pregnancy labor and delivery. Ch 65,66 and 67
The nurse is advising an active pregnant woman on nutritional needs to maintain a healthy pregnancy. What would the nurse state is the average total additional energy (calorie) requirement during pregnancy? Select one: A. 3,500 to 4,000 calories per day B. 1,500 to 2,000 calories per day C. 2,500 to 3,500 calories per day D. 2,000 to 2,500 calories per day
C. 2,500 to 3,500 calories per day
A primigravida client has to undergo an ultrasound examination. Which should the nurse know is the most appropriate time to perform an ultrasound? Select one: A. Between 6 and 8 weeks B. Between 10 and 12 weeks C. Between 16 and 20 weeks D. Between 12 and 14 weeks
C. Between 16 and 20 weeks
The nurse is caring for a client who just delivered a healthy 7 pound 9 ounce baby girl. What is the priority nursing intervention for this new mother? Select one: A. Allow the mother a period of rest with no distractions. B. Give the mother a bed bath. C. Encourage bonding with the infant. D. Perform a comprehensive assessment.
C. Encourage bonding with the infant.
A nurse is caring for a client in labor. During assessment, which of the following should the nurse consider to be a common discomfort of labor? Select one: A. Irregular fetal heartbeat B. Exaggerated fetal movement C. Pain in the lower back D. Prolonged slowing of the fetal heart rate
C. Pain in the lower back
The nurse is teaching a new mother about the advantages/disadvantages of breastfeeding versus formula feeding. Which statements accurately describe the process? Select all that apply. Select one or more: A. Breast milk is always the right temperature. B. Breast milk contains antibodies. C. Nursing slows involution. D. Beast milk is less likely to cause allergic reactions. E. Breast milk is readily available and convenient. F. Nursing ensures another pregnancy will not occur.
A. Breast milk is always the right temperature. B. Breast milk contains antibodies. D. Beast milk is less likely to cause allergic reactions. E. Breast milk is readily available and convenient.
A pregnant woman states that she wants to have her baby at home on her "own territory." What type of professional would be most likely to attend a home birth? Select one: A. Certified nurse midwife B. Nurse practitioner C. Physician D. Registered nurse
A. Certified nurse midwife
A pregnant client in her 38th week of gestation complains of abdominal pains and suspects she is in labor. Which of the following findings are characteristic of true labor contractions? Select one: A. Contractions help create effacement and dilation of the cervix. B. Contractions are generally felt low in the abdomen. C. Contractions are relieved by change of position or activity. D. Contractions are short and irregular.
A. Contractions help create effacement and dilation of the cervix.
The nurse is facilitating bonding of an infant with his parents. Which of the following is a recommended intervention to assist in this process? Select one: A. Delay eye prophylaxis until after this critical time period. B. Place the swaddled baby between the mother's breasts. C. Remove the baby from the parents and allow the mother time to recuperate. D. Place the mother and baby with their bodies in the spoon position.
A. Delay eye prophylaxis until after this critical time period.
A client has four children and is pregnant for the fifth time. What term would the nurse use to describe this client? Select one: A. Primipara B. Nullipara C. Grand multipara D. Primigravida
A client who has given birth many times (specifically, at least five times), is called a grand multipara. If it is her first pregnancy, she is a primigravida. If she has delivered a child for the first time she is a primipara. A client who has never given birth is a nullipara. The correct answer is: Grand multipara
A nurse is informing a client about different choices available to pregnant women choosing a birth setting. Which of the following birth settings promote safe, satisfying, and the most cost-effective childbirth? Select one: A. Free-standing birth centers B. Home setting C. Labor and delivery unit D. Birthing room
A. Free-standing birth centers
The nurse is performing immediate care of the newborn. Which of the following interventions are related to the four goals for immediate management of the newborn? Select all answers that apply. Select one or more: A. Placing a cap on the baby's head B. Placing an identification band on the infants wrist C. Providing a complete body bath and shampoo D. Reporting Mongolian spots if found on the infant's skin E. Assisting the mother to breastfeed F. Suctioning the baby's nasal passages
A. Placing a cap on the baby's head B. Placing an identification band on the infants wrist E. Assisting the mother to breastfeed F. Suctioning the baby's nasal passages
A primigravida client has come to the clinic for a prenatal checkup. What teaching topics would help to promote a healthy pregnancy for this client? Select one: A. Swimming in a pool is a recommended exercise during pregnancy. B. More frequent tooth brushing is recommended to prevent caries related to ptyalism. C. Applying lanolin ointment to the breasts is recommended to prevent cracked nipples. D. Douching is recommended to decrease the risk of vaginal infections.
