OB week 7
The nurse is monitoring a client in labor who has had a previous cesarean section and is trying a vaginal birth with an epidural. The nurse observes a sudden drop in blood pressure, increased heart rate, and deep variable deceleration on the fetal monitor. The client reports severe pain in her abdomen and shoulder. What should the nurse prepare to do?
Prepare the client for a cesarean birth.
A woman arrives at the office for her 4-week postpartal visit. Her uterus is still enlarged and soft, and lochial discharge is still present. Which nursing diagnosis is most likely for this client?
Risk for fatigue related to chronic bleeding due to subinvolution
The nurse is developing a plan of care for a neonate experiencing symptoms of drug withdrawal. What should be included in this plan?
Swaddle the infant between feedings.
The nurse is teaching a client about mastitis. Which statement should the nurse include in her teaching?
Symptoms include fever, chills, malaise, and localized breast tenderness.
The nurse is caring for a newborn of a substance-abusing mother who is withdrawing from alcohol. Which finding would the nurse likely see in this newborn?
hyperactive and irritable
The nurse begins intermittent oral feedings for a small-for-gestational-age newborn to prevent which occurrence?
hypoglycemia
A pregnant woman has just found out that she is having twin girls. She asks the nurse the difference between fraternal and identical twins. The nurse explains that with one set of twins there is fertilization of two ova, and with the other set one fertilized ovum splits. What type of twins result from the split ovum?
identical
A newborn has not passed any stools in the first 24 hours after birth, and his abdomen is becoming distended. The nurse recognizes that which condition could explain such findings?
imperforate anus
A nurse completes the initial assessment of a newborn. According to the due date on the antenatal record, the baby is 12 days' postmature. Which physical finding does not confirm that this newborn is 12 days' postmature?
increased amounts of vernix
Over the course of an eight-hour shift of postoperative care for a child who has had ventriculoatrial shunt placement, the nurse notes that the child's cry has become increasingly shrill and the child has projectile vomiting. The nurse would notify the primary care provider immediately because of the possibility that the child might be experiencing:
increased intracranial pressure.
A nursing instructor is teaching students about fetal presentations during birth. The most common cause for increased incidence of shoulder dystocia is:
increasing birth weight.
A nurse is performing a newborn assessment and notices a small dimple on the sacral area. The infant has a normal neurological assessment and moves all extremities well. What does the nurse suspect that the dimple indicates?
spina bifida occulta
A nurse is caring for a preterm newborn who has developed rapid, irregular respirations with periods of apnea. Which additional sign should the nurse consider as an indication of respiratory distress syndrome (RDS) in the newborn?
sternal retraction
Which finding would lead the nurse to suspect that a large-for-gestational-age newborn is developing hyperbilirubinemia?
tea-colored urine
The nurse is admitting a newborn male for observation with the diagnosis of preterm. What assessment finding corresponds with this gestational age diagnosis?
undescended testes
In working with the child or family of a child with a congenital disorder, the most effective nursing intervention for this child or family would be for the nurse to:
use reflective listening and offer nonjudgmental support.
A fundal massage is sometimes performed on a postpartum woman. The nurse would perform this procedure to address which condition?
uterine atony
What is the most frequent reason for postpartum hemorrhage?
uterine atony
After teaching a class of pregnant women on ways to decrease the postpartum complication of thrombotic conditions, the nurse recognizes more teaching is needed when one of the participants states:
"At least I don't have to give up smoking for this one."
A postpartum client with a history of deep vein thrombosis is being discharged on anticoagulant therapy. The nurse teaches the client about the therapy and measures to reduce her risk for bleeding. Which statement by the client indicates the need for additional teaching?
"I should brush my teeth vigorously to stimulate the gums."
After the nurse teaches a local woman's group about postpartum affective disorders, which statement by the group indicates that the teaching was successful?
"Postpartum depression develops gradually, appearing within the first 6 weeks."
A nurse is caring for a postpartum client diagnosed with von Willebrand disease. What should be the nurse's priority for this client?
Check the lochia.
Which nursing measure is most effective in reducing newborn infections?
