency room. Nurses need to look beyond the obvious "crushing chest pain" textbook symptom that heralds a heart attack in men. Manifestations of heart disease differ between men and women.

20. A nurse is assessing a woman in labor. Which finding would the nurse identify as a cause for concern during a contraction? A) Heart rate increase from 76 bpm to 90 bpm B) Blood pressure rise from 110/60 mm Hg to 120/74 C) White blood cell count of 12,000 cells/mm3 D) Respiratory rate of 10 breaths /minute

Ans: D Feedback: During labor, the mother experiences various physiologic responses including an increase in heart rate by 10 to 20 bpm, a rise in blood pressure by up to 35 mm Hg during a contraction, an increase in white blood cell count to 25,000 to 30,000 cells/mm3, perhaps as a result of tissue trauma, and an increase in respiratory rate with greater oxygen consumption due to the increase in metabolism. A drop in respiratory rate would be a cause for concern.

22. A nurse is caring for several women in labor. The nurse determines that which woman is in the transition phase of labor? A) Contractions every 5 minutes, cervical dilation 3 cm B) Contractions every 3 minutes, cervical dilation 5 cm C) Contractions every 21/2 minutes, cervical dilation 7 cm D) Contractions every 1 minute, cervical dilation 9 cm

Ans: D Feedback: The transition phase is characterized by strong contractions occurring every 1 to 2 minutes and cervical dilation from 8 to 10 cm. Contractions every 5 minutes with cervical dilation of 3 cm is typical of the latent phase. Contractions every 3 minutes with cervical dilation of 5 cm and contractions every 21/2 minutes with cervical dilation of 7 cm suggest the active phase of labor.

12. A fetus is assessed at 2 cm above the ischial spines. The nurse would document fetal station as: A) +4 B) +2 C) 0 D) -2

Ans: D Feedback: When the presenting part is above the ischial spines, it is noted as a negative station. Since the measurement is 2 cm, the station would be -2. A 0 station indicates that the fetal presenting part is at the level of the ischial spines. Positive stations indicate that the presenting part is below the level of the ischial spines.

A nurse is assigned to care for an Asian American client. The nurse develops a plan of care with the understanding that based on this client's cultural background, the client most likely views illness as which of the following? A) Caused by supernatural forces B) A punishment for sins C) Due to spirits or demons D) From an imbalance of forces

Ans: D Feedback: Asian Americans believe that illness is caused by an imbalance of forces, specifically yin and yang. Native Americans believe that illness is caused by supernatural forces, and African Americans may believe that illness is caused by spirits or demons.

After describing the procedure and medical necessity, the nurse asks a 14-year-old child to assent to a skin graft. Which of the following statements accurately describes the requirements for this type of assent? A) The age of assent occurs at 12 years old. B) It is not necessary to obtain assent from a minor for a procedure. C) A minor can dissent to a procedure but his or her wishes are not binding. D) In some cases, such as cases of significant morbidity or mortality, dissent may need to be overridden.

Ans: D Feedback: Assent means agreeing to something. In pediatric health care, the term assent refers to the child's participation in the decision-making process about health care (McCullough & Stein, 2010). In some cases, such as cases of significant morbidity or mortality, dissent may need to be overridden. The age of assent depends on the child's developmental level, maturity, and psychological state. The converse of assent, dissent (disagreeing with the treatment plan), when given by an adolescent 13 to 17 years of age, is considered binding in some states. The American Academy of Pediatrics proposes that a child with an intellectual age of 7 years or older is competent to understand participation in research and therefore provide assent (Sirbaugh & Diekema, 2011).

A 10-year-old girl who is living with a foster family is brought to the clinic for evaluation. When caring for this child, which intervention is a priority? A) Determining if the child is being bullied at school B) Dealing with mixed expectations of parents C) Establishing who the child's actual caretaker is D) Performing a comprehensive health assessment

Ans: D Feedback: Children in foster care are more likely to exhibit a wide range of medical, emotional, behavioral, or developmental problems. Although resilient, they may struggle with certain issues such as unmet health needs. Therefore a comprehensive physical health assessment would be a priority. Determining if the child is being bullied at school is not specific to any one family structure. Assessing for problems related to conflicting feelings toward parents would be more likely common in a blended family. Establishing who the caretaker is would be necessary with a communal family.

The nurse is performing a health assessment of a school-age child. Based on the child's developmental level, on which of the following problems would the nurse focus more attention? A) Infections B) Poisonings C) Risk-taking behaviors D) Accidents and injuries

Ans: D Feedback: Developmental level has a major impact on the health status of children. The physiologic immaturity of an infant's body systems increases the risk for infection. Ingestion of toxic substances and risk of poisoning are major health concerns for toddlers as they become more mobile and inquisitive. Because preschool- and school-age children are, generally, very active, they are more prone to injury and accidents. Adolescents are establishing their identity, which may lead them to separate from the family values and traditions for a period of time and attempt to conform to their peers. This journey may lead to risk-taking behaviors, resulting in injuries or other situations that may impair their health.

A nurse is assessing a family for barriers to health care. Which factor would the nurse identify to be most important? A) Language B) Health care workers' attitudes C) Transportation D) Finances

Ans: D Feedback: Financial barriers are one of the most important factors that limit care. Families may not have any medical insurance, may not have enough insurance to cover the services they need, or may not be able to pay for services. Language, health care workers' attitudes, and transportation are also barriers to health care but are not as fundamentally important as finances.

The student nurse is learning about the past history of child health and health care in the United States. Which of the following statements by the student indicates successful learning about the condition of health care in the past and current centuries? A) In past centuries in the United States, the health of the country was better than it is today due to the simpler style of living. B) In the current century, mortality rates are high, but life expectancy has increased due to technological advances. C) In the late 18th and early 19th centuries urban public health improvements made cities healthier places for growing children. D) By the end of the 20th century, unintentional injuries rather than infectious diseases had become the leading cause of death for children older than 1 year old.

Ans: D Feedback: In past centuries in the United States, the health of the country was poorer than it is today; mortality rates were high and life expectancy was short. Over the years the health of children received more and more attention, leading to a better understanding of sources of illness and improvements in sanitation, water, and nutrition. As a result, by the end of the late 20th century, unintentional injuries rather than infectious diseases had become the leading cause of death for children older than 1 year old.

When preparing a teaching plan for a group of first-time pregnant women, the nurse expects to review how maternity care has changed over the years. Which of the following would the nurse include when discussing events of the 20th century? A) Epidemics of puerperal fever B) First cesarean birth C) X-rays used to assess pelvic size D) Development of freestanding birth centers

Ans: D Feedback: In the 20th century (1900s), freestanding birth centers were developed. Puerperal fever epidemics, the first cesarean birth, and the use of x-rays to assess pelvic size were events occurring during the 19th century (1800s).

The nurse is caring for a 12-year-old child hospitalized for internal injuries following a motor vehicle accident. For which of the following medical treatments would the nurse need to obtain an informed consent beyond the one signed at admission? A) Diagnostic imaging B) Cardiac monitoring C) Blood testing D) Spinal tap

Ans: D Feedback: Most care given in a health care setting is covered by the initial consent for treatment signed when the child becomes a patient at that office or clinic or by the consent to treatment signed upon admission to the hospital or other inpatient facility. Certain procedures, however, require a specific process of informed consent, including major and minor surgery; invasive procedures such as lumbar puncture or bone marrow aspiration; treatments placing the child at higher risk, such as chemotherapy or radiation therapy; procedures or treatments involving research; photography involving children; and applying restraints to children.

A 9-month-old with glaucoma requires surgery. The infant's parents are divorced. To obtain informed consent, which action would be most appropriate? A) Contacting the father for informed consent B) Obtaining informed consent from the mother C) Seeking a court ruling on the course of care D) Determining if there is parental sole or joint custody

Ans: D Feedback: The most appropriate action would be to determine legal custody by court decree. If the parents have joint custody, then either parent may give consent, but it is always best to have consent given by both parents. The parent with only physical custody may give consent for emergency care. The last resort is getting a court ruling; usually this is not necessary unless the parents disagree about the care of the child.

When discussing fetal mortality with a group of students, a nurse addresses maternal factors. Which of the following would the nurse most likely include? Select all that apply. A) Chromosomal abnormalities B) Malnutrition C) Preterm cervical dilation D) Underlying disease condition E) Poor placental attachment

Ans:B,C,D Feedback: Fetal mortality may be attributable to maternal factors (e.g., malnutrition, disease, or preterm cervical dilation) or fetal factors (e.g., chromosomal abnormalities or poor placental attachment).

A client gave birth to a healthy boy 2 days ago. Both mother and baby have had a smooth recovery. The nurse enters the room and tells the client that she and her baby will be discharged home today. The client states, "I do not want to go home." What is the nurse's most appropriate response?

Ask the client why she does not want to go home. It is important for the nurse to identify the client's concerns and reasons for wanting to stay in the hospital. Open-ended questioning facilitates both effective and therapeutic communication and allows the nurse to address concerns appropriately. Asking about supports at home implies that the nurse has made assumptions about why the client may not want to go home. Informing the care provider or telling the client that discharge is hospital policy is not appropriate at this time because the nurse has not addressed the underlying reason for the client's comment. The client may have safety-related concerns, undisclosed fears, or a need for increased support before discharge. It is imperative that the nurse not make assumptions but further explore concerns.

