postpartum and newborn nursing

1 after birth, the nurse should auscultate the client's abdomen in all 4 quadrants to determine the return of bowel sounds. normal bowel elimination usually returns 2 to 3 days postpartum. surgery, anesthesia, and the use of opioids and pain control agents also contribute to the longer period of altered bowel functions.

the postpartum nurse is providing instructions to a client after birth of a healthy newborn. which time frame should the nurse relay to the client regarding the return of bowel function? 1) 3 days postpartum 2) 7 days postpartum 3) on the day of birth 4) within 2 weeks postpartum

4 if pulmonary embolism is suspected, oxygen should be administered, 8 to 10 L/minute, by face mask. oxygen is used to decrease hypoxia. the client is also kept on bed rest with the head of the bed slightly elevated to reduce dyspnea. morphine sulfate may be prescribed for the client, but this would not be the initial nursing action. an intravenous line also will be required, and vital signs need to be monitored, but these actions would follow the administration of oxygen.

a client in a postpartum unit complains of sudden sharp chest pain and dyspnea. the nurse notes that the client is tachycardic and the respiratory rate is elevated. the nurse suspects pulmonary embolism. which should be the initial nursing action? 1) initiate an intravenous line. 2) assess the client's blood pressure. 3) prepare to administer morphine sulfate. 4) administer oxygen, 8 to 10 L/minute, by face mask.

d leathery, crackly, and wrinkled skin is seen in a newborn who is postmature due to placental insufficiency.

a nurse is caring for a client who is at 42 weeks gestation and in labor. the client asks the nurse what to expect because the baby is postmature. which of the following statements should the nurse make? a) "your baby will have excess body fat." b) "your baby will have flat areola without breast buds." c) "your baby's heels will easily move to his ears." d) "your baby's skin will have a leathery appearance."

a a rising pulse rate and decreasing blood pressure are often the first indications of inadequate blood volume.

a nurse is caring for a client who is postpartum. the nurse should identify which of the following findings as an early indicator of hypovolemia caused by hemorrhage? a) increasing pulse and decreasing blood pressure b) dizziness and increasing respiratory rate c) cool, clammy skin, and pale mucous membranes d) altered mental status and level of consciousness

c petroleum gauze is applied to the site for 24 hr to prevent the skin edges from sticking to the diaper.

a nurse is caring for a newborn immediately following a circumcision using a gomco procedure. which of the following actions should the nurse implement? a) apply gelfoam powder to the site b) place the newborn in the prone position. c) apply petroleum gauze to the site. d) avoid changing the diaper until the first voiding.

d the greatest risk to the newborn is cold stress. therefore, the highest priority intervention is to prevent heat loss. covering the newborn's head with a cap prevents cold stress due to excessive evaporative heat loss.

a nurse is caring for a newborn immediately following birth. which of the following nursing interventions is the highest priority? a) initiating breastfeeding b) performing the initial bath c) giving the vitamin K injection d) covering the newborn's head with a cap

b this newborn is classified as appropriate for gestational age because the weight is between the 10th and 90th percentile.

a nurse is caring for a newborn who was born at 38 weeks of gestation, weighs 3,200 g, and is in the 60th percentile for weight. based on the weight and gestational age, the nurse should classify this neonate as which of the following? a) low birth weight b) appropriate for gestational age c) small for gestational age d) large for gestational age

b readiness-to-feed cues include the newborn making hand-to-mouth and hand-to-hand movements, sucking motions, rooting, and mouthing.

a nurse is caring for a newborn. which of the following actions by the newborn indicates readiness to feed? a) spits up clear mucus b) attempts to place their hand in their mouth c) turns the head toward sounds d) lies quietly with their eyes open

a, b, d fatigue, insomnia, and a flat affect are findings suggestive of postpartum depression.

a nurse is caring for a postpartum client who delivered their third infant 2 days ago. which of the following manifestations could indicate postpartum depression? (select all that apply). a) fatigue b) insomnia c) euphoria d) flat affect e) delusions

d effective latching-on includes the infant's nose, cheek, and chin touching the parent's breast.

a nurse is giving instructions to a parent about how to breastfeed their newborn. which of the following actions by the parent indicates understanding of the teaching? a) the parent places a few drops of water on the nipple before feeding. b) the parent gently removes their nipple from the infant's mouth to break the suction. c) when they are ready to breastfeed, the parent gently strokes the newborn's neck with a finger. d) when latched on, the infant's nose, cheek, and chin are touching the breast.

c one mediation of choice for ophthalmia neonatorum is erythromycin ophthalmic ointment 0.5%. this antibiotic provides prophylaxis against neisseria gonorrhoeae and chlamydia trachomatis.

a nurse is preparing to administer prophylactic eye ointment to a newborn to prevent ophthalmia neonatorum. which of the following medications should the nurse anticipate administering? a) ofloxacin b) nystatin c) erythromycin d) ceftriaxone

c a sore nipple that has cracks and fissures is an indication of mastitis.

a nurse is providing discharge instructions for a client. at 4 weeks postpartum, the client should contact the provider for which of the following client findings? a) scant, nonodorous white vaginal discharge b) uterine cramping during breastfeeding c) sore nipple with cracks and fissures d) decreased response with sexual activity

c the nipple should always be kept full of formula to prevent the newborn from sucking in air during the feeding.

a nurse is teaching a group of new parents about proper techniques for bottle feeding. which of the following instructions should the nurse provide? a) burp the newborn at the end of the feeding. b) hold the newborn close in a supine position. c) keep the nipple full of formula throughout the feeding. d) refrigerate any unused formula.

b premature rupture of membranes with prolonged labor poses the greatest risk for developing a postpartum infection because the birth canal was open, allowing pathogens to enter.

a nurse on the postpartum unit is caring for four clients. which of the following clients should the nurse recognize at the greatest risk for development of a postpartum infection? a) a client who experienced a precipitous labor less than 3 hr in duration b) a client who had premature rupture of membranes and prolonged labor c) a client who delivered a large for gestational age infant d) a client who had a boggy uterus that was not we--contracted

2 cystitis is an infection of the bladder. the client should consume 3000 mL of fluids per day if not contraindicated. sitz baths and ice would be appropriate interventions for perineal discomfort. hemoglobin and hematocrit levels would be monitored with hemorrhage.

a postpartum client is diagnosed with cystitis. the nurse should plan for which priority action in the care of the client? 1) providing sitz baths 2) encouraging fluid intake 3) placing ice on the perineum 4) monitoring hemoglobin and hematocrit levels

1 signs of umbilical cord infections are moistness, oozing, discharge, and a reddened base around the cord. if signs of infection occur, the client should be instructed to notify the primary health care provider. if these symptoms occur, antibiotics may be necessary.

the mother of a newborn calls the clinic and reports that when cleaning the umbilical cord, she noticed that the cord was moist and that discharge was present. what is the most appropriate nursing instruction for this mother? 1) bring the infant to the clinic. 2) this is a normal occurrence and no further action is needed. 3) increase the number of times that the cord is cleaned per day. 4) monitor the cord for another 24 to 48 hours and call the clinic if the discharge continues.

a, c, e rapid, precipitous delivery; inversion of the uterus; and retained placental fragments are risk factors for postpartum hemorrhage.

a nurse educator on the postpartum unit is reviewing risk factors for postpartum hemorrhage with a group of nurses. which of the following factors should the nurse include in the teaching? (select all that apply.) a) precipitous delivery b) obesity c) inversion of the uterus d) oligohydramnios e) retained placental fragments

a, c, e hypospadias and epispadias involve a defect in the location of the urethral opening and are contraindications to circumcision. a family history of hemophilia is also a contraindication for circumcision.

a nurse is reviewing contraindications for circumcision with a newly hired nurse. which of the following conditions are contraindications? (select all that apply.) a) hypospadias b) hydrocele c) family history of hemophilia d) hyperbilirubinemia e) epispadias

c, e increased fluid intake can help to flush bacteria from the urinary tract. acetaminophen is taken to reduce discomfort and pain associated with a urinary tract infection.

a nurse is reviewing discharge teaching with a client who has a urinary tract infection. which of the following statements by the client indicates understanding of the teaching? (select all that apply.) a) "i will perform perineal care and apply a perineal pad in a back-to-front direction." b) "i will drink grape juice to make my urine more acidic." c) "i will drink large amounts of fluids to flush the bacteria from my urinary tract." d) "i will go back to breastfeeding after i have finished taking the antibiotic." e) "i will take tylenol for any discomfort."