Maintain medical asepsis while providing care.
When providing care to a newborn with necrotizing enterocolitis (NEC), the nurse would need to report which finding immediately?
abdomen appearing red and shiny
The experienced labor and birth nurse knows to evaluate progress in active labor by using which simple rule?
1 cm/hour for cervical dilation
When educating the postterm pregnant client, what should the nurse be sure to include to prevent fetal complications?
Be sure to monitor fetal movements daily.
A postpartal woman is developing a thrombophlebitis in her right leg. Which assessment should the nurse no longer use to assess for thrombophlebitis?
Dorsiflex her right foot and ask if she has pain in her calf.
to asses Homans' sign
Dorsiflex the patients right foot and ask if she has pain in her calf.
A nurse is assessing a full-term client in labor and determines the fetus is occiput posterior. The client states that all her discomfort is in her lower back. What intervention can the nurse provide that will help alleviate this discomfort?
Use a fist to apply counter pressure to the lower back.
When examining a newborn for developmental hip dysplasia, which motion would the newborn's hip be unable to accomplish?
abduction
A client is entering her 42nd week of gestation and is being prepared for induction of labor. The nurse recognizes that the fetus is at risk for which condition?
macrosomia
A nurse recognizes that which sign is usually the first indication of esophageal atresia?
maternal history of hydramnios
When assessing a client for postpartum hemorrhage, the nurse monitors what every hour?
pad count
A client who has been in prolonged labor reports extreme back pain. She asks why her back hurts so much. What would be the best response by the nurse?
"Different fetal positions can cause prolonged labor and back pain."
A nursing student, observing care of a 30-week-gestation infant in the neonatal intensive care unit, asks the nurse, "Are premature infants more susceptible to infection as I have to wash my hands so often in this department?" What is the nurse's best response?
"That is correct; a 30-week-gestation infant lacks the protective antibody called IgG."
The nurse realizes the educational session conducted on due dates was successful when a participant is overheard making which statement?
"The ability of my placenta to provide adequate oxygen and nutrients to my baby after 42 weeks' gestation is thought to be compromised."
The nurse in the NICU is caring for preterm newborns. Which guidelines are recommended for care of these newborns? Select all that apply.
-Take the newborn's temperature often. -Supply oxygen for the newborn, if necessary. -Dress the newborn in ways to preserve warmth.
A nurse is preparing to administer epinephrine intravenously to a preterm newborn. The newborn weighs 1,500 g, and the primary care provider prescribes 0.1 mL/kg. How much would the nurse administer?
0.15 mL
What percentage of neonates require some type of assistance to transition to extrauterine life?
10%
Which assessment would lead the nurse to believe a postpartal woman is developing a urinary complication?
At 8 hours postdelivery she has voided a total of 100 mL in four small voidings.
what does congenital talipes equinovarus mean?
Club foot
A nurse is caring for an infant born with polycythemia. Which intervention is most appropriate when caring for this infant?
Focus on decreasing blood viscosity by increasing fluid volume.
A nurse is assigned to care for a newborn with esophageal atresia. What preoperative nursing care is the priority for this newborn?
Prevent aspiration by elevating the head of the bed, and insert an NG tube to low suction.
An infant that is diagnosed with meconium aspiration displays which symptom?
intercostal and substernal retractions
The nurse determines a newborn is small-for-gestational age based on which characteristics?
wasted appearance of extremities, thin umbilical cord, and reduced subcutaneous fat stores
Four weeks before the birth of a client's already large child, the primary care provider has told the client that if the baby gets bigger and the baby's lungs are ready, the care provider would like to perform a cesarean birth. The woman asks the nurse what the downside is to having a cesarean rather than a vaginal birth. What is an appropriate response by the nurse?
"As the baby passes through the birth canal some of the excess fluid is expelled from the lungs, if that doesn't happen there's a higher risk of respiratory distress."
While the nurse is weighing and measuring a toddler during the child's annual checkup, the toddler's mother mentions that she is thinking of having another child. The toddler is small in stature and seems mildly developmentally delayed. His eyelid folds are short and his nose is flat. What do the toddler's characteristics suggest is the best advice the nurse can give this mother about pregnancy?
