PassPoint Maternity
At 24 hours of age, assessment of the neonate reveals the following: eyes closed, skin pink, no sign of eye movements, heart rate of 120 bpm, and respiratory rate of 35 breaths/min. What is this neonate most likely experiencing? a) a state of deep sleep b) first period of reactivity c) drug withdrawal d) respiratory distress
a) a state of deep sleep Explanation: At 24 hours of age, the neonate is probably in a state of deep sleep, as evidenced by the closed eyes, lack of eye movements, normal skin color, and normal heart rate and respiratory rate. Jitteriness, a high-pitched cry, and tremors are associated with drug withdrawal. The first period of reactivity occurs in the first 30 minutes after birth, evidenced by alertness, sucking sounds, and rapid heart rate and respiratory rate. There is no evidence to suggest respiratory distress because the neonate's respiratory rate of 35 breaths/min is normal
Lochia normally progresses in which pattern? a) Serosa, rubra, alba b) Serosa, alba, rubra c) Rubra, serosa, alba d) Rubra, alba, serosa
c) Rubra, serosa, alba As the uterus involutes and the placental attachment area heals, lochia changes from bright red (rubra), to pinkish (serosa), to clear white (alba).
A mother is visiting her neonate in the neonatal intensive care unit. Her baby is fussy and the mother wants to know what to do. In order to quiet a sick neonate, what can the nurse teach the mother to do? a) Bring in toys for distraction. b) Stroke the neonate's back. c) Place a musical mobile over the crib. d) Use constant, gentle touch.
d) Use constant, gentle touch. Neonates that are sick do not have the physical resources or energy to respond to all elements of the environment. The use of a constant touch provides comfort and only requires one response to a stimulus. To comfort a sick neonate, the care provider applies gentle, constant physical support or touch. Toys for distraction are not developmentally appropriate for a neonate. Sick neonates react to any stimulus; in responding, the sick neonate may have increased energy demands and increased oxygen requirements. A musical mobile may be too much audio stimulation and thus increases energy and oxygen demands. Repetitive touching with a hand going off and on the neonate, as with stroking or patting, requires the neonate to respond to every touch, thus increasing energy and oxygen demands
When assessing the fetal heart rate tracing, a nurse becomes concerned about the fetal heart rate pattern. In response to the loss of variability, the nurse repositions the client to her left side and administers oxygen. These actions are likely to improve: a) the contraction pattern. b) fetal hypoxia. c) the status of a trapped cord. d) maternal comfort.
b) fetal hypoxia. Explanation: These actions, which will improve fetal hypoxia, increase the amount of maternal circulating oxygen by taking pressure created by the uterus off the aorta and improving blood flow. These actions will not improve the contraction pattern, free a trapped cord, or improve maternal comfort
During a routine clinic visit, a 25-year-old multigravid client who initiated prenatal care at 10 weeks' gestation and is now in her third trimester states, "I've been having strange dreams about the baby. Last week I dreamed he was covered with hair." The nurse should tell the mother: a)"Dreams about the baby late in pregnancy usually mean that labor is about to begin soon." b)"Dreams like the ones that you describe are very unusual. Please tell me more about them." c)"It is not uncommon to have dreams about the baby, particularly in the third trimester." d)"Commonly when a mother has these dreams, she is trying to cope with becoming a parent."
c) "It is not uncommon to have dreams about the baby, particularly in the third trimester." During the third trimester, it is not uncommon for clients to have dreams or fantasies about the baby. Sometimes the dreams are about infants who are malformed or, in this example, covered with hair. There is no evidence to suggest that the client is trying to cope with becoming a parent. Having dreams about the baby does not mean that labor will begin soon.
Urinary tract infection (UTI) is a potential problem after spinal cord injury. To prevent an UTI, the nurse should encourage the client to: a) wash hands frequently. b) drink a glass of citrus fruit juice at every meal. c) drink at least 2,000 mL of fluid daily. d) add extra protein to the daily diet.
c) Drink at least 2,000 mL of fluid daily. Explanation: As soon as the client's vasomotor status stabilizes and is not susceptible to fluid volume overload, it is essential to drink at least 2,000 mL of fluid daily. Increased fluid intake helps flush out bacteria and prevents urinary stasis. Citrus juices are not encouraged. They can promote a urinary tract infection because they are alkaline-forming. Most citrus fruits are not metabolized as acids in the body. Extra protein does not decrease the potential for a urinary tract infection. While washing hands frequently is an appropriate health habit, UTIs in clients with spinal cord injuries primarily are caused by urinary stasis, and not prevented by handwashin
A client hospitalized for preterm labor tells the nurse her mother in law blames her for "overdoing it" and causing the preterm labor. Which of the following is the most appropriate response from the nurse? a)"Did you think that you did anything you shouldn't have?" b)"It is natural to blame one another when things become difficult." c)"Your mother in law was wrong. You didn't do anything to cause this." d)"Let's talk about how preterm labor occurs, so as to help you understand what causes it."
d) "Let's talk about how preterm labor occurs, so as to help you understand what causes it." The nurse needs to explore the client's feelings to assist her in understanding what happened and to disperse the blame she is feeling. The other responses do not explore feelings experienced by the client and may stop the dialogue with the nurse from continuing
A laboring client at 28 weeks gestation is in preterm labor. Her husband gets very agitated with the situation and demands to know why this has happened. Which of the following immediate responses is most appropriate from the nurse? a) "You seem really stressed. Do you have any one to talk to about this?" b) "You and your wife have been through a lot with this pregnancy. Let's talk about this further." c) "Your wife seems to be coping just fine. She has managed very well today." d) "I know you are upset. However you need to put this in perspective for the sake of your wife and infant."
d) "You and your wife have been through a lot with this pregnancy. Let's talk about this further." Explanation: This response acknowledges the experience and provides the opportunity for the partner to discuss his feelings further in order to assist him. The other responses will either aggravate the situation or not acknowledge the feelings experienced by the family.
Which instructions should the nurse give to the parents of a neonate diagnosed with hyperbilirubinemia who is receiving phototherapy? a)Check the rectal temperature every 8 hours. b)Offer feedings every 4 hours. c)Use a regular diaper on the neonate. d)Keep the neonate's eyes completely covered.
d) Keep the neonate's eyes completely covered. Explanation: To prevent eye damage from phototherapy, the eyes must remain covered at all times while under the lights. The eye patches can be removed when the neonate is held out of the lights by the parents for feeding. Instead of a regular diaper, a "string" diaper or disposable face mask may be used to help contain loose stools, while allowing maximum skin exposure. Feeding formula or breast milk every 2 to 3 hours is recommended to prevent hypoglycemia and to encourage gastrointestinal motility. Because the phototherapy lights can overheat the neonate, the temperature should be checked by the axillary route every 2 to 4 hours.
A multigravid client in labor at 38 weeks' gestation has been diagnosed with Rh sensitization and probable fetal hydrops and anemia. Which fetal heart rate pattern would the nurse find is most concerning? a) late deceleration pattern b) variable deceleration pattern c) early deceleration pattern d) sinusoidal pattern
d) sinusoidal pattern A sinusoidal pattern is an ominous sign that reflects an absence of autonomic nervous control over the fetal heart rate resulting from severe hypoxia. Sinusoidal patterns, while rare, are associated with Rh sensitization, fetal hydrops, and anemia. This client will most likely require a cesarean birth to improve the fetal outcome. Variable decelerations, associated with cord compression, and late decelerations, associated with poor placental perfusion, are concerning but may correct with appropriate interventions. Early decelerations are associated with head compression and are considered a normal variation.