A postpartal woman has a history of thrombophlebitis. Which action would help the nurse determine if she is developing this postpartally?

Assess for calf redness and edema. Calf redness and edema, especially at the ankle and along the tibia, suggest thrombophlebitis.

A woman is bottle-feeding her baby. When the nurse comes into the room the woman says that her breasts are painful and engorged. Which nursing intervention is appropriate?

Assist the woman in placing ice packs on her breasts. If the breasts are engorged and the woman is bottle-feeding her newborn, instruct her to keep a support bra on 24 hours per day. Cool compresses or an ice pack wrapped in a towel will usually be soothing and help to suppress milk production.

A father of a newborn tells the nurse, I may not know everything about being a dad, but I'm going to do the best I can for my son. The nurse interprets this as indicating the father is in which stage of adaptation? A) Expectations B) Transition to mastery C) Reality D) Taking-in

A group of nursing students are reviewing information about mastitis and its causes. The students demonstrate understanding of the information when they identify which of the following as the most common cause? A) E. coli B) S. aureus C) Proteus D) Klebsiella

A group of nursing students are reviewing respiratory system adaptations that occur during the postpartum period. The students demonstrate understanding of the information when they identify which of the following as a postpartum adaptation? A) Continued shortness of breath B) Relief of rib aching C) Diaphragmatic elevation D) Decrease in respiratory rate

A group of students are reviewing the causes of postpartum hemorrhage. The students demonstrate understanding of the information when they identify which of the following as the most common cause? A) Labor augmentation B) Uterine atony C) Cervical or vaginal lacerations D) Uterine inversion

A nurse is assessing a postpartum client who is at home. Which statement by the client would lead the nurse to suspect that the client may be developing postpartum depression? A) I just feel so overwhelmed and tired. B) I'm feeling so guilty and worthless lately. C) It's strange, one minute I'm happy, the next I'm sad. D) I keep hearing voices telling me to take my baby to the river.

A nurse is making a home visit to a postpartum woman who delivered a healthy newborn 4 days ago. The woman's breasts are swollen, hard, and tender to the touch. The nurse documents this finding as which of the following? A) Involution B) Engorgement C) Mastitis D) Engrossment

A nurse is massaging a postpartum clients fundus and places the nondominant hand on the area above the symphysis pubis based on the understanding that this action: A) Determines that the procedure is effective B) Helps support the lower uterine segment C) Aids in expressing accumulated clots D) Prevents uterine muscle fatigue

A nurse is observing a postpartum client interacting with her newborn and notes that the mother is engaging with the newborn in the en face position. Which of the following would the nurse be observing? A) Mother placing the newborn next to bare breast. B) Mother making eye-to-eye contact with the newborn C) Mother gently stroking the newborns face D) Mother holding the newborn upright at the shoulder

A nurse is visiting a postpartum woman who delivered a healthy newborn 5 days ago. Which of the following would the nurse expect to find? A) Bright red discharge B) Pinkish brown discharge C) Deep red mucus-like discharge D) Creamy white discharge

A nurse is working as part of a committee to establish policies to promote bonding and attachment. Which practice would be least effective in achieving this goal? A) Allowing unlimited visiting hours on maternity units B) Offering round-the-clock nursery care for all infants C) Promoting rooming-in D) Encouraging infant contact immediately after birth

A postpartum client comes to the clinic for her routine 6-week visit. The nurse assesses the client and suspects that she is experiencing subinvolution based on which of the following? A) Nonpalpable fundus B) Moderate lochia serosa C) Bruising on arms and legs D) Fever

A postpartum client who is bottle feeding her newborn asks, When should my period return? Which response by the nurse would be most appropriate? A)Its difficult to say, but it will probably return in about 2 to 3 weeks. B) It varies, but you can estimate it returning in about 7 to 9 weeks. C) You won't have to worry about it returning for at least 3 months. D)You don't have to worry about that now. It'll be quite a while.

A postpartum woman who developed deep vein thrombosis is being discharged on anticoagulant therapy. After teaching the woman about this treatment, the nurse determines that additional teaching is needed when the woman states which of the following? A) I will use a soft toothbrush to brush my teeth. B) I can take ibuprofen if I have any pain. C) I need to avoid drinking any alcohol. D) I will call my health care provider if my stools are black and tarry.

A postpartum woman who has experienced diastasis recti asks the nurse about what to expect related to this condition. Which response by the nurse would be most appropriate? A) Youll notice that this will fade to silvery lines. B) Exercise will help to improve the muscles. C) Expect the color to lighten somewhat. D) Youll notice that your shoe size will increase.

A postpartum woman who is bottle-feeding her newborn asks the nurse, About how much should my newborn drink at each feeding? The nurse responds by saying that to feel satisfied, the newborn needs which amount at each feeding? A) 1 to 2 ounces B) 2 to 4 ounces C) 4 to 6 ounces D) 6 to 8 ounces

A woman who gave birth 24 hours ago tells the nurse, Ive been urinating so much over the past several hours. Which response by the nurse would be most appropriate? A) You must have an infection, so let me get a urine specimen. B) Your body is undergoing many changes that cause your bladder to fill quickly. C) Your uterus is not contracting as quickly as it should. D) The anesthesia that you received is wearing off and your bladder is working again.

After a normal labor and birth, a client is discharged from the hospital 12 hours later. When the community health nurse makes a home visit 2 days later, which finding would alert the nurse to the need for further intervention? A)Presence of lochia serosa B) Frequent scant voidings C) Fundus firm, below umbilicus D)Milk filling in both breasts

After presenting a class on measures to prevent postpartum hemorrhage, the presenter determines that the teaching was successful when the class states which of the following as an important measure to prevent postpartum hemorrhage due to retained placental fragments? A) Administering broad-spectrum antibiotics B) Inspecting the placenta after delivery for intactness C) Manually removing the placenta at delivery D) Applying pressure to the umbilical cord to remove the placenta

After reviewing information about postpartum blues, a group of students demonstrate understanding when they state which of the following about this condition? A) Postpartum blues is a long-term emotional disturbance. B) Sleep usually helps to resolve the blues. C) The mother loses contact with reality. D) Extended psychotherapy is needed for treatment.

After teaching a postpartum woman about breast-feeding, the nurse determines that the teaching was successful when the woman states which of the following? A) I should notice a decrease in abdominal cramping during breast-feeding. B) I should wash my hands before starting to breast-feed. C) The baby can be awake or sleepy when I start to feed him. D) The babys mouth will open up once I put him to my breast.

After teaching a woman with a postpartum infection about care after discharge, which client statement indicates the need for additional teaching? A) I need to call my doctor if my temperature goes above 100.4 F. B) When I put on a new pad, I'll start at the back and go forward. C) If I have chills or my discharge has a strange odor, I'll call my doctor. D) I'll point the spray of the peribottle so the water flows front to back.

The nurse administers RhoGAM to an Rh-negative client after delivery of an Rh-positive newborn based on the understanding that this drug will prevent her from: A)Becoming Rh positive B) Developing Rh sensitivity C) Developing AB antigens in her blood D)Becoming pregnant with an Rh-positive fetus

The nurse is assessing a postpartum clients lochia and finds that there is about a 4-inch stain on the perineal pad. The nurse documents this finding as which of the following? A) Scant B) Light C) Moderate D) Large

The partner of a woman who has given birth to a healthy newborn says to the nurse, I want to be involved, but I'm not sure that I'm able to care for such a little baby. The nurse interprets this as indicating which of the following stages? A) Expectations B) Reality C) Transition to mastery D) Taking-hold

Which of the following would lead the nurse to suspect that a postpartum woman is experiencing a problem? A) Elevated white blood cell count B) Acute decrease in hematocrit C) Increased levels of clotting factors D) Pulse rate of 60 beats/minute

Which of the following would the nurse interpret as being least indicative of paternal engrossment? A) Demonstrating pleasure when touching or holding the newborn B) Identifying imperfections in the newborns appearance C) Being able to distinguish his newborn from others in the nursery D) Showing feelings of pride with the birth of the newborn

Which statement would alert the nurse to the potential for impaired bonding between mother and newborn? A)You have your daddys eyes. B) He looks like a frog to me. C) Where did you get all that hair? D)He seems to sleep a lot.

A nursing student is preparing a class presentation about changes in the various body systems during the postpartum period and their effects. Which of the following would the student include as influencing a postpartum woman's ability to void? (Select all that apply.) A) Use of an opioid anesthetic during labor B) Generalized swelling of the perineum C) Decreased bladder tone from regional anesthesia D) Use of oxytocin to augment labor E) Need for an episiotomy

B, C, D

A nurse is developing a teaching plan for a postpartum woman who is breast-feeding about sexuality and contraception. Which of the following would the nurse most likely include? (Select all that apply.) A) Resumption of sexual intercourse about two weeks after delivery B) Possible experience of fluctuations in sexual interest C) Use of a water-based lubricant to ease vaginal discomfort D) Use of combined hormonal contraceptives for the first three weeks E) Possibility of increased breast sensitivity during sexual activity

B, C, E

A nurse is observing a postpartum woman and her partner interact with the their newborn. The nurse determines that the parents are developing parental attachment with their newborn when they demonstrate which of the following? (Select all that apply.) A) Frequently ask for the newborn to be taken from the room B) Identify common features between themselves and the newborn C) Refer to the newborn as having a monkey-face D) Make direct eye contact with the newborn E) Refrain from checking out the newborns features

B, D

B, D, E

A nurse is providing care to a postpartum woman. The nurse determines that the client is in the taking-in phase based on which finding?