"It's a good idea to stop drinking alcohol 3 months before trying to get pregnant."
A group of nursing students is discussing hydrocephalus. Which statement made by the students related to the noncommunicating type of congenital hydrocephalus is the most accurate?
"There is an obstruction that keeps cerebrospinal fluid from passing between the ventricles and the spinal cord."
A nurse notices a mother in the NICU crying next to her premature 25-week-old neonate. What is the most appropriate response by the nurse?
"This situation must be difficult for you. Can you tell me what concerns you have right now?"
A newborn boy is diagnosed with esophageal atresia and tracheoesophageal fistula. After the nurse provides preoperative teaching, which statement indicates that the parents need additional teaching?
"We can probably start feeding him with the bottle about a day after the surgery."
A premature infant is admitted to the neonatal intensive care unit with respiratory distress syndrome and requires assisted ventilation. The parents asks the nurse, "Why won't our baby breath on its own?" What is the nurse's best response?
"Your infant cannot sustain respirations yet due to the lack of assistance from surfactant."
A neonatal nurse admits a preterm infant with the diagnosis of respiratory distress syndrome and reviews the maternal labor and birth record. Which factors in the record would the nurse correlate with this diagnosis? Select all that apply.
-32 weeks' gestation -cesarean birth -male gender -newborn asphyxia -maternal diabetes
The nurse is teaching a prenatal class emphasizing factors that pregnant mothers can implement to ensure a healthy newborn. Which nursing recommendations would be important to discuss? Select all that apply.
-Keep all prenatal checkups. -Have good blood sugar control. -Avoid the use of any types drugs and alcohol. -Visit the dentist regularly.
The second-year nursing student taking an obstetrics course correctly attributes which descriptions to the term dystocia? Select all that apply.
-Progress of labor deviates from normal. -Labor is slow.
A nursing student correctly identifies the causes of labor dysfunction to include which factors? Select all that apply.
-problems with the uterus -problems with the fetus
A nurse is assessing a newborn. The nurse suspects that the newborn was exposed to drugs while in utero based on which findings? Select all that apply.
-tremors -frequent yawning -nasal flaring
On the third day postpartum, which temperature is internationally defined as a postpartal infection?
100.4° F (38° C)
A client has had a cesarean birth. Which amount of blood loss would the nurse document as a postpartum hemorrhage in this client?
1000 mL
Hypoglycemia in a mature infant is defined as a blood glucose level below which amount?
40 mg/100 mL whole blood
Before calling the primary care provider to notify him or her of a slow progression or an arrest of labor, several assessments need to be made. What other maternal assessment does the nurse need to make prior to calling the care provider?
Check for a full bladder.
The nurse collects a urine specimen for culture from a postpartum woman with a suspected urinary tract infection. Which organism would the nurse expect the culture to reveal?
Escherichia coli
Which assessment on the third postpartal day would make the nurse evaluate a woman as having uterine subinvolution?
Her uterus is at the level of the umbilicus.
The nurse who is caring for a newborn boy notices that although he has seemed healthy at 18 hours of age, the newborn's abdomen is now distended. By 24 hours he has passed no stool. What should the nurse do?
Inform the primary care provider of the findings.
When the nurse is assisting the parents in the grieving process after the death of their neonate, what is the nurse's most important action?
Keep the communication lines open.
A nurse is teaching a 42-week nulliparous pregnant woman about labor induction which is being recommended by her health care provider. The nurse determines that the woman needs additional teaching when she identifies which assessment as being done before induction?
Leopold's maneuver
A laboring client has been pushing without delivering the fetal shoulders. The primary care provider determines the fetus is experiencing shoulder dystocia. What intervention can the nurse assist with to help with the birth?
McRobert's maneuver
Which instruction should the nurse offer a client as primary preventive measures to prevent mastitis?
Perform handwashing before breastfeeding.
A client is admitted to the health care facility. The fetus has a gestational age of 42 weeks and is suspected to have cephalopelvic disproportion. Which should the nurse do next?