1 because the client has had epidural anesthesia and is anesthetized, she cannot feel pain, pressure, or a tearing sensation. changes in vital signs indicate hypovolemia in an anesthetized postpartum client with vulvar hematoma.

the nurse is monitoring a postpartum client who received epidural anesthesia for delivery for the presence of a vulvar hematoma. which assessment finding would best indicate the presence of a hematoma? 1) changes in vital signs 2) signs of heavy bruising 3) complaints of intense pain 4) complaints of a tearing sensation

1 the priority nursing consideration for a client who delivered 2 hours ago and who has an episiotomy and hemorrhoids is client pain level. most clients have some degree of discomfort during the immediate postpartum period. there are no data in the question that indicate inadequate urinary output, the presence of client perception of body changes, and potential for imbalanced body fluid volume.

the nurse is planning care for a postpartum client who had a vaginal delivery 2 hours ago. the client required an episiotomy and has several hemorrhoids. what is the priority nursing consideration for this client? 1) client pain level 2) inadequate urinary output 3) client perception of body changes 4) potential for imbalanced body fluid volume

4 Rh incompatibility can occur when an Rh-negative mother becomes sensitized to the Rh antigen. sensitization may develop when an Rh-negative woman becomes pregnant with a fetus who is Rh positive. during pregnancy and at delivery, some of the fetus's Rh-positive blood can enter the maternal circulation, causing the mother's immune system to form antibodies against Rh-positive blood. administration of Rh immune globulin prevents the mother from developing antibodies against Rh-positive blood by providing passive antibody protection against the Rh antigen.

Rh immune globulin is prescribed for a client after delivery, and the nurse provides information to the client about the purpose of the medication. the nurse determines that the woman understands the purpose if the woman states that it will protect her next baby from which condition? 1) having Rh-positive blood 2) developing a rubella infection 3) developing physiological jaundice 4) being affected by Rh incompatibility

b recognize that the client is in the taking-in phase, which begins immediately following birth and lasts a few hours to a couple of days.

a client in the early postpartum period is very excited and talkative. they repeatedly tell the nurse every detail of the labor and birth. because the client will not stop talking, the nurse is having difficulty completing the postpartum assessments. which of the following actions should the nurse take? a) come back later when the client is more cooperative. b) give the client time to express feelings. c) tell the client they need to be quiet so the assessment can be completed. d) redirect the client's focus so that they will become quiet.

d nursing interventions to promote paternal bonding include providing education about newborn care and encouraging the parent to take a hands-on approach.

a nurse concludes that the parent of a newborn is not showing positive indications of parent-infant bonding. the parent appears very anxious and nervous when asked to bring the newborn to the other parent. which of the following actions should the nurse use to promote parent-infant bonding? a) hand the parent the newborn, and suggest that they change the diaper. b) ask the parent why they are so anxious and nervous. c) tell the parent that they will grow accustomed to the newborn. d) provide education about infant care when the parent is present.

a, b, d abdominal distention, flatus, and occasional diarrhea are findings associated with a lactose intolerance.

a nurse is assessing a 6-month-old infant who has a lactose intolerance. which of the following findings should the nurse expect? (select all that apply.) a) abdominal distention b) flatus c) hypoactive bowel sounds d) occasional diarrhea e) visible peristalsis

b, c, d, e feelings of financial inadequacy to provide for family, anxiety about assuming a new role as a parent, the rapid decline in estrogen and progesterone, and feeling of inadequacies with the new role as a mother are findings associated with postpartum depression.

a nurse is assessing a client who has postpartum depression. the nurse should expect which of the following manifestations? (select all that apply). a) paranoia that their infant will be harmed b) concerns about lack of income to pay bills c) anxiety about assuming a new role as a parent d) rapid decline in estrogen and progesterone e) feeling of inadequacy with the new role as a parent

d postpartum blues are characterized by tearfulness, insomnia, lack of appetite, and feeling let-down.

a nurse is assessing a postpartum client who is exhibiting tearfulness, insomnia, lack of appetite, and a feeling of letdown. which of the following conditions are associated with these manifestations? a) postpartum fatigue b) postpartum psychosis c) letting-go phase d) postpartum blues

a staphylococcus aureus, escherichia coli, and and streptococcus are usually the infecting agents that enter the breast due to sore or cracked nipples, which results in mastitis.

a nurse is caring for a client who has mastitis. which of the following is the typical causative agent of mastitis? a) stahpylococcus aureus b) chlamydia trachomatis c) klebsiella pneumonia d) clostridium perfringens

b identify that the greatest risk to the client and the infant is self-harm or harm directed toward the infant. therefore, the priority action to take is to directly ask the client if they have thoughts of self-harm, suicide, or harming the infant.

a nurse is caring for a client who has postpartum psychosis. which of the following actions is the nurse's priority? a) reinforce the need to take antipsychotics as prescribed. b) ask the client if they have thoughts of harming themselves or their infant. c) monitor the infant for indications of failure to thrive. d) review the client's medical record for a history of bipolar disorder.

a, c this behavior demonstrates a lack of interest in the newborn and impaired parent-infant bonding. a client's view of their newborn as being uncooperative during diaper changing is a sign of impaired parent-infant bonding.

a nurse is caring for a client who is 1 day postpartum. the nurse is assessing for maternal adaptation and parent-infant bonding. which of the following behaviors by the client indicates a need for the nurse to intervene? (select all that apply.) a) demonstrates apathy when the newborn cries b) touches the newborn and maintains close physical proximity c) views the newborn's behavior as uncooperative during diaper changing d) identifies and relates newborn's characteristics to those of family members e) interprets the newborn's behavior as meaningful and a way of expressing needs

b adverse responses by a sibling to a new infant can include regression in toileting habits.

a nurse is caring for a client who is 2 days postpartum. the client states, "my 4-year-old son was toilet trained and now he is frequently wetting himself." which of the following statements should the nurse provide to the client? a) "your son was probably not ready for toilet training and should wear training pants." b) "your son is showing an adverse sibling response." c) "your son may need counseling." d) "you should try sending your son to preschool to resolve the behavior."

a surfactant stabilizes the alveoli and helps increase oxygen saturation.

a nurse is caring for a newborn who is preterm and has respiratory distress syndrome. which of the following should the nurse monitor to evaluate the newborn's condition following administration of synthetic surfactant? a) oxygen saturation b) body temperature c) serum bilirubin d) heart rate

c using the safety and risk reduction framework, sunken fontanelles is the priority finding. since receiving phototherapy they are at risk for dehydration from loose stools due to increased bilirubin excretion.