B. Client states, "He has my eyes and nose."

When the nurse is assessing a postpartum client approximately 6 hours after delivery, which finding would warrant further investigation?

B. blood pressure 90/50 mm Hg Answers: A. voiding of 350 cc CorrectB. blood pressure 90/50 mm Hg C. deep red, fleshy-smelling lochia D. profuse sweating

Assessment of a newborn reveals transient tachypnea. The nurse reviews the newborn's medical record. Which factor would the nurse most likely identify as a risk for this condition?

B. central nervous system depressant during labor

A nurse is teaching a group of new parents about their newborns' sensory capabilities. The nurse would identify which sense as being well-developed at birth?

B. hearing

Assessment of a newborn reveals rhythmic spontaneous movements. The nurse interprets this as indicating:

B. motor maturity.

A nurse is visiting a postpartum woman who delivered a healthy newborn 5 days ago. Which finding would the nurse expect?

B. pinkish brown discharge

When making a home visit, the nurse observes a newborn sleeping on his back in a bassinet. In one corner of the bassinet is some soft bedding material, and at the other end is a bulb syringe. The nurse determines that the mother needs additional teaching because:

B. soft bedding material should not be in areas where infants sleep.

A patient who delivered her infant 3 days ago and was discharged home calls her provider's office with a complaint of sweating all night. What is the cause of the increased perspiration?

Body secreting the excess fluids from pregnancy Copious diaphoresis occurs in the first few days after childbirth as the body rids itself of excess water and waste via the skin. The excessive diaphoresis is not caused by changes in hormones, nor because of the patient drinking too much fluid, nor because of the body trying to rid itself of the excess blood made during pregnancy.

A group of nursing students are reviewing information about maternal and paternal adaptations to the birth of a newborn. The nurse observes the parents interacting with their newborn physically and emotionally. The nurse documents this as which of the following? A) Puerperium B) Lactation C) Attachment D) Engrossment

A nurse is assessing a postpartum woman's adjustment to her maternal role. Which of the following would the nurse expect to occur first? A) Reestablishing relationships with others B) Demonstrating increasing confidence in care of the newborn C) Assuming a passive role in meeting her own needs D) Becoming preoccupied with the present

A nurse is completing a postpartum assessment. Which finding would alert the nurse to a potential problem? A) Lochia rubra with a fleshy odor B) Respiratory rate of 16 breaths per minute C) Temperature of 101 F D) Pain rating of 2 on a scale from 0 to 10

A nurse is developing a plan of care for a woman who is at risk for thromboembolism. Which of the following would the nurse include as the most cost-effective method for prevention? A) Prophylactic heparin administration B) Compression stocking C) Early ambulation D) Warm compresses

A postpartum client has a fourth-degree perineal laceration. The nurse would expect which of the following medications to be ordered? A)Ferrous sulfate (Feosol) B) Methylergonovine (Methergine) C) Docusate (Colace) D)Bromocriptine (Parlodel)

A postpartum woman is having difficulty voiding for the first time after giving birth. Which of the following would be least effective in helping to stimulate voiding? A) Pouring warm water over her perineal area B) Having her hear the sound of water running nearby C) Placing her hand in a basin of cool water D) Standing her in the shower with the warm water on

A postpartum woman is ordered to receive oxytocin to stimulate the uterus to contract. Which of the following would be most important for the nurse to do? A) Administer the drug as an IV bolus injection. B) Give as a vaginal or rectal suppository. C) Piggyback the IV infusion into a primary line. D) Withhold the drug if the woman is hypertensive.

A primipara client who is bottle feeding her baby begins to experience breast engorgement on her third postpartum day. Which instruction would be most appropriate to aid in relieving her discomfort? A)Express some milk from your breasts every so often to relieve the distention. B) Remove your bra to relieve the pressure on your sensitive nipples and breasts. C) Apply ice packs to your breasts to reduce the amount of milk being produced. D)Take several warm showers daily to stimulate the milk let-down reflex.

Review of a primiparous woman's labor and birth record reveals a prolonged second stage of labor and extended time in the stirrups. Based on an interpretation of these findings, the nurse would be especially alert for which of the following? A) Retained placental fragments B) Hypertension C) Thrombophlebitis D) Uterine subinvolution

The nurse develops a teaching plan for a postpartum client and includes teaching about how to perform Kegel exercises. The nurse includes this information for which reason? A) Reduce lochia B) Promote uterine involution C) Improve pelvic floor tone D) Alleviate perineal pain

The nurse is assessing a woman with abruption placentae who has just given birth. The nurse would be alert for which of the following? A)Severe uterine pain B) Board-like abdomen C) Appearance of petechiae D)Inversion of the uterus

To decrease the pain associated with an episiotomy immediately after birth, which action by the nurse would be most appropriate? A) Offer warm blankets. B) Encourage the woman to void. C) Apply an ice pack to the site. D) Offer a warm sitz bath.

When caring for a mother who has had a cesarean birth, the nurse would expect the clients lochia to be: A) Greater than after a vaginal delivery B) About the same as after a vaginal delivery C) Less than after a vaginal delivery D) Saturated with clots and mucus

When reviewing the medical record of a postpartum client, the nurse notes that the client has experienced a third-degree laceration. The nurse understands that the laceration extends to which of the following? A) Superficial structures above the muscle B) Through the perineal muscles C) Through the anal sphincter muscle D) Through the anterior rectal wall

When the nurse is assessing a postpartum client approximately 6 hours after delivery, which finding would warrant further investigation? A)Deep red, fleshy-smelling lochia B)Voiding of 350 cc C) Heart rate of 120 beats/minute D)Profuse sweating

Which of the following factors in a clients history would alert the nurse to an increased risk for postpartum hemorrhage? A)Multiparity, age of mother, operative delivery B) Size of placenta, small baby, operative delivery C) Uterine atony, placenta previa, operative procedures D)Prematurity, infection, length of labor

Which of the following would be most appropriate when massaging a woman's fundus? A) Place the hands on the sides of the abdomen to grasp the uterus. B) Use an up-and-down motion to massage the uterus. C) Wait until the uterus is firm to express clots. D) Continue massaging the uterus for at least 5 minutes.

A nurse is preparing a class on newborn adaptations for a group of soon-to-be parents. When describing the change from fetal to newborn circulation, which information would the nurse most likely include? Select all that apply.

C. Decrease in right atrial pressure leads to closure of the foramen ovale. D. Onset of respirations leads to a decrease in pulmonary vascular resistance. E. Increase in pressure in the left atrium results from increases in pulmonary blood flow. A. Closure of the ductus venosus eventually forces closure of the ductus arteriosus.

A nurse is explaining to a group of new parents about the changes that occur in the neonate to sustain extrauterine life, describing the cardiac and respiratory systems as undergoing the most changes. Which information would the nurse integrate into the explanation to support this description?

C. Pulmonary vascular resistance (PVR) is decreased as lungs begin to function.

Just after delivery, a newborn's axillary temperature is 94° F (34.4° C). What action would be most appropriate?

C. Rewarm the newborn gradually.

A primipara client gave birth vaginally to a healthy newborn girl 48 hours ago. The nurse palpates the client's fundus and documents which finding as normal?

C. two fingerbreadths below the umbilicus

A client who is breast-feeding her newborn tells the nurse, I notice that when I feed him, I feel fairly strong contraction-like pain. Labor is over. Why am I having contractions now? Which response by the nurse would be most appropriate? A)Your uterus is still shrinking in size; thats why youre feeling this pain. B) Let me check your vaginal discharge just to make sure everything is fine. C) Your body is responding to the events of labor, just like after a tough workout. D)The babys sucking releases a hormone that causes the uterus to contract.

A group of students are reviewing the process of breast milk production. The students demonstrate understanding when they identify which hormone as responsible for milk let-down? A) Prolactin B) Estrogen C) Progesterone D) Oxytocin

A nurse is assessing a postpartum woman. Which finding would cause the nurse to be most concerned? A) Leg pain on ambulation with mild ankle edema B) Calf pain with dorsiflexion of the foot. C) Perineal pain with swelling along the episiotomy D) Sharp stabbing chest pain with shortness of breath

A nurse teaches a postpartum woman about her risk for thromboembolism. Which of the following would the nurse be least likely to include as a factor increasing her risk? A) Increased clotting factors B) Vessel damage C) Immobility D) Increased red blood cell production

A postpartum client comes to the clinic for her 6-week postpartum checkup. When assessing the clients cervix, the nurse would expect the external cervical os to appear: A) Shapeless B) Circular C) Triangular D) Slit-like

A woman experiencing postpartum hemorrhage is ordered to receive a uterotonic agent. Which of the following would the nurse least expect to administer? A) Oxytocin B) Methylergonovine C) Carboprost D) Terbutaline

A woman who is 2 weeks postpartum calls the clinic and says, My left breast hurts. After further assessment on the phone, the nurse suspects the woman has mastitis. In addition to pain, the nurse would assess for which of the following? A)An inverted nipple on the affected breast B) No breast milk in the affected breast C) An ecchymotic area on the affected breast D)Hardening of an area in the affected breast

After teaching a group of nursing students about the process of involution, the instructor determines that additional teaching is needed when the students identify which of the following as being involved? A) Catabolism B) Muscle fiber contraction C) Epithelial regeneration D) Vasodilation

As part of an inservice program, a nurse is describing a transient, self-limiting mood disorder that affects mothers after childbirth. The nurse correctly identifies this as postpartum: A) Depression B) Psychosis C) Bipolar disorder D) Blues

The nurse is developing a teaching plan for a client who has decided to bottle feed her newborn. Which of the following would the nurse include in the teaching plan to facilitate suppression of lactation? A)Encouraging the woman to manually express milk B) Suggesting that she take frequent warm showers to soothe her breasts C) Telling her to limit the amount of fluids that she drinks D) Instructing her to apply ice packs to both breasts every other hour

While changing a female newborn's diaper, the nurse observes a mucus-like, slightly bloody vaginal discharge. Which action would the nurse do next?