Prepare the client for a cesarean birth.
An infant is suspected of having persistent pulmonary hypertension of the newborn (PPHM). What intervention implemented by the nurse would be most beneficial in treating this client?
Provide oxygen by oxygen hood or ventilator.
The nurse is giving an educational presentation to the local Le Leche league chapter. One woman asks about mastitis. What would be the nurse's best response?
Risk factors include nipple piercing.
The nurse would prepare a client for amnioinfusion when which action occurs?
Severe variable decelerations occur and are due to cord compression.
The nurse is teaching a client with newly diagnosed mastitis about her condition. The nurse would inform the client that she most likely contracted the disorder from which organism?
Staphylococcus aureus
A woman receiving an oxytocin infusion for labor induction develops contractions that occur every minute and last 75 seconds. Uterine resting tone remains at 20 mm Hg. Which action would be most appropriate?
Stop the infusion immediately.
what does subinvolution mean?
Subinvolution is a medical condition in which after childbirth, the uterus does not return to its normal size.
A 20-year-old client gave birth to a baby boy during the 43rd week of gestation. What might the nurse observe in the newborn during routine assessment?
The newborn may look wrinkled and old at birth.
A one-day-old neonate born at 32 weeks' gestation is in the neonatal intensive care unit under a radiant overhead warmer. The nurse assesses the morning axilla temperature as 95 degrees F (35 degrees C). What could explain the assessment finding?
The supply of brown adipose tissue is not developed.
When diagnosed with a deep vein thrombosis, the nurse knows the client will be treated with which medication?
anticoagulants
The nurse examines a 26-week-old premature infant. The skin temperature is lowered. What could be a consequence of the infant being cold?
apnea
The nurse is caring for a newborn diagnosed with congenital talipes equinovarus. Which treatment would the nurse expect for this newborn?
application of a cast
A preterm newborn is noted to be cyanotic. Which laboratory test will the nurse prepare the infant for to determine if the cyanosis is due to respiratory or circulatory problems?
arterial blood gases
The nurse is caring for a postpartum woman who exhibits a large amount of bleeding. Which areas would the nurse need to assess before the woman ambulates?
blood pressure, pulse, reports of dizziness
When discussing heat loss in newborns, placing a newborn on a cold scale would be an example of what type of heat loss?
conduction
Which intervention would be most important when caring for the client with breech presentation confirmed by ultrasound?
continuing to monitor maternal and fetal status
Which finding would lead the nurse to suspect that the fetus of a woman in labor is in hypertonic uterine dysfuction?
contractions most forceful in the middle of uterus rather than the fundus
A woman's nurse-midwife tells her that the woman has developed dystocia. The nurse explains that this term means:
difficult or abnormal labor.
The nurse recognizes that the postpartum period is a time of rapid changes for each client. What is believed to be the cause of postpartum affective disorders?
drop in estrogen and progesterone levels after birth
A premature infant develops respiratory distress syndrome. With this condition, circulatory impairment is likely to occur because with increased lung tension, the:
ductus arteriosus remains open.
At 31 weeks' gestation, a 37-year-old woman who has a history of preterm birth reports cramps, vaginal pain, and low, dull backache accompanied by vaginal discharge and bleeding. Her cervix is 2.1 cm long; she has fetal fibronectin in her cervical secretions, and her cervix is dilated 3 to 4 cm. For what does the nurse prepare her?
hospitalization, tocolytic therapy, and IM corticosteroids
A nurse is assigned to care for a high-risk newborn with a periventricular-intraventricular hemorrhage (PVH-IVH) in the home environment after discharge. For which condition should the nurse monitor the infant?
hydrocephalus
A primary care provider prescribes intravenous tocolytic therapy for a woman in preterm labor. Which agent would the nurse expect to administer?
magnesium sulfate
A newborn is diagnosed with respiratory distress syndrome (RDS). While assessing the newborn, the nurse realizes that which maternal factor would most place the infant at risk for RDS?