A. Swimming in a pool is a recommended exercise during pregnancy.
The nurse is teaching a new mother how to handle and dress her newborn. Which of the following statements from the mother indicates that teaching was effective? Select one: A. "I should hold my baby close to my body like I'm holding a football." B. "I should not wrap the baby in a blanket to avoid overheating." C. "I should fold the diaper above the cord stump." D. "When I pick up my baby I should turn him over on his stomach first."
A. "I should hold my baby close to my body like I'm holding a football."
A pregnant woman at her first prenatal visit asks the nurse if it is safe to have sex during her pregnancy. Which of the following patient statements alerts the nurse to the need for further teaching? Select one: A. "I should substitute intercourse with nonsexual touch to avoid harming the fetus." B. "I will experience a heightened need for touch throughout my pregnancy." C. "If I experience bleeding, I will abstain from vaginal intercourse." D. "I will avoid having intercourse following the rupture of the membranes."
A. "I should substitute intercourse with nonsexual touch to avoid harming the fetus."
The nurse is teaching a prenatal class about preparing for their expanding families. Which of the following is helpful advice from the nurse? Select one: A. "The hormones of pregnancy may cause anxiety or depression postpartum." B. "Your old coping methods will adequately get you through this period of adjustment." C. "Expect your other children to react positively to their new brother/sister." D. "Caring for your new infant is instinctual and will come naturally to you."
A. "The hormones of pregnancy may cause anxiety or depression postpartum."
It is the responsibility of the nurse to initiate some form of identification while the infant is still in the delivery or birth room. Which of the following accurately describes a step in this process? Select one: A. An electronic bracelet may be placed on the infant to create an alarm if the infant is taken off the obstetrical unit. B. The mother and infant's fingerprints may be taken and placed in the medical record. C. A chart with all identifying information must be prepared after the newborn leaves the delivery room. D. A two-band system with identifying information may be used, with one placed on the mother and the other on the infant.
A. An electronic bracelet may be placed on the infant to create an alarm if the infant is taken off the obstetrical unit.
The certified nurse midwife is discussing the birth plan with a client. Which of the following data would most likely be documented in the plan? Select all answers that apply. Select one or more: A. The type of pain relief measures desired B. The woman's living will or advance directives C. The parents' choice of birth announcements D. The woman's feelings about fetal monitoring E. The outcome of labor and delivery
A. The type of pain relief measures desired D. The woman's feelings about fetal monitoring
The nurse is bringing a newborn to her mother to breastfeed for the first time. Which of the following interventions would be appropriate to facilitate the process? Select one: A. When finished nursing, teach the mother to place the baby on his or her back. B. Allow the baby to feed on one breast for 20 minutes before offering the other breast. C. If engorgement occurs, teach the mother to apply cold compresses. D. Set a schedule; do not allow the newborn to breastfeed as often as the mother wishes.
A. When finished nursing, teach the mother to place the baby on his or her back.
The nurse is determining a pregnant client's estimated date of delivery (EDD) using Nägele's Rule. The date of the first day of the woman's last normal menstrual period (LNMP) was April 20. What would be her EDD? Select one: A. December 20 B. January 20 C. December 27 D. January 27
According to Nägele's Rule, the nurse would determine the date of the first day of the woman's LNMP (April 20), add 7 days (April 27) and subtract 3 months (January 27) to obtain the EDD. The correct answer is: January 27
The nurse midwife is performing a pelvic examination on a client who came to her following a positive home pregnancy test. The nurse checks the woman's cervix for the probable sign of pregnancy known as Goodell's sign. Which of the following describes this alteration? Select one: A. The cervix softens. B. The fundus enlarges. C. The lower uterine segment softens. D. The cervix looks blue or purple when examined.
At about the eighth week of gestation, the cervix softens, a probable sign known as Goodell's sign. The cervix also looks blue or purple when examined; this is Chadwick's sign, and may occur as early as the sixth week of pregnancy. At about 6 weeks, the lower uterine segment softens, a probable sign called Hegar's sign. A softening of the uterine fundus, where the embryo has implanted, also occurs by about the seventh week and the fundus enlarges by the eighth week. The correct answer is: The cervix softens.