D. Document this as pseudo menstruation.

A postpartum client has a fourth-degree perineal laceration. The nurse would expect which medication to be ordered?

D. ducosate

D. identify common features between themselves and the newborn E. make direct eye contact with the newborn

The nurse develops a teaching plan for a postpartum client and includes teaching about how to perform pelvic floor muscle training or Kegel exercises. The nurse includes this information for which reason?

D. improve pelvic floor tone

A nurse is reviewing the laboratory test results of a newborn. Which result would the nurse identify as a cause for concern?

D. platelets 75,000/uL

A nurse is completing a postpartum assessment. Which finding would alert the nurse to a potential problem?

D. temperature of 101° F (38.3° C)

While making a follow up home visit to a client in her first week postpartum, the nurse notes that she has lost 5 pounds. Which of the following would be the most likely reason for the weight loss?

Diuresis Diuresis is the most likely reason for the weight loss during the first postpartum week. Lactation accelerating postpartum weight loss is a popular notion but it is not statistically significant. Blood loss or nausea in postpartum week does not cause major weight loss.

A postpartum client is having difficulty stopping her urine stream. Which should the nurse do next?

Educate the client on how to perform Kegel exercises. Clients should begin Kegel exercises on the first postpartum day to increase the strength of the perineal floor muscles. Priority for this client would be to educate her how to perform Kegel exercises as strengthening these muscles will allow her to stop her urine stream.

A breastfeeding client informs the nurse that she is unable to maintain her milk supply. What instruction should the nurse give to the client to improve milk supply?

Empty the breasts frequently. The nurse should tell the client to frequently empty the breasts to improve milk supply. Encouraging cold baths and applying ice on the breasts are recommended to relieve engorgement in nonbreastfeeding clients. Kegel exercises are encouraged to promote pelvic floor tone.

For several hours after birth a multigravida client who experienced a much more difficult labor this time than any time previously, wants to talk about why the birthing process was so hard for her. She is focusing on this aspect to the point that she seems relatively indifferent to her newborn. How should the nurse handle this situation?

Encourage her to discuss her experience of the birth and answer any questions or concerns she may have. The client needs to explore her birth experience and clarify her questions. The nurse should allow her to ask questions, be supportive, and encourage her to express her feelings. Redirecting her attention to the baby, asking her to describe how she plans to integrate the new baby into the family, or pointing out positive features of the new baby do not meet the needs of the client at this time.

A client reports she has not had a bowel moment since her infant was born 2 days ago. She asks the nurse what she can do to help her have a bowel movement. What intervention is appropriate to encourage having a bowel movement?

Encourage the client to eat more fiber rich foods. Encouraging fiber rich foods will help with prevention of constipation. The client needs plenty of water, to ambulate, and take stool softeners if ordered by the provider. Offering a stimulant laxative is not appropriate. Adding dairy products to the diet may be a good thing, but will not generally produce a bowel movement. Holding the feces until there is a strong urge to defecate will only increase the risk of constipation as well as possible resultant complications.

A nurse is applying ice packs to the perineal area of a client who has had a vaginal birth. Which intervention should the nurse perform to ensure that the client gets the optimum benefits of the procedure?

Ensure ice pack is changed frequently. The nurse should ensure that the ice pack is changed frequently to promote good hygiene and to allow for periodic assessments. Ice packs are wrapped in a disposable covering or clean washcloth and then applied to the perineal area, not directly. The nurse should apply the ice pack for 20 minutes, not 40 minutes. Ice packs should be used for the first 24 hours, not for a week after birth.

A woman who has just given birth seems to be bonding with her newborn, despite the fact that earlier in labor she had expressed an intent to give the baby up for adoption. In this case, the nurse should encourage the mother to keep her baby.

False Do not attempt to change a woman's mind about keeping her child or placing the child for adoption during the postpartal period as she is extremely vulnerable to suggestion at this time, and such decisions are too long range and too important to be made at such an emotional time. Her earlier conclusion may be the sound one. Instead, offer nonjudgmental support. Be especially aware of your own feelings about this issue, to avoid influencing a woman's decision making unnecessarily.

A nurse is caring for a breastfeeding client who reports engorgement. The nurse identifies that the client's condition is due to not fully emptying her breasts at each feeding. Which suggestion should the nurse make to help her prevent engorgement?

Feed the baby at least every two or three hours. The nurse should suggest the client feed the baby every two or three hours to help her reduce and prevent further engorgement. Application of cold compresses to the breasts is suggested to reduce engorgement for nonbreastfeeding clients. If the mother has developed a candidal infection on the nipples, the treatment involves application of an antifungal cream to the nipples following feedings and providing the infant with oral nystatin. The nurse can suggest drying the nipples following feedings if the client experiences nipple pain.

A nurse is performing an assessment on a female client who gave birth 24 hours ago. On assessment, the nurse finds that the fundus is 2 cm above the umbilicus and boggy. Which intervention is a priority?

Have the client void, and then massage the fundus until it is firm. The fundus in a postpartum client should decrease 1 cm below the umbilicus each day. The fundus should also be firm to decrease the risk of postpartum hemorrhage. All of the listed interventions are appropriate, but a firm fundus is the priority.

As the nurse caring for postpartum patients, what laboratory study would you expect to have ordered by the birth attendant the morning after delivery of the baby?

Hemoglobin and hematocrit (H&H) Monitor the H&H and note the H&H before delivery. Most practitioners order a postpartum H&H on the morning after delivery. If the values drop significantly, the woman may have experienced postpartum hemorrhage. Note the blood type and Rh. If the woman is Rh-, she will need a RhoGAM workup. Determine the woman's rubella status. If she is nonimmune, she will need a rubella immunization before she is discharged home.

A concerned client tells the nurse that her husband, who was very excited about the baby before its birth, is apparently happy but seems to be afraid of caring for the baby. What suggestion should the nurse give to the client's husband to resolve the issue?

Hold the baby frequently. The nurse should suggest that the father care for the newborn by holding and talking to the child. Reading up on parental care and speaking to his friends or the primary care provider will not help the father resolve his fears about caring for the child.

When counseling a mother about the immunologic properties of breast milk, the nurse would emphasize breast milk as a major source of which immunoglobulin?

IgA

A nurse is assessing a postpartum client. Which measure is appropriate?

Instruct the client to empty her bladder before the examination. An empty bladder facilitates examination of the fundus. The client should be supine with arms at her sides and her knees bent. The arms-overhead position is unnecessary. Clean gloves should be used when assessing the perineum; sterile gloves are not necessary. The postpartum examination should not be done quickly. The nurse can take this time to teach the client about the changes in her body after birth.

A client reports pain in the lower back, hips, and joints 10 days after the birth of her baby. What instruction should the nurse give the client after birth to prevent low back pain and injury to the joints?

Maintain correct posture and positioning. The nurse should recommend that clients maintain correct position and good body mechanics to prevent pain in the lower back, hips, and joints. Avoiding carrying her baby and soaking several times per day is unrealistic. Application of ice is suggested to help relieve breast engorgement in nonbreastfeeding clients.

Upon assessment, a nurse notes the client has a pulse of 90 bpm, moderate lochia, and a boggy uterus. What should the nurse do next?

Massage the client's fundus. Tachycardia and a boggy fundus in the postpartum woman indicate excessive blood loss. The nurse would massage the fundus to promote uterine involution. It is not priority to notify the healthcare provider, assess blood pressure, or change the peri-pad at this time.

During a physical assessment of a newborn, the nurse observes bluish markings across the newborn's lower back. The nurse interprets this finding as:

Mongolian spots

A client who has a breastfeeding newborn reports sore nipples. Which intervention can the nurse suggest to alleviate the client's condition?

Offer suggestions based on observation to correct positioning or latching. The nurse should observe positioning and latching-on technique while breastfeeding so that she may offer suggestions based on observation to correct positioning/latching. This will help minimize trauma to the breast. The client should use only water, not soap, to clean the nipples to prevent dryness. Breast pads with plastic liners should be avoided. Leaving the nursing bra flaps down after feeding allows nipples to air dry.

A client delivered vaginally 2 days prior and wishes to prevent getting pregnant again. She asks the nurse when she will need to begin birth control measures. How should the nurse respond?

Ovulation may start at soon as 3 weeks after delivery. The client needs to be aware and use a form of birth control. She needs to be cleared by her provider prior to intercourse if she has a vaginal delivery, but in the event that she has intercourse, needs to be prepared for the possibility of pregnancy. Options C and D are incorrect because they give the patient misinformation. Ovulation can occur without the return of the menstrual cycle, and ovulation does return sooner than six months after delivery.

What is the relationship between oxytocin and prostaglandins at the end of pregnancy?

Oxytocin aids in stimulating prostaglandin synthesis through receptors in the decidua.