maternal gestational diabetes
A nurse is caring for a client in the postpartum period. When observing the client's condition, the nurse notices that the client tends to speak incoherently. The client's thought process is disoriented, and she frequently indulges in obsessive concerns. The nurse notes that the client has difficulty in relaxing and sleeping. The nurse interprets these findings as suggesting which condition?
postpartum psychosis
Two weeks after their baby is born, a father calls to report that his wife is behaving strangely. She is extremely talkative and energetic, and he has not observed her sleeping for more than an hour or two at a time. She is also forgetting to eat and neglecting her appearance, but worse, she seems to barely be aware of the baby's needs and appears surprised when the father asks her about the child, "As if," the father says, "she's forgotten that we even have a baby!" The nurse tells him to bring the mother in right away because the nurse suspects the mother is suffering from what condition?
postpartum psychosis
A woman is experiencing dystocia that appears related to psyche problems. Which intervention would be most appropriate for the nurse initiate?
providing a comfortable environment with dim lighting
Which safety precautions should a nurse take to prevent infection in a newborn? Select all that apply.
-Use sterile gloves for an invasive procedure. -Initiate universal precautions when caring for the infant. -Avoid coming to work when ill.
Which maternal factors should the nurse consider contributory to a newborn being large for gestational age? Select all that apply.
-diabetes mellitus -postdates gestation -prepregnancy obesity
The nurse caring for newborns on an obstetrical ward assesses an SGA newborn. What characteristics are typical for this classification of newborn? Select all that apply.
-diminished muscle tissue -sparse or absent hair -poor skin turgor
A nurse is providing care to a preterm neonate. Which interventions would be most effective in minimizing the newborn's pain? Select all that apply.
-encouraging kangaroo care during procedures -using a colorful mobile for distraction -removing tape gently from the skin
Prevention and early identification of newborns at risk are necessary nursing functions. A nurse anticipates the need for newborn resuscitation secondary to birth asphyxia based on which prenatal risk factors? Select all that apply.
-gestational hypertension -maternal infection -congenital heart disease
A client in her seventh week of the postpartum period is experiencing bouts of sadness and insomnia. The nurse suspects that the client may have developed postpartum depression. What signs or symptoms are indicative of postpartum depression? Select all that apply.
-loss of confidence -inability to concentrate -decreased interest in life
The nurse needs to conduct a procedure on a preterm newborn. Which measures would be most effective in reducing pain? Select all that apply.
-offering a pacifier prior to a procedure -swaddling the newborn closely -encouraging kangaroo care during procedures
A preterm infant of 32 weeks' gestation is admitted from the birth suite to the neonatal intensive care unit with symptoms of respiratory distress. What would the nurse expect to see during assessments? Select all that apply.
-pH 7 -PaCO2 54 mm Hg -PaO2 35
At the breech forceps birth of a 32 weeks' gestation neonate, the nurse notes olygohydramnios with green thick amniotic fluid. The maternal history reveals a mother of Hispanic ethnicity with marked hypertension, who admits to using cocaine daily. Which factors may contribute to meconium aspiration syndrome (MAS)? Select all that apply.
-the forceps breech birth -maternal heroin use -maternal hypertension -oligohydramnios present
Why is it important for the nurse to thoroughly assess maternal bladder and bowel status during labor?
A full bladder or rectum can impede fetal descent.
A nurse is assessing a term newborn and finds the blood glucose level is 23 mg/dl. The newborn has a weak cry, is irritable, and exhibits bradycardia. Which intervention is most appropriate?
Administer dextrose intravenously.
A woman is going to have labor induced with oxytocin. Which statement reflects the induction technique the nurse anticipates the primary care provider will prescribe?
Administer oxytocin diluted as a "piggyback" infusion.
Shoulder dystocia is a true medical emergency that can cause fetal demise because the baby cannot be born. Stuck in the birth canal, the infant cannot take its first breath. What is the first maneuver tried to deliver an infant with shoulder dystocia?
McRoberts maneuver
A nurse is caring for an infant born after a prolonged and difficult maternal labor. What nursing intervention should the nurse perform when assessing for trauma and birth injuries in the newborn?
Note any absence of or decrease in deep tendon reflexes.