a nurse is caring for an infant who has a high bilirubin level and is receiving phototherapy. which of the following is the priority finding in the newborn? a) conjunctivitis b) bronze skin discoloration c) sunken fontanels d) maculopapular skin rash

d epstein's pearls are small yello-white nodules that appear on the roof of a newborn's mouth.

a nurse is completing a newborn assessment and observes small pearly white nodules on the roof of the newborn's mouth. this finding is a characteristic of which of the following conditions? a) mongolian spots b) milia spots c) erythema toxicum d) epstien's pearls

c, d periods of apnea lasting less than 15 seconds are an expected finding. newborns are obligatory nose breathers.

a nurse is completing an assessment. which of the following date indicate the newborn is adapting to extrauterine life? (select all that apply.) a) expiratory grunting b) inspiratory nasal flaring c) apnea for 10-second periods d) obligatory nose breathing e) crackles and wheezing

b a second varicella immunization is needed 4 to 8 weeks following delivery by clients who had no history of immunity.

a nurse is completing postpartum discharge teaching to a client who had no immunity to varicella and was given the varicella vaccine. which of the following statements by the client indicates understanding of the teaching? a) "i will need to use contraception for 3 months before considering pregnancy." b) "i need a second vaccination at my postpartum visit." c) "i was given the vaccine because my baby is O-positive." d) "i will be tested in 3 months to see if i have developed immunity."

a cold compresses applied to the breasts after the feeding can help with breast engorgement.

a nurse is conducting a home visit for a client who is 1 week postpartum and breastfeeding. the client reports breast engorgement. which of the following recommendations should the nurse make? a) "apply cold compresses between feedings." b) "take a warm shower right after feedings." c) "apply breast milk to the nipples and allow them to air dry." d) "use the various infant positions for feedings."

a, b, c, d epidural anesthesia, urinary bladder catheterization, a history of frequent pelvic examinations, and a history of UTIs are risk factors for developing UTIs.

a nurse is discussing risk factors for urinary tract infections with a newly licensed nurse. which of the following conditions should the nurse include in the teaching? (select all that apply.) a) epidural anesthesia b) urinary bladder catheterization c) frequent pelvic examinations d) history of UTIs e) vaginal birth

a the client has moderate lochia rubra containing small clots, which is an expected finding for the second day postpartum.

a nurse is performing a fundal assessment for a client who is 2 days postpartum and observes the perineal pad for lochia. the pad is saturated approximately 12 cm with lochia that is bright red and contains small clots. which of the following findings should the nurse document? a) moderate lochia rubra b) excessive lochia serosa c) light lochia rubra d) scant lochia serosa

d plan to measure the circumference of the leg to assess for changes in the client's condition.

a nurse is planning care for a client who is postpartum and has thrombophlebitis. which of the following nursing interventions should the nurse include in the plan of care? a) apply cold compresses to the affected extremity. b) massage the affected extremity. c) allow the client to ambulate. d) measure leg circumferences.

2 the newborn of a diabetic mother is at risk for hypoglycemia, so maintaining safety because of low blood glucose levels would be a priority. the newborn would also be at risk for hyperbilirubinemia, respiratory distress, hypocalcemia, and congenital anomalies. developmental delays, choking, and and elevated body temperature are not expected problems.

a nurse is planning care for a newborn of a mother with diabetes mellitus. what is the priority nursing consideration for this newborn? 1) developmental delays because of excessive size 2) maintaining safety because of low blood glucose levels 3) choking because of impaired suck and swallow reflexes 4) elevated body temperature because of excess fat and glycogen

a vitamin K is deficient in a newborn because the colon is sterile. until bacteria are present to stimulate vitamin K production, the newborn is at risk for hemorrhagic disease.

a nurse is preparing to administer a vitamin K injection to a newborn. which of the following responses should the nurse make to the newborn's parent regarding why this medication is given? a) "it assists with blood clotting." b) "it promotes maturation of the bowel." c) "it is a preventative vaccine." d) "it provides immunity."

b the client who does not wash their hands between perineal care and breastfeeding is at an increased risk for developing mastitis. therefore, they are most at risk for developing a postpartum infection.

a nurse is providing care to four clients on the postpartum unit. which of the following clients is at greatest risk for developing a postpartum infection? a) a client who has an episiotomy that is erythematous and has extended into a third-degree laceration b) a client who does not wash their hands between perineal care and breastfeeding c) a client who is not breastfeeding and is using measures to suppress lactation d) a client who has a cesarean incision that is well-approximated with no drainage

c kegel exercises consist of the voluntary contraction and relaxation of the pubococcygeus muscle to strengthen the pelvic muscles, which will assist the client in decreasing urinary stress incontinence that occurs with sneezing and coughing.

a nurse is providing discharge instructions to a postpartum client following a cesarean birth. the client reports leaking urine every time they sneeze or cough. which of the following interventions should the nurse suggest? a) sit-ups b) pelvic tilt exercises c) kegel exercises d) abdominal crunches

a instruct the client to wear a well-fitting support bra continuously for the first 72 hr.

a nurse is providing discharge teaching for a nonlactating client. which of the following instructions should the nurse include in the teaching? a) "wear a supportive bra continuously for the first 72 hours." b) "pump your breasts every 4 hours to relieve discomfort." c) "use breast shells throughout the day to decrease milk supply." d) "apply warm compresses until milk suppression occurs."

c the penis should be cleaned with warm water with each diaper change.

a nurse is providing discharge teaching to the parents of a newborn regarding circumcision care. which of the following statements made by a parent indicates an understanding of the teaching? a) "the circumcision will heal within a couple of days." b) "i should remove the yellow mucus that will form." c) "i will clean the penis with each diaper change." d) "i will give him a tub bath within a couple of days."

a, c, e use a perineal squeeze bottle filled with warm water to cleanse the perineum and promote healing. the application of a topical anesthetic cream or spray to the perineum will promote comfort. the application of cold or ice packs to the perineum will promote comfort and decrease swelling.

a nurse is providing education to a client who is 2 hr postpartum and has perineal laceration. which of the following information should the nurse include? (select all that apply.) a) use a perineal squeeze bottle to cleanse the perineum. b) sit on the perineum while resting in bed. c) apply a topical anesthetic cream or spray to the perineum. d) wipe the perineum thoroughly with and back-and-forth motion. e) apply cold or ice packs to the perineum.

d the cradle position for breastfeeding includes the parent laying the newborn across one forearm with their hand supporting the lower back and buttocks.

a nurse is reviewing breastfeeding positions with the parent of a newborn. which of the following positions should the nurse discuss? a) over-the-shoulder b) supine c) chin-supported d) cradle

c the newborn should be restrained in the car seat in a rear-facing position in the back seat until 2 years of age.

a nurse is reviewing car seat safety with the parents of a newborn. which of the following instructions should the nurse include in the teaching regarding car seat position? a) front seat, rear-facing b) front seat, forward-facing c) back seat, rear-facing d) back seat, forward-facing

d folding the diaper below the cord prevents urine from the diaper penetrating the court site.

a nurse is reviewing care of the umbilical cord with the parent of a newborn. which of the following instructions should the nurse include in the teaching? a) cover the cord with a small gauze square. b) trickle clean water over the cord with each diaper change. c) apply hydrogen peroxide to the cord twice a day. d) keep the diaper folded below the cord.

c, d, e bottles can be placed in a dishwasher or washed by hand in hot soapy water using a good bottle brush. the flow of formula from the nipple should be checked to determine that it is not too fast or too slow. tap water is used to mix concentrated or powder formula. if the water is from a questionable source, it should be boiled first.