A postpartum client reports stress incontinence. What information should the nurse suggest to the client to overcome stress incontinence?

Perform Kegel exercises. The nurse should ask the client to perform the Kegel exercises in which the client needs to alternately contract and relax the perineal muscles. Aerobic exercises will not help to strengthen perineal muscles. Reduced fluid intake and frequent emptying of the bladder will not help the client overcome stress incontinence.

A client who gave birth about 12 hours ago informs the nurse that she has been voiding small amounts of urine frequently. The nurse examines the client and notes the displacement of the uterus from the midline to the right. What intervention would the nurse perform next?

Perform urinary catheterization. Displacement of the uterus from the midline to the right and frequent voiding of small amounts suggests urinary retention with overflow. Catheterization may be necessary to empty the bladder to restore tone. An IV and oxytocin are indicated if the client experiences hemorrhage due to uterine atony from being displaced. The healthcare provider would be notified if no other interventions help the client.

During a postpartum exam on the day of birth, the woman reports that she is still so sore that she cannot sit comfortably. The nurse examines her perineum and find the edges of the episiotomy approximated without signs of a hematoma. Which intervention will be most beneficial at this point?

Place an ice pack. The labia and perineum may be edematous after birth and bruised; the use of ice would assist in decreasing the pain and swelling. Applying a warm washcloth would bring more blood as well as fluid to the sore area, thereby increasing the edema and the soreness. Applying a witch hazel pad needs the order of the primary care provider. Notifying a care provider is not necessary at this time as this is considered a normal finding.

Which action would lead the nurse to assess that a postpartal woman is entering the taking-hold phase of the postpartal period?

She did her perineal care independently. During the taking-in phase, women tend to be dependent; during the taking-hold phase, they begin independent actions.

Which maternal reaction is the most concerning?

She neglects to engage with or provide care for the baby and shows little interest in it. A mother not bonding with the infant or showing disinterest is a cause for concern and requires a referral or notification of the primary health care provider. Some mothers hesitate to take their newborn and express disappointment in the way the baby looks, especially if they want a child of one sex and have a child of the opposite sex. Expressing doubt about the ability to care for the baby is not unusual, and being tearful for several days with difficulty eating and sleeping is common with "postpartum blues".

Which information would the nurse emphasize in the teaching plan for a postpartal woman who is reluctant to begin taking warm sitz baths?

Sitz baths increase the blood supply to the perineal area. Sitz baths decrease pain and aid healing by increasing blood flow to the perineum.

Which instruction should the nurse provide to a breast-feeding woman experiencing breast engorgement?

Standing in a warm shower or applying warm compresses immediately before feedings will help soften the breasts and nipples to allow the newborn to latch on more easily and will enhance the let-down reflex. Wearing a tight supportive bra all day is appropriate for the woman who is not breast-feeding. Frequent emptying of the breasts helps to resolve engorgement, so the mother should be encouraged to feed the newborn, which would involve touching her breasts and nipples. The breast-feeding woman should apply cold compresses but not ice to her breasts between feedings to reduce swelling.

A nurse is caring for a client in the postpartum period. The nurse observes that distention of the abdominal muscles during pregnancy has resulted in separation of the rectus muscles. What intervention should the nurse perform to assist in healing the distended abdominal muscles?

Suggesting proper exercise The nurse should suggest proper exercise to the client to heal the distended abdominal muscles. Application of warm compresses, application of moist heat, and massaging the muscles gently are not suggested for distended abdominal muscles.

While educating a class of postpartum clients before discharge home after birth, one woman asks when "will I stop bleeding?" How should the nurse respond?

The bleeding may slowly decrease over the next 1 to 3 weeks, changing color to a white discharge, which may continue for up to 6 weeks. The lochia changes color in the first few weeks postpartum; the active bleeding stops in the first week, but a white discharge may continue for up to 6 weeks after birth. Bleeding does not occur "off and on"; the bleeding stops during the first week but a discharge continues to occur. The discharge may continue for up to six weeks, not just bleeding.

A nurse helps a postpartum woman out of bed for the first time postpartally and notices that she has a very heavy lochia flow. Which assessment finding would best help the nurse decide that the flow is within normal limits?

The color of the flow is red. A typical lochia flow on the first day postpartally is red; it contains no large clots; the uterus is firm, indicating that it is well contracted.

Charting on the nursing care plan patient care, which nursing diagnosis has the highest priority for a postpartum patient?

The highest priority is the risk for injury related to postpartum hemorrhage. The patient needs close observation and assessment for hemorrhage.

While visiting a client at home on the 10th day postpartum, the nurse assesses the client's lochia. Which of the following would the nurse interpret as an expected finding?

The normal color of lochia on the tenth day of postpartum is yellowish white. The color of lochia changes from red to pink by approximately four or five days postpartum. The color of lochia is never yellowish pink.

Feel for the fetal buttocks or head while palpating the abdomen.

The nurse is performing Leopold's maneuvers to determine fetal presentation, position, and lie. Which action would the nurse do first?

Continue to monitor the FHR because this pattern is benign.

The nurse notes persistent early decelerations on the fetal monitoring strip. Which of the following would the nurse do next?

Which reason explains why women should be encouraged to perform Kegel exercises after birth?

They promote blood flow, enabling healing and muscle strengthening. Exercising the pubococcygeal muscle increases blood flow to the area. The increased blood flow brings oxygen and other nutrients to the perineal area to aid in healing. Additionally, these exercises help strengthen the musculature, thereby decreasing the risk of future complications, such as incontinence and uterine prolapse. Performing Kegel exercises may assist with lochia removal, but that isn't their main purpose. Bowel function is not influenced by Kegel exercises. Kegel exercises do not generate sufficient energy expenditure to burn many calories.

For the first hour after birth, the height of the fundus is at the umbilicus or even slightly above it.

True

The nurse can expect a patient who had a cesarean birth to have less lochia discharge than the patient who had a vaginal birth.

True Women who had a cesarean birth will have less lochia discharge than those who had a vaginal birth, but stages and color changes remain the same.

true vs false labor: contraction strength

True: --become stronger with time --vaginal pressure usually felt False: --frequently weak --not getting stronger with time --strong one followed by weaker ones

true vs false labor: any change in activity

True: --contractions continue no matter what positional change is made False: --contractions may stop or slow down with walking or making a position change

true vs false labor: contraction timing

True: --regular --becoming closer together --usually 4-6 mins apart --lasting 30-60 secs False: --irregular --not occurring close together

true vs false labor: contraction discomfort

True: --starts in the back and radiates around toward the front of the abdomen False: --usually felt in the front of the abdomen

true vs false labor: stay or go

True: --stay home until contractions are 5 mins apart --last 45-60 sec --strong enough so that a conversation is not possible --now go to hospital/birth center False: --drink fluids and walk around to see if there is any change in the intensity of the contractions --if contractions diminish in intensity after either or both --> stay home

A nurse is teaching new parents about bathing their newborn. The nurse determines that the teaching was successful when the parents make which statement?

We should avoid using any kind of baby powder

The nurse is providing education to a mother who is going to bottle feed her infant. What information will the nurse provide to this mom regarding breast care?

Wear a tight, supportive bra. The client trying to dry up her milk supply should do as little stimulation to the breast as possible. She needs to wear a tight, supportive bra and use ice. Running warm water over the breasts in the shower will only stimulate the secretion, and therefore the production, of milk. Massaging the breasts will stimulate them to expel the milk and therefore produce more milk, as will expressing small amounts of milk when the breasts are full.

A nurse is caring for a nonbreastfeeding client in the postpartum period. The client reports engorgement. What suggestion should the nurse provide to alleviate breast discomfort?

Wear a well-fitting bra. The nurse should suggest the client wear a well-fitting bra to provide support and help alleviate breast discomfort. Application of warm compresses and expressing milk frequently is suggested to alleviate breast engorgement in breastfeeding clients. Hydrogel dressings are used prophylactically in treating nipple pain.

Between the umbilicus and the symphysis pubis

When applying the ultrasound transducers for continuous external electronic fetal monitoring, at which location would the nurse place the transducer to record the FHR?

Notify the health care provider.

When assessing fetal heart rate, the nurse finds a heart rate of 175 bpm, accompanied by a decrease in variability and late decelerations. Which of the following would the nurse do next?

Moderate

When palpating the fundus during a contraction, the nurse notes that it feels like a chin. The nurse interprets this finding as indicating which type of contraction?

Every 15 to 30 minutes

When planning the care of a woman in the active phase of labor, the nurse would anticipate assessing the fetal heart rate at which interval?

Assessing the uterine fundus

Which of the following is a priority when caring for a woman during the fourth stage of labor?

"Choose whatever method you feel most comfortable with for pushing."

Which of the following would be most appropriate for the nurse to suggest about pushing to a woman in the second stage of labor?

Walking with partner support, straddling with forward leaning over a chair, rocking back and forth with foot on chair

Which position would be most appropriate for the nurse to suggest as a comfort measure to a woman who is in the first stage of labor?

What does the body do to protect the baby when a woman has a spontaneous rupture of membranes?

a continuous supply of amniotic fluid is produced Barrier to infection is gone and infant can be at risk!

When assessing the uterus of a 2-day postpartum client, which finding would the nurse evaluate as normal?

a moderate amount of lochia rubra The client should have lochia rubra for 3 to 4 days postpartum. The client would then progress to lochia serosa being expelled from day 3 to 10. Last the client would have lochia alba from day 10 to 14 until 3 to 6 weeks.