A ventilated 33 weeks' gestation newborn in the neonatal intensive care unit (NICU) receives surfactant therapy. Which would the nurse expect to assess as a positive response to this therapy?
Oxygen saturation levels are at 98%.
A nurse is caring for a newborn client after birth who is diagnosed with myelomeningocele. Which nursing intervention would protect the newborn from injury?
Place the newborn in a prone or lateral position.
The newborn nursery nurse suspects a newborn of having neonatal abstinence syndrome. What assessment findings would most correlate with the diagnosis?
frequent yawning and sneezing
A nurse is preparing for a class to teach pregnant women and their partners about postpartum complications. Whiich measure would be most important for the nurse to emphasize as helping to prevent postpartum infection?
handwashing
A client has arrived to the birthing center in labor, requesting a VBAC. The nurse knows that she would be a good candidate after reading the client's previous history based on which finding?
has previous lower abdominal incision
if he be doin that wiggity wiggity wooty
he commin fo that booty
A premature newborn has repeated blood work drawn by heel prick. The mother asks the nurse, "Does my baby feel the pain from all these procedures?" What is the nurse's best response?
"Your baby is more sensitive to the pain than adults are."
Immediately after birth, the nurse is caring for a newborn with a myelomeningocele. What intervention should the nurse provide to prevent drying out of the sac to avoid damage?
Apply a sterile dressing moistened in a warm sterile saline solution.
The nurse identifies a nursing diagnosis of risk for injury related to possible effects of oxytocin therapy. Which action would the nurse perform to ensure a positive outcome for the client?
Assess contractions by using external monitor.
A nurse is assessing a client with postpartal hemorrhage; the client is presently on IV oxytocin. Which interventions should the nurse perform to evaluate the efficacy of the drug treatment? Select all that apply.
Assess the client's uterine tone. Monitor the client's vital signs. Get a pad count.
On examining a woman who gave birth 5 hours ago, the nurse finds that the woman has completely saturated a perineal pad within 15 minutes. Which action by the nurse should be implemented first?
Assess the woman's fundus.
A 29-year-old postpartum client is receiving anticoagulant therapy for deep venous thrombophlebitis. The nurse should include which instructions in her discharge teaching?
Avoid over-the-counter (OTC) salicylates.
A nurse is assigned to care for a client with deep vein thrombosis who has to undergo anticoagulation therapy. Which instruction should the nurse offer the client as a caution when the client receives anticoagulation therapy?
Avoid products containing aspirin.
A woman experiences an amniotic fluid embolism as the placenta is delivered. The nurse's first action would be to:
administer oxygen by mask.
A 39-year-old multigravida with diabetes presents to the clinic at 32 weeks' gestation because she has not felt the fetus moving lately. FHR is absent; sonogram confirms that the fetus has died. The nurse's institution has a policy of taking photographs of such fetuses once they are born. The nurse informs the woman that pictures have been taken and asks her if she wants them; she angrily tells the nurse no, then bursts into tears. How should the nurse respond?
Tell her that the hospital will keep the photos for her in case she changes her mind.
The nurse is caring for a newborn with retinopathy of prematurity (ROP). Which statement best explains this disorder?
The infant has a degenerative disease of the retina.
A nurse is assigned to care for a newborn with hyperbilirubinemia. The newborn is relatively large in size and shows signs of listlessness. What most likely occurred?
The infant's mother probably had diabetes.
A neonate born at 40 weeks' gestation, weighing 2300 grams (5 lb, 1 oz) is admitted to the newborn nursery for observation only. What is the nurse's first observation about the infant?
The neonate is small for its gestational age.
A neonatal intensive care nurse is caring for a preterm newborn diagnosed with transient tachypnea who is NPO and receiving intravenous fluid therapy. When would the nurse expect the newborn to begin oral feedings?
When the respiratory rate is 44 BPM.
A woman who has given birth to a postterm newborn asks the nurse why her baby looks so thin with so little muscle. The nurse integrates understanding about which concept when responding to the mother?
With postterm birth, the fetus uses stored nutrients to stay alive, and wasting occurs.