a nurse is reviewing formula preparation with parents who plan to bottle-feed their newborn. which of the following information should the nurse include in the teaching? (select all that apply.) a) use a disinfectant wipe to clean the lid of the formula can. b) store prepared formula in the refrigerator for up to 72 hr. c) place used bottles in the dishwasher. d) check the nipple for appropriate flow of formula. e) use tap water to dilute concentrated formula.

c each time the newborn is taken to the parent, the identification band should be verified against the mothers identification band.

a nurse is taking a newborn to a parent following a circumcision. which of the following actions should the nurse take for security purposes? a) ask the parent to state their full name. b) look at the name on the newborn's bassinet. c) match the parent's identification band with the newborn's band. d) compare name on the bassinet and room number.

c instruct the client to completely each breast at each feeding to prevent milk stasis, which provides a medium for bacterial growth.

a nurse is teaching a client who is breastfeeding and has mastitis. which of the following responses should the nurse make? a) "limit the amount of time the infant nurses on each breast." b) "nurse the infant only on the unaffected breast until resolved." c) "completely empty each breast at each feeding or use a pump." d) "wear a tight-fitting bra until lactation has ceased."

b a continuous high-pitched cry is often an indication of CNS disturbances in a newborn who has neonatal abstinence syndrome.

a nurse is teaching a newly licensed nurse about neonatal abstinence syndrome. which of the following statements by the newly licensed nurse indicate understanding of the teaching? a) "the newborn will have decreased muscle tone." b) "the newborn will have a continuous high-pitched cry." c) "the newborn will sleep for 2 to 3 hours after a feeding." d) "the newborn will have mild tremors when disturbed."

a mongolian spots are commonly found over the lumbosacral area of newborns who have dark skin and can be linked to genetics.

a nurse is teaching a newly licensed nurse how to bathe a newborn and observes a bluish brown marking across the newborn's lower back. the nurse should include which of the following information in the teaching? a) "this is more commonly seen in newborns who have dark skin." b) "this is a finding indicating hyperbilirubinemia." c) "this is a forceps mark from an operative delivery." d) "this is related to prolonged birth or trauma during delivery."

a, c, d a client report of calf tenderness to palpation, elevated temperature, and an area of warmth over the thrombus are expected findings in a client who has a DVT.

a nurse on a postpartum unit is assessing a client who is being admitted with a suspected deep-vein thrombosis. which of the following clinical findings should the nurse expect? (select all that apply.) a) calf tenderness to palpation b) mottling of the affected extremity c) elevated temperature d) area of warmth e) report of nausea

2 precipitous labor is labor that lasts 3 hours or less. women who have experienced precipitous labor often describe feelings of disbelief that their labor progressed so rapidly. to assist the client to process what has happened, the best option is to support the client in her reaction to the newborn infant.

after a precipitous delivery, the nurse notes that the new mother is passive and touches her newborn infant only briefly with her fingertips. what should the nurse do to help the woman process the delivery? 1) encourage the mother to breast-feed soon after birth. 2) support the mother in her reaction to the newborn infant. 3) tell the mother that it is important to hold the newborn infant. 4) document a complete account of the mother's reaction on the birth record.

c lochia typically trickles from the vaginal opening but flows more steadily during uterine contractions. massaging the uterus or ambulation can result in a gush of lochia with the expression of clots and dark blood that has been pooled in the vagina, but it should soon decrease back to a trickle of bright red lochia in the early puerperium.

during ambulation to the bathroom, a postpartum client experiences a gush of dark red blood that soon stops. on assessment, the nurse finds the uterus to be firm, midline, and at the level of the umbilicus. which of the following findings should the nurse interpret this data as being? a) evidence of a possible vaginal hematoma b) an indication of a cervical or perineal laceration c) a normal postural discharge of lochia d) abnormally excessive lochia rubra flow

4 methylergonovine is an ergot alkaloid used to treat postpartum hemorrhage. ergot alkaloids are contraindicated in clients with significant cardiovascular disease, peripheral vascular disease, hypertension, preeclampsia, or eclampsia. these conditions are worsened by the vasoconstrictive effects of the ergot alkaloids.

methylergonovine is prescribed for a client with postpartum hemorrhage. before administering the medication, the nurse should contact the obstetrician who prescribed the medication if which condition is documented in the client's medical history? 1) hypotension 2) hypothyroidism 3) diabetes mellitus 4) peripheral vascular disease

2 methylergonovine, an ergot alkaloid, is used to prevent or control postpartum hemorrhage by contracting the uterus. methylergonovine causes continuous uterine contractions and may elevate the blood pressure. a priority assessment before the administration of the medication is to check the blood pressure. the obstetrician needs to be notified if hypertension is present.

methylergonovine is prescribed for a woman to treat postpartum hemorrhage. before administration of methylergonovine, what is the priority assessment? 1) uterine tone 2) blood pressure 3) amount of lochia 4) deep tendon reflexes

3 if the uterus is not contracted firmly, the initial intervention is to massage the fundus until it is firm and to express clots that may have accumulated in the uterus. elevating the client's legs would not assist in managing uterine atony. documenting the findings is appropriate action but is not the initial action. pushing on an uncontracted uterus can invert the uterus and cause massive hemorrhage.

on assessment of a postpartum client, the nurse notes that the uterus feels soft and boggy. the nurse should take which initial action? 1) document the findings. 2) elevate the client's legs. 3) massage the fundus until it is firm. 4) push on the uterus to assist in expressing clots.

4 erythromycin ophthalmic ointment 0.5% is used as a prophylactic treatment for ophthalmia neonatorum, which is caused by the bacterium neisseria gonorrhoeae. preventative treatment of gonorrhea is required by law.

the nurse administers erythromycin ointment to the eyes of a newborn and the mother asks the nurse why this is performed. which explanation is best for the nurse to provide about neonatal eye prophylaxis? 1) protects the newborn's eyes from possible infection acquired while hospitalized. 2) prevents cataracts in the newborn born to a woman who is susceptible to rubella. 3) minimize the spread of microorganisms to the newborn from invasive procedures during labor. 4) prevents an infection called ophthalmia neonatorum from occurring after birth in a newborn born to a woman with an untreated gonococcal infection.

1 eye prophylaxis protects the newborn against neisseria gonorrhoeae and chlamydia trachomatis. the eyes are not flushed after instillation of the medication because the flush would wash away the administered medication.

the nurse asks a nursing student to describe the procedure for administering erythromycin ointment to the eyes of a newborn. which student statement indicates that further teaching is needed about administration of the eye medication? 1) "i will flush the eyes after instilling the ointment." 2) "i will clean the newborn's eyes before instilling ointment." 3) "i need to administer the eye ointment within 1 hour after delivery." 4) "i will instill the eye ointment into each of the newborn's conjunctival sacs."