Bonding between a mother and her infant can be defined how?

a process of developing an attachment and becoming acquainted with each other Bonding in the maternal-newborn world is the attachment process that occurs between a mother and her newborn infant. This is how the mother and infant become engaged with each other and is the foundation for the relationship. Bonding is a process and not a single event. The process of bonding is not a year-long process, and the family growing closer together after the birth of a new baby is not bonding.

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

applying ice Ice promotes comfort by decreasing blood flow (vasoconstriction), numbing the area, and discouraging further letdown of milk. Restricting fluids does not reduce engorgement and should not be encouraged. Warm compresses will promote blood flow and hence, milk production, worsening the problem of engorgement. Bromocriptine has been removed from the market for lactation suppression.

what is an amniotomy

artificial rupture of the fetal membranes

A nurse finds the uterus of a postpartum woman to be boggy and somewhat relaxed. This a sign of which condition?

atony The uterus in a postpartum client should be midline and firm. A boggy or relaxed uterus signifies uterine atony, which can predispose the woman to hemorrhage.

A new mother, who is an adolescent, was cautious at first when holding and touching her newborn. She seemed almost afraid to make contact with baby and only touched it lightly and briefly. However, 48 hours after the birth, the nurse now notices that the new mother is pressing the newborn's cheek against her own and kissing her on the forehead. The nurse recognizes these actions as which behavior?

attachment When a woman has successfully linked with her newborn it is termed attachment or bonding. Although a woman carried the child inside her for 9 months, she often approaches her newborn not as someone she loves but more as she would approach a stranger. The first time she holds the infant, she may touch only the blanket. Gradually, as a woman holds her child more, she begins to express more warmth, touching the child with the palm of her hand rather than with her fingertips. She smoothes the baby's hair, brushes a cheek, plays with toes, and lets the baby's fingers clasp hers. Soon, she feels comfortable enough to press her cheek against the baby's or kiss the infant's nose; she has successfully bonded or become a mother tending to her child. Engrossment describes the action of new fathers when they stare at their newborn for long intervals. Involution is the process whereby the reproductive organs return to their nonpregnant state. Engorgement is the tension in the breasts as they begin to fill with milk.

A new mother tells the nurse at the baby's 3 month check-up, "When she cries, it seems like I am the only one who can calm her down." This is an example of which behavior?

attachment Attachment is the development of strong affection between an infant and a significant other. It does not occur overnight. It occurs through mutually satisfying experiences. Attachment behaviors include seeking, staying close to, and exchanging gratifying experiences with the infant. Bonding is the close emotional attraction to a newborn by the parents that develops in the first 30 to 60 minutes after birth. This is not an example of being spoiled.

On assessment of a 2-day postpartum client the nurse finds that the fundus is boggy, at the umbilicus, and slightly to the right. What is the most likely cause of this assessment finding?

bladder distention The most often cause of a displaced uterus is a distended bladder. Ask the client to void and then reassess the uterus. According to the scenario described, the most likely cause of the uterine findings would not be uterine atony. A full bowel or poor bladder tone would not cause a boggy and displaced fundus.

A nurse is monitoring the vital signs of a client 24 hours after birth. She notes that the client's blood pressure is 100/60 mm Hg. Which postpartum complication should the nurse most suspect in this client, based on this finding?

bleeding Blood pressure should also be monitored carefully during the postpartal period because a decrease in this can also indicate bleeding. In contrast, an elevation above 140 mm Hg systolic or 90 mm Hg diastolic may indicate the development of postpartal gestational hypertension, an unusual but serious complication of the puerperium. An infection would best be indicated by an elevated oral temperature. Diabetes would be indicated by an elevated blood glucose level.

A woman has just given birth to a baby. Her prelabor vital signs were temperature: 98.8° F (37.1° C); blood pressure: 120/70 mm Hg; pulse; 80 beats/min. and respirations: 20 breaths/min. Which combination of findings during the early postpartum period are the most concerning?

blood pressure 90/50 mm Hg, pulse 120 beats/min, respirations 24 breaths/min. The decrease in BP with an increase in HR and RR indicate a potential significant complication and are out of the range of normals from birth and need to be reported immediately. Shaking chills with a temperature of 100.3º F (37.9º C) can occur due to stress on the body and is considered a normal finding. A fever of 100.4º F (38º C) should be reported. The other options are considered to be within normal limits after giving birth to a baby.

The nurse is concerned with the interactions between a mother and her 2-day-old infant. The nurse observes signs of impaired bonding and attachment. Which action should the nurse document as a cause for concern?

calling the baby it or they Many new parents will need assistance with diaper changes; this is not a flag for concern; making eye contact and breastfeeding are positive interaction behaviors; if the mother calls the baby "it" and does not use the child's name, this is a sign that further information needs to be gathered and assessments should be completed.

A nurse is conducting a refresher in-service program for a group of neonatal nurses. After teaching the group about hepatic system adaptations after birth, the nurse determines that the teaching was successful when the group identifies which process as reflective of the change of bilirubin from a fat-soluble product to a water-soluble product?

conjunction

A mother who just given birth has difficulty sleeping despite her exhaustion from labor. What are the causes of this inability to rest? Select all that apply.

crying baby inability to get adequate pain relief frequent trips to the bathroom due to diuresis excess fatigue and overstimulation by visitors The period before labor and birth can be uncomfortable for the mother, thus preventing adequate rest and creating a sleep hunger. The early postpartum period involves many adjustments that can take a toll on the mother's sleep.

When caring for a postpartum client who has given birth vaginally, the nurse assesses the client's respiratory status, noting that it has quickly returned to normal. The nurse understands that which factor is responsible for this change?

decreased intra-abdominal pressure The nurse should identify decreased intra-abdominal pressure as the cause of the respiratory system functioning normally. Progesterone levels do not influence the respiratory system. Decreased bladder pressure does not affect breathing. Anesthesia used during birth causes the respiratory system to take a longer time to return to normal.

Many clients experience a slight fever after birth especially during the first 24 hours. To what should the nurse attribute this elevated temperature?

dehydration Many women experience a slight fever (100.4° F [38° C]) during the first 24 hours after birth. This results from dehydration because of fluid loss during labor. With the replacement of fluids the temperature should return to normal after 24 hours.

The nurse, assessing the lochia of a client, attempts to separate a clot and identifies the presence of tissue. Which observation would indicate the presence of tissue?

difficult to separate clots If tissue is identified in the lochia, it is difficult to separate clots. Yellowish-white lochia indicates increased leukocytes and decreased fluid content. Easily separable lochia indicates the presence of clots only. Foul-smelling lochia indicates endometritis.

While making a follow-up home visit to a client in her first week postpartum, the nurse notes that she has lost 5 pounds. Which reason for this loss would be the most likely?

diuresis Diuresis is the most likely reason for the weight loss during the first postpartum week. Lactation accelerating postpartum weight loss is a popular notion, but it is not statistically significant. Blood loss or nausea in postpartum week does not cause major weight loss.

Which nursing intervention is appropriate for prevention of a urinary tract infection (UTI) in the postpartum woman?

encouraging the woman to empty her bladder completely every 2 to 4 hours The nurse should advise the woman to urinate every 2 to 4 hours while awake to prevent overdistention and trauma to the bladder. Maintaining a good fluid intake is also important, but it is not necessary to increase fluids if the woman is consuming enough. Screening for bacteria in the urine would require a primary care provider's order and is not necessary as a prevention measure.

The nurse is assessing a breastfeeding mom 72 hours after birth. When assessing her breasts, the client reports bilateral breast pain around the entire breast. What is the most likely cause of the pain?

engorgement The client is only 72 hours postbirth and is reporting bilateral breast tenderness. Milk typically comes in at 72 hours after birth, and with the production of the milk comes engorgement. The other problems do not typically develop until there is fully established breastfeeding

The nurse is assessing a breastfeeding mom 72 hours after delivery. When assessing her breast, the patient reports bilateral breast pain around the entire breast. What is the most likely cause of the pain?

engorgement The patient is only 72 hours post-delivery and is complaining of bilateral breast tenderness. Milk typically comes in at 72 hours after delivery, and with the production of the milk comes engorgement. The other problems do not typically develop until there is fully established breastfeeding.

The LVN/LPN will be assessing a postpartum client for danger signs after a vaginal birth. What assessment finding would the nurse assess as a danger sign for this client?

fever more than 100.4° F (38° C) A fever more than 100.4° F (38° C) is a danger sign that the client may be developing a postpartum infection. Lochia rubra is a normal finding as is a firm uterine fundus. A uterine fundus above the umbilicus may indicate that the client has a full bladder but does not indicate a postpartum infection.

A nurse is caring for a client who has just received an episiotomy. The nurse observes that the laceration extends through the perineal area and continues through the anterior rectal wall. How does the nurse classify the laceration?

fourth degree The nurse should classify the laceration as fourth degree because it continues through the anterior rectal wall. First-degree laceration involves only skin and superficial structures above muscle; second-degree laceration extends through perineal muscles; and third-degree laceration extends through the anal sphincter muscle but not through the anterior rectal wall.

what type of breech can result in a vaginal birth

frank breech

When doing a health assessment, at which location would the nurse expect to palpate the fundus in a woman on the second postpartal day and how should it feel?

fundus two fingerbreadths below umbilicus and firm A uterine fundus typically regresses at a rate of one fingerbreadth a day, so on the second day postpartum it would be two fingerbreadths under the umbilicus and would feel firm.