A client and her infant are being discharged home after an unplanned cesarean birth. The nurse explains to her that she is at a higher risk for postpartum infection than most clients. What is the major risk factor for a postpartum infection?
a nonelective cesarean birth
A nurse is caring for a neonate of 25 weeks' gestation who is at risk for intraventricular hemorrhage (IVH). Which assessment finding should be reported immediately?
a sudden drop in hemoglobin
A nurse assesses a client in labor and suspects hypotonic uterine dysfunction. Which intervention would the nurse expect to include in the plan of care for this client?
administering oxytocin
When documenting the newborn's weight on a growth chart, the nurse recognizes the newborn is large-for-gestational-size based on which percentile on growth charts?
above 90th percentile
Which measure would the nurse expect to be included in the plan of care for an infant of a diabetic mother who has a serum calcium level of 6.2 mg/dL?
administration of calcium gluconate
After teaching a review class to a group of perinatal nurses about various methods for cervical ripening, the nurse determines that the teaching was successful when the group identifies which method as surgical?
amniotomy
A nurse is assessing a newborn for jaundice. The nurse would first notice jaundice at which area?
face
A nursing student has read that cleft lip is diagnosed at birth based on inspection of physical appearance and that cleft palate is diagnosed in which way?
feeling the palate with a gloved finger or using a tongue blade
In reviewing the postpartum G3, P3 woman's history the nurse notes it is positive for obesity and smoking. The nurse recognizes this client is at risk for which complication?
deep venous thrombosis
The nurse notices while holding him upright that a day-old newborn has a significantly indented anterior fontanelle. She immediately brings it to the attention of the primary care provider. What does this finding indicate?
dehydration
Which clinical manifestation in a woman with deep vein thombosis (DVT) should the nurse report immediately?
dyspnea
A woman is two weeks postpartum when she calls the clinic and tells the nurse that she has a fever of 101° F (38.3° C). She reports abdominal pain and a "bad smell" to her lochia. The nurse recognizes that these symptoms are associated with which condition?
endometritis
A nurse is assessing vital signs for a postpartum client 48 hours after birth. The vital signs are: temp 101.2° F (38.4° C); HR 82 beats/min.; RR 18 breaths/min.; BP 125/78 mm Hg. How will the nurse interpret the vital signs?
infection
A nurse assisting in a birth notices that the amniotic fluid is stained greenish black as the baby is being born. Which intervention should the nurse implement as a result of this finding?
intubation and suctioning of the trachea
A nurse is assessing a preterm newborn. The nurse determines that the newborn is comfortable and without pain based on which finding?
lack of body posturing
At the hospital, a client is attached to the fetal monitor for uterine rupture. The nurse would assess for which pattern indicating change in the uterus impacting the fetus?
late decelerations
An Rh positive client vaginally gives birth to a 6 lb, 10 oz (3,005 g) neonate after 17 hours of labor. Which condition puts this client at risk for infection?
length of labor
A newborn is designated as extremely low birth weight. The nurse understands that this newborn's weight is:
less than 1,000 g.
A nursing student has learned that precipitous labor is when the uterus contracts so frequently and with such intensity that a very rapid birth will take place. This means the labor will be completed in which span of time?
less than 3 hours
What would the nurse suspect as a cause of meconium aspiration syndrome (MAS) after reviewing the maternal history of a client whose newborn is diagnosed with MAS?
maternal hypertension
A 35-year-old client has just given birth to a healthy newborn during her 43rd week of gestation. What should the nurse expect when assessing the condition of the newborn?
meconium aspiration in utero or at birth
The nurse is admitting a term, large-for-gestational-age neonate weighing 4,610 g (10 lb, 2 oz), born vaginally with a mid-forceps assist, to a 15-year-old primipara. What would the nurse anticipate as a result of the birth?
midclavicular fracture
A newborn is found to have hemolytic disease. Which combination would be found related to the blood types of this newborn and the parents of the newborn?
newborn who is type A, mother who is type O
A nurse is working in the newborn observational unit and is assigned four newborns. In which newborn will the nurse suspect difficulties with thermal regulation?
newly born preterm infant
When planning preoperative care for a newborn with a cleft lip and palate, a major need for which the nurse would plan interventions is:
nutrition.