3 evaporation of moisture from a wet body dissipates heat along with the moisture. keeping the newborn dry by drying the wet newborn at birth prevents hypothermia via evaporation. hypothermia caused by conduction occurs when the newborn is on a cold surface, such as a cold pad or mattress, and heat from the newborn's body is transferred to the colder object. warming the crib pad assists in preventing hypothermia by conduction. convection occurs as air moves across the newborn's skin from an open door and heat is transferred to the air. radiation occurs when heat from the newborn radiates to a colder surface.

the nurse assisted with the birth of a newborn. which nursing action is most effective in preventing heat loss by evaporation? 1) warming the crib pad 2) closing the doors to the room 3) drying the infant with a warm blanket 4) turning on the overhead radiant warmer

2 an infant born to a mother infected with HIV must be cared for with a strict attention to standard precautions. this prevents the transmission of HIV from the newborn, if infected, to others and prevents transmission of other infectious agents to the possibly immunocompromised newborn.

the nurse creates a plan of care for a woman with human immunodeficiency virus infection and her newborn. the nurse should include which intervention in the plan of care? 1) monitoring the newborn's vital signs routinely 2) maintaining standard precautions at all times while caring for the newborn 3) initiating referral to evaluate for blindness, deafness, learning problems, or behavioral problems 4) instructing the breast-feeding mother regarding the treatment of the nipples with nystatin ointment

1 a cesarean delivery requires an incision made through the abdominal wall and into the uterus. abdominal exercises should not start immediately after abdominal surgery; the client should wait at least 3 to 4 weeks postoperatively to allow for healing of the incision.

the nurse has provided discharge instructions to a client who delivered a healthy newborn by cesarean delivery. which statement made by the client indicates a need for further instruction? 1) "i will begin abdominal exercises immediately." 2) "i will notify my obstetrician if i develop a fever." 3) "i will turn on my side and push up with my arms to get out of bed." 4) "i will lift nothing heavier than my newborn baby for at least 2 weeks."

1, 2, 4, 5 a newborn infant with respiratory distress syndrome may present with clinical signs of cyanosis, tachypnea or apnea, nasal flaring, chest wall retractions, or audible grunts. hypotension and barrel chest are not clinical manifestations associated with respiratory distress syndrome.

the nurse in a newborn nursery is monitoring a preterm newborn for respiratory distress syndrome. which assessment findings should alert the nurse to the possibility of this syndrome? select all that apply. 1) cyanosis 2) tachypnea 3) hypotension 4) retractions 5) audible grunts 6) presence of a barrel chest

3 if bleeding is excessive, the cause may be laceration of the cervix or birth canal. massaging the fundus if it is firm would not assist in controlling the bleeding. trendelenburg's position should be avoided because it may interfere with cardiac and respiratory function. although the nurse would record the findings, the initial nursing action would be to notify the OB.

the nurse is assessing a client in the fourth stage of labor and notes that the fundus is firm, but that bleeding is excessive. which should be the initial nursing action? 1) record the findings. 2) massage the fundus. 3) notify the obstetrician. 4) place the client in trendelenburg's position.

3 orthostatic hypotension may be evident during the first 8 hours after birth. feelings of faintness or dizziness are signs that caution the nurse to focus interventions on the client's safety. the nurse should advise the client to get help the first few times she gets out of bed.

the nurse is assessing a client who is 6 hours postpartum after delivering a full-term healthy newborn. the client complains to the nurse of feelings of faintness and dizziness. which nursing action is most appropriate? 1) raise the head of the client's bed. 2) obtain hemoglobin and hematocrit levels. 3) instruct the client to request help when getting out of bed. 4) inform the nursery room nurse to avoid bringing the newborn to the client until the client's symptoms have subsided.

3 the penis is normally red during the healing process after circumcision. a yellow exudate may be noted in 24 hourt ofs, and this is part of normal healing. the nurse would expect that the area would be red with a small amount of bloody drainage. only if the bleeding were excessive would the nurse apply gentle pressure with a sterile gauze. if bleeding cannot be controlled, the blood vessel may need to be ligated, and the nurse would notify the PHCP. because the findings identified in the question are normal, the nurse would document the assessment findings.

the nurse is assessing a newborn after circumcision and notes that the circumcised area is red with a small amount of bloody drainage. what nursing action is most appropriate? 1) apply gentle pressure. 2) reinforce the dressing. 3) document the findings. 4) contact the primary health care provider.

3, 4, 5 a newborn of a woman who uses drugs is irritable. the infant is overloaded easily by sensory stimulation. the infant may cry incessantly and be difficult to console. the infant would hyperextend and posture rather than cuddle when being held. the infant is not lethargic or sleepy.

the nurse is assessing a newborn who was born to a mother who is addicted to drugs. which findings should the nurse expect to note during the assessment of this newborn? select all that apply. 1) lethargy 2) sleepiness 3) irritability 4) constant crying 5) difficult to comfort 6) cuddles when being held

4 lochia, the discharge present after birth, is red for the first 1 to 3 days and gradually decreases in amount. normal lochia has a fleshy odor or an odor similar to menstrual flow. foul-smelling or purulent lochia usually indicates infection, and these findings are not normal.

the nurse is caring for four 1-day postpartum clients. which client assessment requires the need for follow-up? 1) the client with mild afterpains 2) the client with a pulse rate of 60 beats per minute 3) the client with colostrum discharge from both breasts 4) the client with lochia that is red and has a foul-smelling odor

4 fetal alcohol syndrome, a diagnostic category delineated under fetal alcohol spectrum disorders, is caused by maternal alcohol use during pregnancy. a primary nursing goal for the newborn diagnosed with fetal alcohol syndrome is to establish nutritional balance after birth. these newborns may exhibit hyperirritability, vomiting, diarrhea, or an uncoordinated sucking and swallowing ability. a quiet environment with minimal stimuli and handling would help establish appropriate sleep-rest cycles in the newborn as well.

the nurse is creating a plan of care for a newborn diagnosed with fetal alcohol syndrome. the nurse should include which priority intervention in the plan of care? 1) allow the newborn to establish own sleep-rest pattern. 2) maintain the newborn in a brightly lighted area of the nursery. 3) encourage frequent handling of the newborn by staff and parents. 4) monitor the newborn's response to feedings and weight gain pattern.

4 a hematoma is a localized collection of blood in the tissues of the reproductive tissues after delivery. vulvar hematoma is the most common. application of ice reduces swelling caused by hematoma formation in the vulvar area.

the nurse is creating a plan of care for a postpartum client with a small vulvar hematoma. the nurse should include which specific action during the first 12 hours after delivery? 1) encourage ambulation hourly. 2) assess vital signs every 4 hours. 3) measure fundal height every 4 hours. 4) prepare an ice pack for application to the area.

2 during the fourth stage of labor, the maternal blood pressure, pulse, and respiration should be checked every 15 minutes during the first hour. an increasing pulse is an early sign of excessive blood loss because the heart pumps faster to compensate for reduced blood volume. a slight increase in temperature is normal. the blood pressure decreases as the blood volume diminishes, but a decreased blood pressure would not be the earliest sign of hemorrhage. the respiratory rate is slightly increased from normal.

the nurse is monitoring a client in the immediate postpartum period for signs of hemorrhage. which sign, if noted, would be an early sign of excessive blood loss? 1) a temperature of 100.4 degrees F 2) an increase in the pulse rate from 88 to 102 beats per minute 3) a blood pressure change from 130/88 to 124/80 mm Hg 4) an increase in the respiratory rate from 18 to 22 breaths per minute

4 lochia is the discharge from the uterus in the postpartum period; it consists of blood from the vessels of the placental site and debris from the decidua. the following can be used as a guide to determine the amount of flow: scant=less than 2.5 cm on menstrual pad in 1 hour; light=less than 10 cm on menstrual pad in 1 hour; moderate=less than 15 cm on menstrual pad in 1 hour; heavy=saturated menstrual pad in 1 hour; and excessive=menstrual pad saturated in 15 minutes. if the client is experiencing excessive bleeding, the nurse should contact the OB in the event that postpartum hemorrhage is occurring. it may be appropriate to encourage increased fluid intake, but this is not the initial action. it is not appropriate to encourage ambulation at this time. documentation should occur once the client has been stabilized.

the nurse is monitoring the amount of lochia drainage in a client who is 2 hours postpartum and notes that the client has saturated a perineal pad in 15 minutes. how should the nurse respond to this finding initially? 1) document the finding. 2) encourage the client to ambulate. 3) encourage the client to increase fluid intake. 4) contact the obstetrician and inform him or her of this finding.