A newborn is scheduled to undergo a screening test for phenylketonuria (PKU). The nurse prepares to obtain the blood sample from the newborn's

heel

Thirty minutes after receiving pain medication, a postpartum woman states that she still has severe pain in the perineal region. Upon assessing and palpating the site, what can the nurse expect to find that might be causing this severe pain?

hematoma If a postpartum woman has severe perineal pain despite use of physical comfort measures and medication, the nurse should check for a hematoma by inspecting and palpating the area. If one is found, the nurse needs to notify the primary care provider immediately.

When caring for postpartum clients, the nurse would expect the birth attendant to prescribe what laboratory study the morning after the birth of the baby?

hemoglobin and hematocrit H&H Monitor the H&H and note the H&H before birth. Most practitioners prescribe a postpartum H&H on the morning after birth. If the values drop significantly, the woman may have experienced postpartum hemorrhage. Note the blood type and Rh. If the woman is Rh-, she will need a Rho(D) immune globulin workup. Determine the woman's rubella status. If she is nonimmune, she will need a rubella immunization before she is discharged home.

A client who gave birth to twins 6 hours ago becomes restless and nervous. Her blood pressure falls from 130/80 mm Hg to 96/50 mm Hg. Her pulse drops from 80 to 56 bpm. She was induced earlier in the day and experienced abruptio placentae. Based on this information, what postpartum complication would the nurse expect is happening?

hemorrhage Some risk factors for developing hemorrhage after birth include precipitous labor, uterine atony, placenta previa and abruptio placentae, labor induction, operative procedures, retained placenta fragments, prolonged third stage of labor, multiparity, and uterine overdistention.

A client in her sixth week postpartum reports general weakness. The client has stopped taking iron supplements that were prescribed to her during pregnancy. The nurse would assess the client for which condition?

hypovolemia The nurse should assess the client for hypovolemia as the client must have had hemorrhage during birth and puerperium. Additionally, the client also has discontinued iron supplements. Hyperglycemia can be considered if the client has a history of diabetes. Hypertension and hyperthyroidism are not related to discontinuation of iron supplements.

A woman who is breastfeeding her newborn reports that her breasts seem quite full. Assessment reveals that her breasts are engorged. Which factor would the nurse identify as the most likely cause for this development?

inability of infant to empty breasts For the breastfeeding mother, engorgement is often the result of vascular congestion and milk stasis, primarily caused by the infant not fully emptying the mother's breasts at each feeding. Cracking of the nipple could lead to infection. Improper positioning may lead to nipple tenderness or pain. Inadequate secretion of prolactin causes a decrease in the production of milk.

What is thought to be the cause of "nesting/ increased energy level" in premonitory labor?

increase in epinephrine release caused by a decrease in progesterone. 24-48 hours before onset of labor

Though the direct cause of initiation of labor is unknown what are some of the factors that can cause it?

increased release of Prostaglandins*, uterine stretch, progesterone withdrawal, increased oxytocin sensitivity(inconclusive), a change in estrogen- to progesterone ratio.

A client appears to be resting comfortably 12 hours after giving birth to her first child. In contrast, she labored for more than 24 hours, the primary care provider had to use forceps to deliver the baby, and she had multiple vaginal examinations during labor. Based on this information what postpartum complication is the client at risk for developing?

infection There are many risk factors for developing a postpartum infection: operative procedures (e.g., forceps, cesarean section, vacuum extraction), history of diabetes, prolonged labor (longer than 24 hours), use of Foley catheter, anemia, multiple vaginal examinations during labor, prolonged rupture of membranes, manual extraction of placenta, and HIV.

A group of nurses are reviewing information about the changes in the newborn's lungs that must occur to maintain respiratory function. The nurses demonstrate understanding of this information when they identify which event as occurring first?

initiation of respiratory movement

The process by which the reproductive organs return to the nonpregnant size and function is termed what?

involution Involution is the term used to describe the process of the return to nonpregnancy size and function of reproductive organs. Evolution is change in the genetic material of a population of organisms from one generation to the next. Decrement is the act or process of decreasing. Progression is defined as movement through stages such as the progression of labor.

The nurse explains to a client who recently gave birth that she will undergo both retrogressive and progressive changes in the postpartal period. Which changes are retrogressive? Select all that apply.

involution of the uterus contraction of the cervix decrease of pregnancy hormones return of blood volume to prepregnancy level Retrogressive changes represent a return to prepregnancy conditions and include involution of the uterus, contraction of the cervix, decrease of pregnancy hormones, and return of the blood volume to prepregnancy level. Progressive changes involve changes to new processes or roles, such as the formation of breast milk (lactation) and the beginning of a parental role.

The nurse assesses a postpartum woman's perineum and notices that her lochial discharge is moderate in amount and red. The nurse would record this as what type of lochia?

lochia rubra Lochia rubra is red; it lasts for the first few days of the postpartal period.

What is the bloody show in premonitory labor?

losing the mucous plug mixed with blood from the cervical capillaries.

A new mother who is breastfeeding reports that her right breast is very hard, tender, and painful. Upon examination the nurse notices several nodules and the breast feels very warm to the touch. What do these findings indicate to the nurse?

mastitis Engorged breasts are hard, tender, and taut. If the breasts have nodules, masses, or areas of warmth, they may have plugged ducts, which can lead to mastitis if not treated promptly.

Inspection of a woman's perineal pad reveals a 5-inch stain. How should the nurse document this amount?

moderate Moderate lochia would describe a 4- to 6-inch stain, scant lochia a 1- to 2-inch stain, and light or small an approximately 4-inch stain. Heavy or large lochia would describe a pad that is saturated within 1 hour.

A nurse is assessing a client's lochia every 15 minutes for the first hour during the fourth stage of labor. Which finding would the nurse expect to assess?

moderate lochia rubra with no clots During the first hour following birth, the nurse should find moderate lochia rubra with no clots. Lochia rubra with few clots or saturation of two or more pads within this first hour are not abnormal findings that require further investigation. Lochia alba appears around the 10th day postpartum.

Which lochia pattern should be reported immediately?

moderate lochia serosa on day 4 postpartum, increasing in volume and changing to rubra on day 5 Lochia by day 4 should be decreasing in amount, and the color should be changing to pink tinge. Red rubra on day 4 may indicate bleeding, and the healthcare provider should be notified. A moderate flow of lochia rubra on day 3 postpartum, changing to serosa on day 5, is a normal finding; as is lochia progressing from rubra to serosa to alba within 10 days of delivery; and so is moderate lochia rubra on day 3, mixed serosa and rubra on day 4, and light serosa on day 5.

what happens when the cervix is fully dilated

no longer palpable on vaginal exam

What is lightening?

occurs when the fetal presenting part begins to descent into the maternal pelvis. The uterus lowers and moves more anterior position. in primiparas can occur 2 weeks or more in multiparas it may occur right before labor starts

The nurse working on a postpartum client must check lochia in terms of amount, color, change with activity and time, and:

odor The nurse when assessing lochia must do so in terms of amount, color, odor, and change with activity and time.

The nurse is observing a client who gave birth yesterday. Where should the nurse expect to find the top of the client's fundus?

one fingerbreadth below the umbilicus After a client gives birth, the height of her fundus should decrease by approximately one fingerbreadth (1 cm) each day. By the end of the first postpartum day, the fundus should be one fingerbreadth below the umbilicus. Immediately after birth, the fundus may be above the umbilicus; 6 to 12 hours after birth, it should be at the level of the umbilicus; 10 days after birth, it should be below the symphysis pubis.

Dilation

opening or enlargement of the external cervical os

A nurse is caring for a client who is nursing her baby boy. The client reports afterpains. Secretion of which substance should the nurse identify as the cause of afterpains?

oxytocin Secretion of oxytocin stimulates uterine contraction and causes the woman to experience afterpains. Decrease in progesterone and estrogen after placental delivery stimulates the anterior pituitary to secrete prolactin which causes lactation.

The nurse is used to working on the postpartum floor taking care of women who have had normal vaginal births. Today, however, the nurse has been assigned to help care for women who are less than 24 hours post cesarean birth. The nurse realizes that some areas will not be assessed. What would the nurse leave out of the client assessments?

perineum Usually a woman who experiences cesarean birth does not have an episiotomy, although rarely this may be the case.

A nurse is reviewing a postpartum woman's history and labor and birth record. The nurse determines the need to closely monitor this client for infection based on which factor?

placenta removed via manual extraction Manual removal of the placenta places a woman at risk for postpartum infection, as does a hemoglobin level less than 10.5 mg/dL. Precipitous labor, less than 3 hours, and multiparity, more than three births closely spaced, place a woman at risk for postpartum hemorrhage.

A woman who gave birth to a healthy baby 5 days ago is experiencing fatigue and weepiness, lasting for short periods each day. Which condition does the nurse believe is causing this experience?

postpartum baby blues Postpartum baby blues is common in women after giving birth. It is a mild depression; however, functioning usually is not impaired. Postpartum blues usually peaks at day 4 or 5 after birth. Postpartum anxiety and postpartum depression do not usually start until at least 3 to 4 weeks and up to 1 year following the birth of a baby. Postpartum reaction is a term to include postpartum depression, anxiety, and psychosis.