When caring for a client requiring a forceps-assisted birth, the nurse would be alert for:
potential lacerations and bleeding.
The nurse preceptor explains that several factors are involved with the "powers" that can cause dystocia. She focuses on the dysfunction that occurs when the uterus contracts so frequently and with such intensity that a very rapid birth will take place. This is known as which term?
precipitous labor
A client presents to the emergency department reporting regular uterine contractions. Examination reveals that her cervix is beginning to efface. The client is in her 36th week of gestation. The nurse interprets the findings as suggesting which condition is occurring?
preterm labor
A nurse is working with a child who has spina bifida. Which nursing goal for this child would have the highest priority?
preventing infection
After assessing a client's progress of labor, the nurse suspects the fetus is in a persistent occiput posterior position. Which finding would lead the nurse to suspect this condition?
reports of severe back pain
A thin newborn has a respiratory rate of 80 breaths/min, nasal flaring with sternal retractions, a heart rate of 120 beats/min, temperature of 36° C (96.8° F) and persisting oxygen saturation of <87%. The nurse interprets these findings as:
respiratory distress.
Which assessment finding would best validate a problem in a small-for-gestational age newborn secondary to meconium in the amniotic fluid?
respiratory rate of 60 to 70 bpm
When providing care for a postpartum client at a 6-week check up, which behavior would alert the nurse the client may have postpartum psychosis?
restless and agitated, concerned with self
A woman gives birth to a newborn at 39 weeks' gestation. The nurse classifies this newborn as:
term
A newborn girl who was born at 38 weeks of gestation weighs 2000 g and is below the 10th percentile in weight. The nurse recognizes that this girl will be placed in which classification?
term, small for gestational age, and low-birth-weight infant
A nurse is assessing the following antenatal clients. Which client is at highest risk for having a multiple gestation?
the 41-year-old client who conceived by in vitro fertilization
Which newborn would the nurse suspect to be most at risk for cognitive challenge due to the mother's actions during pregnancy?
the child of a client who admits to drinking a liter of alcohol daily during the pregnancy
A nurse working in the newborn observational unit is assigned four newborns closely being monitored. Which newborn is at greatest risk of developing respiratory distress syndrome?
the male preterm infant born by cesarean birth with cold stress
A client with a pendulous abdomen and uterine fibroid tumors had just begun labor and arrived at the hospital. After examining the client, the primary care provider informs the nurse that the fetus appears to be malpositioned in the uterus. Which fetal position or presentation should the nurse most expect in this woman?
transverse lie
A pregnant woman near term is brought to the emergency department because she has been in an automobile accident. She has sustained blunt trauma to her abdomen and has gone into labor. An epidural is started, and labor is going as well as can be expected under the circumstances. Suddenly the woman reports severe pain in her back and shoulder. What does the nurse suspect?
uterine rupture
While in labor a woman with a prior history of cesarean birth reports light-headedness and dizziness. The nurse assesses the client and notes an increase in pulse and decrease in blood pressure from the vital signs 15 minutes prior. What might the nurse consider as a possible cause for the symptoms?
uterine rupture
Parents often vent their frustration and anger over the loss of their newborn on the nurse. The most appropriate reaction for the nurse is:
validate their feelings and refocus their anger.
Following birth, the newborn's independent circulatory system is established. If there is an abnormal opening between the chambers in the heart, which cardiac defect may occur?
ventricular septal defect
When assessing a postpartum client who was diagnosed with a cervical laceration which has been repaired, what sign should the nurse report as a possible development of hypovolemic shock?
weak and rapid pulse
After completing an assessment of a newborn, the nurse determines that the newborn is small-for-gestational-age based on which weight assessment?
weight of 2,400 g
A client who is hypertensive and who received corticosteroids during pregnancy gave birth by cesarean and subsequently developed endometritis. Her incision is red, warm, and very sensitive to touch, and she remains febrile despite antibiotic therapy. What is the most important aspect of post hospital care the nurse should teach her?
wound care and hand washing