1, 2, 3, 4 mastitis is an inflammation of the lactating breast as a result of infection. client instructions include resting during the acute phase, maintaining a fluid intake of at least 3000 mL/day, and taking analgesics to relieve discomfort. antibiotics may be prescribed and are taken until the complete prescribed course is finished. they are not stopped when the soreness subsides. additional supportive measures include the use of moist heat or ice packs and wearing a supportive bra. continued decompression of the breast by breast-feeding or breast pump is important to empty the breast and prevent the formation of an abscess.

the nurse is preparing a list of self-care instructions for a postpartum client who was diagnosed with mastitis. which instructions should be included on the list? select all that apply. 1) wear a supportive bra. 2) rest during the acute phase. 3) maintain a fluid intake of at least 3000 mL/day. 4) continue to breast-feed if the breasts are not too sore. 5) take the prescribed antibiotics until the soreness subsides. 6) avoid decompression of the breasts by breast-feeding or breast pump.

2 if the uterus is not contracted firmly, the initial intervention is to massage until it is firm and to express clots that may have accumulated in the uterus. elevating the client's legs and positioning the client on the side would not assist in managing uterine atony. pushing on an uncontracted uterus can invert the uterus and cause massive hemorrhage.

the nurse is preparing to assess the uterine fundus of a client in the immediate postpartum period. after locating the fundus, the nurse notes that the uterus feels soft and boggy. which nursing intervention is appropriate? 1) elevate the client's legs. 2) massage the fundus until it is firm. 3) ask the client to turn on her left side. 4) push on the uterus to assist in expressing clots.

4, 5, 6 phototherapy is the use of intense fluorescent light to reduce serum bilirubin levels in the newborn. adverse effects from treatment, such as eye drainage, dehydration, or sensory deprivation, can occur. interventions include exposing as much of the newborn's skin as possible; however, the genital area is covered. the newborn's eyes are also covered with eye shields or patches, ensuring that the eyelids are closed when shields or patches are applied. the shields or patches are removed at least once per shift to inspect the eyes for infection or irritation and to allow eye contact. the nurse measures the lamp energy output to ensure efficacy of the treatment, monitors skin temperature closely, and increases fluids to compensate for water loss. the newborn may have loose green stools and green-colored urine. the newborn's skin color is monitored with the fluorescent light turned off every 4 to 8 hours and is monitored for bronze baby syndrome, a grayish brown discoloration of the skin. the newborn is repositioned every 2 hours, and stimulation is provided. after treatment, the newborn is monitored for signs of hyperbilirubinemia because rebound elevations can occur after therapy is discontinued.

the nurse is preparing to care for a newborn receiving phototherapy. which interventions should be included in the plan of care? select all that apply. 1) avoid stimulation. 2) decrease fluid intake. 3) expose all of the newborn's skin. 4) monitor skin temperature closely. 5) cover the newborn's eyes with eye shields or patches.

3 the causes of postpartum hemorrhage include uterine atony; laceration of the vagina; hematoma development in the cervix, perineum, or labia; and retained placental fragments. predisposing factors for hemorrhage include a previous history of postpartum hemorrhage, placenta previa, abruptio placentae, overdistention of the uterus from polyhydramnios, multiple gestation, a large neonate, infection, multiparity, dystocia or labor that is prolonged, operative delivery such as a cesarean or forceps delivery, and intrauterine manipulation. the multiparous client who delivered a large fetus after oxytocin induction has more risk factors associated with postpartum hemorrhage than do other clients.

the nurse is preparing to care for four assigned clients. which client is at most risk for hemorrhage? 1) a primiparous client who delivered 4 hours ago 2) a multiparous client who delivered 6 hours ago 3) a multiparous client who delivered a large baby after oxytocin induction 4) a primiparous client who delivered 6 hours ago and had epidural anesthesia

4 mastitis is inflammation of the breast as a result of infection. it generally is caused by an organism that enters through an injured area of the nipples, such as a crack or blister. measures to prevent the development of mastitis include changing nursing pads when they are wet and avoiding continuous pressure on the breasts. soap is drying and could lead to cracking of the nipples, and the client should be instructed to avoid using soap on the nipples. the mother is taught about the importance of hand washing and that she should breast-feed every 2 to 3 hours.

the nurse is providing instructions about measures to prevent postpartum mastitis to a client who is breast-feeding her newborn. which client statement would indicate a need for further instruction? 1) "i should breast-feed every 2 to 3 hours." 2) "i should change the breast pads frequently." 3) "i should wash my hands well before breast-feeding." 4) "i should wash my nipples daily with soap and water."

1, 2, 3, 6 the postpartum client should wear a bra that is well fitted and supportive. common causes of decreased milk supply include formula use; inadequate rest or diet; smoking by the mother or others in the home; and the use of caffeine, alcohol, or medications. breast-feeding clients should increase their daily fluid intake; having bottled water available indicates that the postpartum client understands the importance on increasing fluids. if engorgement occurs, the client should not limit breast-feeding but should breast-feed frequently. oral contraceptives containing estrogen are not recommended for breast-feeding mothers.

the nurse is providing postpartum instructions to a client who will be breast-feeding their newborn. the nurse determines that the client understood the instructions if she makes which statements? select all that apply. 1) "i should wear a bra that provides support." 2) "drinking alcohol can affect my milk supply." 3) "the use of caffeine can decrease my milk supply." 4) "i will start my estrogen birth control pills again as soon as i get home." 5) "i know if my breasts get engorged, i will limit my breast-feeding and supplement the baby." 6) "i plan on having bottled water available in the refrigerator so i can get additional fluids easily."

1 the diet for a breast-feeding client should include additional fluids. prenatal vitamins should be taken as prescribed, and soap should not be used on the breasts because it tends to remove natural oils, which increases the chance of cracked nipples. breast-feeding is not a method of contraception, so birth control measures should be resumed.

the nurse is teaching a postpartum client about breast-feeding. which instruction should the nurse include? 1) the diet should include additional fluids. 2) prenatal vitamins should be discontinued. 3) soap should be used to cleanse the breasts. 4) birth control measures are unnecessary while breast-feeding.

2 fetal alcohol syndrome, a diagnostic category of fetal alcohol spectrum disorders, is caused by maternal alcohol use during pregnancy. features of newborns diagnosed with fetal alcohol syndrome include craniofacial abnormalities, intrauterine growth restriction, cardiac abnormalities, abnormal palmer creases, and respiratory distress.

the nurse notes hypotonia, irritability, and a poor sucking reflex in a full-term newborn on admission to the nursery. the nurse suspects fetal alcohol syndrome and is aware that which additional signs would be consistent with this syndrome? 1) length of 19 inches 2) abnormal palmer creases 3) birth weight of 6 lb, 14 oz 4) head circumference appropriate for gestational age

4 phytonadione is necessary for the body to synthesize coagulation factors. it is administered to the newborn to prevent bleeding disorders. it also promotes liver formation of the clotting factors II, VII, IX, and X. newborns are vitamin K-deficient because the bowel does not have the bacteria necessary to synthesize fat-soluble vitamin K. the normal flora in the intestinal tract produces vitamin K. the newborn's bowel does not support the normal production of vitamin K until bacteria adequately colonize it. the bowel becomes colonized by bacteria as food is ingested. vitamin K does not promote the development of immunity or prevent the infant from becoming jaundiced.

the nurse prepares to administer phytonadione injection to a newborn, and the mother asks the nurse why her infant needs the injection. what best response should the nurse provide? 1) "your newborn needs the medicine to develop immunity." 2) "the medicine will protect your newborn from being jaundiced." 3) "newborns have sterile bowels, and the medicine promotes the growth of bacteria in the bowel." 4) "newborns are deficient in vitamin K, and this injection prevents your newborn from bleeding."