A nurse is caring for a client on the second day postpartum. The client informs the nurse that she is voiding a large volume of urine frequently. Which factor should the nurse identify as a potential cause for urinary frequency?

postpartum diuresis The nurse should identify postpartum diuresis as the potential cause for urinary frequency. Urinary overflow occurs if the bladder is not completely emptied. Urinary tract infection may be accompanied by fever and a burning sensation. Trauma to pelvic muscles does not affect urinary frequency.

what does the second letter in fetal position denote

represents the particular presenting part of the fetus -- O, S, M, A, D

While observing the interaction between a newborn and the mother, the nurse notes the newborn nestling into the arms of the mother. The nurse identifies this as which behavior?

social behaviors

Which factor might result in a decreased supply of breast milk in a postpartum client?

supplemental feedings with formula Routine formula supplementation may interfere with establishing an adequate milk volume because decreased stimulation to the client's nipples affects hormonal levels and milk production. Vitamin C levels have not been shown to influence milk volume. One drink containing alcohol generally tends to relax the client, facilitating letdown. Excessive consumption of alcohol may block letdown of milk to the infant, though supply is not necessarily affected. Frequent feedings are likely to increase milk production.

While caring for a client following a lengthy labor and birth, the nurse notes that the client repeatedly reviews her labor and birth and is very dependent on her family for care. The nurse is correct in identifying the client to be in which phase of maternal role adjustment?

taking-in The taking-in phase occurs during the first 24 to 48 hours following the birth of the newborn and is characterized by the mother taking on a very passive role in caring for herself, as well as recounting her labor experience. The second maternal adjustment phase is the taking-hold phase and usually lasts several weeks after the birth. This phase is characterized by both dependent and independent behavior, with increasing autonomy. During the letting-go phase the mother reestablishes relationships with others and accepts her new role as a parent. Acquaintance/attachment phase is a newer term that refers to the first 2 to 6 weeks following birth when the mother is learning to care for her baby and is physically recuperating from the pregnancy and birth.

A new mother gave birth to her baby 24 hours ago and today has been content to rest in her hospital bed, hold her baby, allow the nurse to care for her, and to discuss her labor and birth experience with visitors. Which phase of the puerperium is this client in?

taking-in phase The taking-in phase is largely a time of reflection. During this 1- to 3-day period, a woman is largely passive. She prefers having a nurse attend to her needs and make decisions for her, rather than do these things herself. As a part of thinking and pondering about her new role, the woman usually wants to talk about her pregnancy, especially about her labor and birth. After a time of passive dependence, a woman enters the taking-hold phase and begins to initiate action. She prefers to get her own washcloth or to make her own decisions. In the letting-go phase, a woman finally redefines her new role. She gives up the fantasized image of her child and accepts the real one; she gives up her old role of being childless or the mother of only one or two (or however many children she had before this birth). Rooming-in is a feature offered by hospitals in which the infant is allowed to stay in the same hospital room as the mother following birth; it is not a phase of the puerperium.

Rubin identified a series of changes that a new mother makes during the postpartum period. The correct sequence of these changes is:

taking-in, taking-hold, letting-go. The new mother makes progressive changes to know her infant, review the pregnancy and labor, validate her safe passage through these phases, learn the initial tasks of mothering, and let go of her former life to incorporate this new child.

During the second day postpartum, a nurse notices that a client is initiating breastfeeding with her infant and changing her infant's diapers with some assistance from her partner. Which phase does the nurse recognize that the woman is experiencing?

the taking-hold phase The taking-in phase is characterized by the woman's dependency on and passivity with others. Maternal needs are dominant, and talking about the birth is an important task. The new mother follows suggestions, is hesitant about making decisions, and is still preoccupied with her needs. The taking-hold phase is characterized by the woman becoming more independent and interested in learning how to care for her infant. Learning how to be a competent parent is an important task. The letting-go phase is an interdependent phase after birth in which the mother and family move forward as a family system, interacting together. The binding-in phase is a distractor for this question.

What hormone affects the frequency of braxton hicks as labor gets closer

the uterus becomes more sensitive to oxytocin

Review of a woman's labor and birth record reveals a laceration that extends through the anal sphincter muscle. The nurse identifies this laceration as which type?

third-degree laceration A third-degree laceration extends through the anal sphincter muscle. A first-degree laceration involves only skin and superficial structures above the muscle. A second-degree laceration extends through the perineal muscles. A fourth-degree laceration continues through the anterior rectal wall.

What are braxton hicks?

throughout pregnancy aids in moving the cervix from posterior to anterior position. can also help ripen and soften cervix. -These will be irregular and can be decreased by: walking, voiding, eating, increasing fluid intake or changing position. -usually last 30 sec but could last up to 2 min

A primipara client gave birth vaginally to a healthy newborn girl 48 hours ago. The nurse palpates the client's fundus and documents which finding as normal?

two fingerbreadths below the umbilicus During the first few days after birth, the uterus typically descends downward from the level of the umbilicus at a rate of 1 cm (1 fingerbreadth) per day so that by day 2, it is about 2 fingerbreadths below the umbilicus.

The nurse is caring for a client in the postpartum period. The client has difficulty in voiding and is catheterized. The nurse then would monitor the client for which condition?

urinary tract infection The nurse would need to monitor the client for signs and symptoms of a urinary tract infection, a risk associated with catheterization. Stress incontinence is caused due to loss of pelvic muscle tone after birth. Increased urinary output is observed in diuresis. Catheterization does not cause loss of pelvic muscle tone, increased urine output, or stress incontinence.

A nurse is caring for a client with postpartum hemorrhage. What should the nurse identify as the significant cause of postpartum hemorrhage?

uterine atony Uterine atony is the significant cause of postpartum hemorrhage. Discomfort from hemorrhoids increases risk for constipation during postpartum, diuresis causes weight loss during the first postpartal week, whereas iron deficiency causes anemia in the puerperium.

A postpartum woman is experiencing subinvolution. When reviewing the client's history for factors that might contribute to this condition, which factors would the nurse identify? Select all that apply.

uterine infection hydramnios prolonged labor Factors that inhibit involution include prolonged labor and difficult birth, uterine infection, overdistention of the uterine muscles such as from hydramnios, a full bladder, close childbirth spacing, and incomplete expulsion of amniotic membranes and placenta. Breastfeeding, early ambulation, and an empty bladder would facilitate uterine involution.

The nurse is making a home visit to a woman who is 4 days postpartum. Which finding would indicate to the nurse that the woman is experiencing a problem?

uterus 1 cm below umbilicus By the fourth postpartum day, the uterus should be approximately 4 cm below the umbilicus. Being only at 1 cm indicates that the uterus is not contracting as it should. Lochia serosa is normal from days 3 to 10 postpartum. After birth the vagina is edematous and thin with few rugae. It eventually thickens and rugae return in approximately 3 weeks. Diaphoresis is common during the early postpartum period, especially in the first week. It is a mechanism to reduce fluids retained during pregnancy and restore prepregnant body fluid levels.

A postpartum client who had a cesarean birth reports right calf pain to the nurse. The nurse observes that the client has nonpitting edema from her right knee to her foot. The nurse knows to prepare the client for which test first?

venous duplex ultrasound of the right leg Right calf pain and nonpitting edema may indicate deep vein thrombosis (DVT). Postpartum clients and clients who have had abdominal surgery are at increased risk for DVT. Venous duplex ultrasound is a noninvasive test that visualizes the veins and assesses blood flow patterns. A venogram is an invasive test that utilizes dye and radiation to create images of the veins and would not be the first choice. Transthoracic echocardiography looks at cardiac structures and is not indicated at this time. Right calf pain and edema are symptoms of venous outflow obstruction, not arterial insufficiency.

The nurse assesses a postpartum woman for thromboembolism based on the understanding that her risk is increased because of which factor?

vessel damage during birth A woman's risk for thromboembolism increases due to her hypercoagulable state, vessel damage during birth, and immobility. The increase in white blood cell count is unrelated to her risk for thromboembolism. Coagulation factors remain elevated for 2 to 3 weeks postpartum. An episiotomy is not a risk factor for thromboembolism.

When teaching new parents about the sensory capabilities of their newborn, which sense would the nurse identify as being the least mature?

vision

when is the term floating used

when engagement has not occurred because the fetal part is freely moveable above the pelvic inlet

when is the fetus said to be "engaged"

when the presenting part reaches 0 (zero) station

what does the first letter in fetal position denote

whether presenting part is tilted toward the L or R side of the maternal pelvis

What happens to oxytocin receptors at the end of pregnancy?

while research is inconclusive on whether oxytocin initiates labor or not it is clear there is an increase in oxytocin receptors at the end of pregnancy.

While visiting a client at home on the 10th day postpartum, the nurse assesses the client's lochia. Which color would the nurse expect the lochia to be?

yellowish white The normal color of lochia on the tenth day of postpartum is yellowish white. The color of lochia changes from red to pink by approximately four or five days postpartum. The color of lochia is never yellowish pink.

postpartum woman is experiencing subinvolution. When reviewing the client's history for factors that might contribute to this condition, which factors would the nurse identify?

• Uterine infection • Hydramnios • Prolonged labor Factors that inhibit involution include prolonged labor and difficult birth, uterine infection, overdistention of the uterine muscles such as from hydramnios, a full bladder, close childbirth spacing, and incomplete expulsion of amniotic membranes and placenta. Breast-feeding, early ambulation, and an empty bladder would facilitate uterine involution.

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