A nurse attending the delivery of a newborn assesses and records the vital signs of the newborn. Which of the following is a cause for concern? Select one: A. Axillary temperature is 98.2°F B. Pulse rate is 90 beats per minute C. Respiratory rate is 55 breaths per minute D. Blood pressure is 60/40 mm Hg
B. Pulse rate is 90 beats per minute
A client in the first stage of labor has an episode of bright-red bleeding. What is the best action for the nurse to take? Select one: A. Perform a vaginal examination per protocol. B. Report any bleeding at once. C. Inject vitamin K, as ordered, to stop bleeding. D. Perform an ultrasound examination, as ordered.
B. Report any bleeding at once.
A 25-year-old client who has given birth is apprehensive about the use of certain drugs when breastfeeding. Which of the following drugs should the nurse ask the client to avoid during breastfeeding? Select one: A. Codeine B. Amphetamines C. Acetaminophen D. Pseudoephedrine
B. Amphetamines
The nurse is teaching a new mother breastfeeding techniques. What would be an appropriate measure to teach to help relieve engorgement? Select one: A. Do not wear a bra or other constricting clothing. B. Avoid manual expression or pumping breasts. C. Increase fluid intake by 30%. D. Apply cold packs to the breast for 15 minutes before nursing.
B. Avoid manual expression or pumping breasts.
A client planning to have her first baby comes to the healthcare facility for a preconceptual visit. Which of the following instructions should the nurse give the client as part of preconceptional care? Select one: A. Avoid prescription drugs once pregnancy is confirmed. B. Eat sour, salty foods (potato chips, lemonade) to prevent nausea. C. Eat sweets at bedtime if the client wakes up feeling hungry. D. Replace insulin with an oral diabetic agent.
B. Eat sour, salty foods (potato chips, lemonade) to prevent nausea.
The nurse is describing pregnancy danger signs to a pregnant woman who is in her first trimester. Which of the following danger sign might occur at this point in her pregnancy? Select one: A. Swelling of extremities B. Excessive vomiting C. Lower abdominal pressure D. Dyspnea
B. Excessive vomiting
A nurse caring for a 2-day-old infant assesses the infant's movement and activity. Which of the following should the nurse report as abnormal? Select one: A. Keeping the extremities in a flexed position B. Moving the limbs asymmetrically C. Being unable to support the weight of the head D. Sleeping for approximately 17 hours a day
B. Moving the limbs asymmetrically
The nurse is caring for a laboring woman who has been given oxytocin to induce labor. She is having contractions at an interval of every 2 minutes with 90 seconds duration in between. What would be the appropriate intervention in this situation? Select one: A. Provide a back rub for the woman when the pain is at its greatest intensity. B. Report this emergency situation to the birth attendant. C. Encourage the woman's coach to help her with breathing exercises. D. Check her pain medication preferences and administer an analgesic, if indicated.
B. Report this emergency situation to the birth attendant.
A new mother who is breastfeeding complains of sore and cracked nipples. What would be the best nursing interventions to help alleviate this problem? Select one: A. Apply cold compresses to the nipple. B. Reposition the infant. C. Swab the nipple with alcohol. D. Shorten the feeding period.
B. Reposition the infant.
he nurse is teaching the new mother what occurs when her baby takes its first breath. Which one of the following teaching points is accurate? Select one: A. The baby's respirations should stabilize immediately at birth. B. The breath establishes neonatal lung volume and function. C. The baby's respiratory rate should be more than 60 breaths per minute after 2 hours. D. The breath assists conversion to adult circulation and fills the lungs with fluid.