3 thrombosis of superficial veins usually is accompanied by signs and symptoms of inflammation, including swelling, redness, tenderness, and warmth of the involved extremity. it also may be possible to palpate the enlarged, hard vein. clients sometimes experience pain when they walk. palpable dorsalis pedis pulses is a normal finding.

the postpartum nurse is assessing a client who delivered a healthy infant by cesarean section for signs and symptoms of superficial venous thrombosis. which sign should the nurse note if superficial venous thrombosis is present? 1) paleness of the calf area 2) coolness of the calf area 3) enlarged, hardened veins 4) palpable dorsalis pedis pulses

2 hyperbilirubinemia is an elevated serum bilirubin level. at any serum bilirubin level, the appearance of jaundice during the first day of life indicates a pathological process. early and frequent feeding hastens the excretion of bilirubin. breast-feeding should be initiated within 2 hours after birth and every 2 to 4 hours thereafter. the infant should not be fed less frequently. switching to bottle-feeding for 2 weeks or stopping breast-feeding permanently is unncecessary.

the postpartum nurse is providing instructions to the mother of a newborn with hyperbilirubinemia who is being breast-fed. the nurse should provide which instruction to the mother? 1) feed the newborn less frequently. 2) continue to breast-feed every 2 to 4 hours. 3) switch to bottle-feeding the infant for 2 weeks. 4) stop breast-feeding and switch to bottle-feeding permanently.

4 the client's temperature should be taken every 4 hours while she is awake. temperatures up to 100.4 degrees F in the first 24 hours after birth often are related to the dehydrating effects of labor. the appropriate action is to increase hydration by encouraging oral fluids, which should bring the temperature to a normal reading. although the nurse also would document the findings, the appropriate action would be to increase hydration. taking the temperature in another 15 minutes is an unnecessary action. contacting the obstetrician is not necessary.

the postpartum nurse is taking the vital signs of a client who delivered a healthy newborn 4 hours ago. the nurse notes that the client's temperature is 100.2 degrees F. what is the priority nursing action? 1) document the findings. 2) notify the obstetrician. 3) retake the temperature in 15 minutes. 4) increase hydration by encouraging oral fluids.

assessment

-breast -uterus -bladder -bowels -lochia -homan's -episiotomy and perineum

interventions

-health promotion -pain management -promoting healing -preventing complications -discharge planning and education

postpartum depression

10-15% progress to PPD may be mild to severe, "good days and bad days" many embarrassed to admit... you need to look for warning signs- unable to eat or sleep, not wanting to get out of bed, concerns over hurting self or child may progress to psychosis

b urinary retention can result in a distention of the bladder. a distended bladder can cause uterine atony and lateral displacement from the midline.

a nurse is assessing a postpartum client for fundal height, location, and consistency. the fundus is noted to be displaced laterally to the right, and there is uterine atony. the nurse should identify which of the following conditions as the cause of the uterine atony? a) poor involution b) urinary retention c) hemorrhage d) infection

lab evaluation

CBC -H/H: assess drop from pre-delivery and s/s of adaptation -WBC: assess change, consider norms -platelets: assess for bleeding disorders rubella status RH status

d the moro reflex is elicited by holding the newborn in a semi-sitting position and then allowing the head and trunk to fall backward.

a nurse is assessing the reflexes of a newborn. in checking for the moro reflex, the nurse should perform which of the following? a) hold the newborn vertically under arms and allow one foot to touch table. b) stimulate the pads of the newborn's hands with stroking or massage. c) stimulate the soles of the newborn's feet on the outer lateral surface of each foot. d) hold the newborn in a semi-sitting position, then allow the newborn's head and trunk to fall backward.

a, c, d characteristics of a preterm newborn include the presence of abundant lanugo; a weak grasp reflex; and skin that is thin, smooth, shiny, and translucent.

a nurse is called to the birthing room to assist with the assessment of a newborn who was born at 32 weeks of gestation. the newborn's birth weight is 1,000 g. which of the following are expected findings in this newborn? (select all that apply.) a) lanugo b) long nails c) weak grasp reflex d) translucent skin e) plump face

a DIC can occur secondary in a client who has preeclampsia.

a nurse is caring for a client who has disseminated intravascular coagulation. which of the following antepartum complications should the nurse understand is a risk factor for this condition? a) preeclampsia b) thrombophlebitis c) placenta previa d) hyperemesis gravidarum

d placing the neonate in the en face position on the client's chest immediately after birth is the priority nursing intervention to promote parent-infant bonding.

a nurse in the delivery room is planning to promote parent-infant bonding for a client who just delivered. which of the following is the priority action by the nurse? a) encourage the parents to touch and explore the neonate's features. b) limit noise and interruption in the delivery room. c) place the neonate at the client's breast. d) position the neonate skin-to-skin on the client's chest.

vital signs

RR- 30-60 HR- 100-160 BP- 60-80/40-50 temp- 97.7-98.9 F

c evaporation is the loss of heat that occurs when a liquid is converted to a vapor. in a newborn, heat loss by evaporation occurs as a result of vaporization of the moisture from the skin.

a newborn was not dried completely after birth. this places the infant at risk for which of the following types of heat loss? a) conduction b) convection c) evaporation d) radiation

LGA- large for gestational age

birth weight above the 90th percentile nursing care -obtain early and frequent heel sticks -initiate early feedings or IV therapy to maintain glucose levels within the expected reference range

SGA- small for gestational age

birth weight is at or below the 10th percentile nursing care -support respiratory efforts -provide a neutral thermal environment -initiate early feedings

diagnostics

cord blood is collected at birth laboratory tests are conducted to determine ABO blood type and Rh status CBC to evaluate for anemia, polycythemia, infection, or clotting problems blood glucose to evaluate hypoglycemia metabolic screening

assessing attachment

do the parents: -reach for baby -call baby by name -discuss who the baby "looks like" -offer stimulation to the baby -appear comfortable handling the baby -use appropriate quieting techniques

hyperbilirubinemia

elevation of serum bilirubin levels -physiologic -pathologic treatment -phototherapy

infections

endometritis, mastitis, wound infections, UTI -endometritis is an infection of the uterine lining or endometrium. -sites of wound infections include cesarean incisions, episiotomies, lacerations, and/or any trauma wounds present in the birth canal following labor and birth. -mastitis is an infection of the breast (staphylococcus aureus) -UTIs are a common postpartum infection secondary to bladder trauma incurred during the delivery

medications

erythromycin vitamin K hepatitis B immunization topical antimicrobial therapy

infant behaviors

facilitating -eye contact -vocalization -grasp reflex -clings to parent -consoled by parent inhibiting -sleepy -excessive crying -resists holding -ignores parent -unresponsive

health promotion- rubella

give rubella if non-immune -virus may be shed in urine and body fluids but transmission is unlikely except if a household family member is immunocompromised -allergies to eggs and neomycin- avoid -do not get pregnant for one month to avoid possible congenital rubella syndrome.

physical exam

head to toe assessment

health promotion- RH isoimmunization

if mom is RH-, assess baby's blood type -if baby is RH-, mom does not need -if baby is RH+, mom needs within 72 hrs -usual dose is 300 micrograms -if patient is also given rubella, her immune response from the immune globulin may suppress conversion so plan to check labs.

substance withdrawal

illegal drugs alcohol tobacco prescription drugs monitor for withdrawal -increased wakefulness, a high-pitched, shrill cry, incessant crying, irritability, tremors, hyperactive with an increased moro reflex, increased deep-tendon reflexes, increased muscle tone, abrasions and/or excoriations on the face and knees, and convulsions. -nasal congestion with flaring, frequent yawning, skin mottling, tachypnea greater than 60/min, sweating, and a temperature greater than 37.2 degrees C. -poor feeding, regurgitation, diarrhea, and excessive, uncoordinated, and constant sucking.

lacerations/hematomas

lacerations- tearing of soft tissues in the birth canal and adjacent structures including the cervical, vaginal, vulvar, perineal, and/or rectal areas -first degree- laceration extends through the skin of the perineum and does not involve the muscles. -second degree- laceration extends through the skin and muscles into the perineum. -third degree- laceration extends through the skin, muscles, perineum, and anal sphincter muscle. -fourth degree- laceration extends through skin, muscles, anal sphincter, and the anterior rectal wall. hematoma- a collection of clotted blood within tissues

assessment of breastfeeding

maternal breast: texture, nipple, soft/full infant: readiness/cues assess -latch -suck -swallow -nipples -satiety

postpartum hemorrhage

measure blood loss by weighing items

breastfeeding- benefits

mom -decreased risk of ovarian, uterine, and breast cancer -PP hemorrhage decreased -quicker return to pre-pregnancy weight -convenient and cheap baby -enhances GI development and immune factors -decreased respiratory, urinary, and ear infections -decreased allergies -less likely to develop type I diabetes

birth trauma/injury

occurs during childbirth resulting in physical injury to a newborn skull scalp intracranial spinal cord plexus cranial and peripheral nerve

uterine atony

results from the inability of the uterine muscle to contract adequately after birth. this can lead to postpartum hemorrhage. nursing care -fundal height, consistency, and location -lochia for quantity, color, and consistency -perform fundal massage if indicated

rhogam administration

rhogam should be given to any Rh negative woman within 72 hours of: -abortion, early bleeding, ectopic, miscarriage, amniocentesis or other invasive procedure -routinely 28 weeks gestation -postpartum if the infant is Rh positive and direct coombs' is negative

promoting attachment

rooming in point out positive reactions from the baby appropriate pain relief for mother open visiting hours for father involve siblings promote breastfeeding assess for any risks: ignoring baby, negative comments, excessive frustration

hypoglycemia

serum glucose level of less than 40 mg/dL obtain blood by heel stick for glucose monitoring. provide frequent oral and/or gavage feedings, or continuous parenteral nutrition early after birth to treat monitor the neonate's blood glucose level closely per facility protocol monitor IV if the neonate is unable to feed orally

RDS

surfactant deficiency in the lung perform a respiratory assessment including ABGs, respiratory rhythm, rate suction the newborn's mouth, trachea, and nose maintain adequate oxygenation medications -beractant restores surfactant and improves respiratory compliance

phases of maternal adjustment

taking in: first 24-48 hrs, mother needs nurturing taking-hold: by 3rd postpartum day, dependent-independent phase, alternates between neediness and need to take charge, becomes curious and interested, most ready to learn "blues": 75-80% of women, days 5-10, emotional lability

2 the highest priority on admission to the nursery for a newborn with a low apgar score is the airway, which would involve preparing respiratory resuscitation equipment and oxygen.

the nurse in a neonatal intensive care unit receives a telephone call to prepare for the admission of a 43-week gestation newborn with apgar scores of 1 and 4. in planning for admission of this newborn, what is the nurse's highest priority? 1) turn on the apnea and cardiorespiratory monitors. 2) connect the resuscitation bag to the oxygen outlet. 3) set up the intravenous line with 5% dextrose in water. 4) set the radiant warmer control temperature at 36.5 degrees C.

2 respiratory distress syndrome is a serious lung disorder caused by immaturity and the inability to produce surfactant, resulting in hypoxia and acidosis. it is common in premature infants and may be due to lung immaturity as a result of surfactant deficiency. the mainstay of treatment is the administration of exogenous surfactant, which is administered by the intratracheal route.

the nurse is preparing to administer exogenous surfactant to a premature infant who has respiratory distress syndrome. the nurse prepares to administer the medication by which route? 1) intradermal 2) intratracheal 3) subcutaneous 4) intramuscular

retained placenta

the placentas or fragments of the placenta remain in the uterus and prevents the uterus from contracting

inversion of the uterus

the turning inside out of the uterus an emergency situation

methylergonovine

therapeutic use -prevention and treatment of postpartum and post-abortion hemorrhage adverse drug reactions -rare with PO or IM administration- more common when administered IV -hypertension -nausea, vomiting -cramps -arrhythmias -seizures interventions -monitor blood pressure. -monitor for nausea and vomiting. -monitor for headache and note any worsening of headache. -monitor heart rate. -monitor for signs of seizure activity. -institute seizure precautions if indicated. administration -check blood pressure before administration. do not give if B/P exceeds parameters set by provider -give orally for 2 to 7 days or IM every 2 hr as needed. -give the drug IV only for emergency control of severe hemorrhage. -administer IV doses slowly. -administer after the delivery of the placenta. -monitor vital signs and uterine response. -tell clients to expect some cramping. client instructions -report any nausea. -report headache. -report any weakness or palpitations. contraindications -induction of labor -threatened spontaneous abortion -hypertension precautions -sepsis -liver disease -renal disease -do not take if breastfeeding interactions -other ergot alkaloids, vasopressors, and triptans increase the risk of hypertension. -protease inhibitors and itraconazole increase the risk of toxicity. -smoking increases vasoconstrictive effects. -grapefruit juice increases blood levels of drug.

2 normally, a few small clots may be noted in the lochia in the first 1 to 2 days after birth from pooling of blood in the vagina. clots larger than 1 cm are considered abnormal. the cause of these clots, such as uterine atony or retained placental fragments, needs to be determined and treated to prevent further blood loss. although the findings would be documented, the appropriate action is to notify the OB. reassessing the client in 2 hours would delay necessary treatment. increasing oral intake of fluids would not be a helpful action in this situation.

when performing a postpartum assessment on a client, the nurse notes the presence of clots in the lochia. the nurse examines the clots and notes that they are larger than 1 cm. which nursing action is most appropriate? 1) document the findings. 2) notify the obstetrician. 3) reassess the client in 2 hours. 4) encourage increased oral intake of fluids.

3 precautions to prevent infant abduction include placing a newborn's crib away from the door, transporting a newborn only in the crib and never carrying the newborn, expecting health care personnel to wear identification that is easily visible at all times, and asking the nurse to attend to the newborn if the mother is napping and no family member is available to watch the newborn. if the mother states that she will ask the nurse to watch the newborn while she is sleeping, she has understood the teaching.

which statement reflects a new mother's understanding of the teaching about the prevention of newborn abduction? 1) "i will place my baby's crib close to the door." 2) "some health care personnel won't have name badges." 3) "i will ask the nurse to attend to my infant if i am napping and my husband is not here." 4) "it's okay to allow the nurse assistant to carry my newborn to the nursery."

emotional needs

will want to discuss the birth experience help promote a positive self-image promote adaptation to parenthood cultural considerations: -yin/yang- needs hot food/warm air -modesty issues -who cares for the infant/mother