B. The breath establishes neonatal lung volume and function.
A nurse is assessing a pregnant client whose membranes have ruptured. Which of the following findings may indicate an infection? Select one: A. Clear and colorless amniotic fluid B. White or cloudy amniotic C. Nitrazine paper remains yellow D. Nitrazine paper turns blue
B. White or cloudy amniotic
The nurse is assessing a woman who is 26 weeks' pregnant and is brought to the ER with complaints of vaginal bleeding with severe abdominal pain. What complication would the nurse suspect? Select one: A. Placenta previa B. Preterm labor C. Pregnancy induced hypertension D. Placental abruption
Bleeding with severe abdominal pain is a sign of placental abruption, or premature separation of the placenta. Painless vaginal bleeding may be a sign of placenta previa, a condition in which the placenta lies partly over the cervical opening. Preterm labor is characterized by backache, pelvic/abdominal cramping, rhythmic pelvic pressure, diarrhea, change in vaginal discharge, vaginal spotting, leaking fluid, and malaise. Signs of pregnancy-induced hypertension include severe headache, visual changes, sudden edema or swelling, and epigastric pain. The correct answer is: Placental abruption
A 28-year-old client is concerned that her day-old infant has some blood-stained discharge from the vagina. Which of the following should the nurse tell the client is the cause for the discharge? Select one: A. Medication used by the nursing mother B. Lack of vitamin K in the newborn baby C. Injury during delivery procedure D. Sudden absence of the mother's hormones
Blood-stained discharge from the vagina is common in most newborn babies, caused by the sudden absence of the mother's hormones; this condition known as pseudomenstruation, will last only a few days following birth. Injuries during the delivery procedure are rare, and bleeding will be noticed as soon as the infant is born. Certain medications used by the nursing mother can be dangerous to the newborn, but incidence of genital bleeding in infants can be seen even in newborns of mothers who have not used any medications. Deficiency of vitamin K can lead to bleeding in infants; however, as soon as the baby is born, an intramuscular dose of vitamin K is administered to the baby in the delivery room. The correct answer is: Sudden absence of the mother's hormones
The nurse is caring for a new mother who states she is worried about the soft spots on her newborn son's head. What would be the nurse's proper response? Select one: A. "These soft spots are congenital defects known as fontanels that will require surgery when the infant is a year old." B. "These soft spots are called Mongolian spots caused by birth trauma that will resolve in time." C. "These soft spots are called fontanels and occur so the head can mold to fit through the mother's birth canal. They will close within 3 months." D. "These soft spots are called molding and are caused by delivering your baby vaginally and will resolve with time."
C. "These soft spots are called fontanels and occur so the head can mold to fit through the mother's birth canal. They will close within 3 months."
A primigravida who is 2 weeks away from her delivery date tells the obstetrical nurse that she feels like "the baby has dropped." What would be the nurse's best response to this client? Select one: A. "This is a normal feeling at this stage and it is called 'Braxton-Hicks' contractions." B. "This is a normal feeling called lightening signaling that labor has begun." C. "This feeling is called lightening and means that the fetus has settled into the pelvis." D. "This feeling may be a sign that there is a complication with your pregnancy."
C. "This feeling is called lightening and means that the fetus has settled into the pelvis."
The nurse is aware that a well-nourished mother ensures an adequate and nutritious milk supply for her newborn and protects her own health. Which of the following is an accurate guideline for the nutritional needs of nursing mothers? Select one: A. Moderate alcohol can be used to relax the mother and stimulate the let-down reflex. B. The nursing mother needs 1,000 extra calories per day. C. Strongly flavored foods should be avoided because they can cause colic in newborns. D. Fluid intake should be limited to prevent engorgement.
C. Strongly flavored foods should be avoided because they can cause colic in newborns.
The nurse is discharging a new mother from the hospital. Which of the following is a recommended teaching guideline that should be discussed? Select one: A. Tell the nursing mother that contraception is not necessary until her period returns. Incorrect B. Tell the client to return for a follow-up examination in 1 month. C. Tell the nonnursing client that menstruation should resume in 6 to 8 weeks. D. Advise the client to resume sexual intercourse as soon as it feels comfortable.
C. Tell the nonnursing client that menstruation should resume in 6 to 8 weeks.
The neonatal nurse knows that the neonate must work to keep warm. What is the most efficient process the neonate uses to maintain its temperature? Select one: A. Shivering B. Taking shallow breaths C. Using stores of brown fat D. Producing muscle movement
C. Using stores of brown fat
When assessing the physical condition of a 2-day-old infant, the nurse notices a relatively soft swelling on one side of the skull extending up to the midline. Which of the following does this condition indicate? Select one: A. Fontanels B. Molding C. Caput succedaneum D. Cephalhematoma
Cephalhematoma is an accumulation of blood between the bones of the skull and the periosteum, the membrane that covers the skull. This swelling stops at the midline and will eventually disappear. Fontanels are the "soft spots" in the newborn's skull, formed at the junction of the individual skull bones. These bones do not fuse completely before birth, so that the head can mold to fit through the mother's birth canal. Caput succedaneum results from an accumulation of fluid within the newborn's scalp. It is caused by pressure to the head during delivery. The swelling crosses the midline of the baby's scalp. Molding or elongation of the head may develop temporarily because of the overlap of skull bones during the birth process. The correct answer is: Cephalhematoma
The school nurse is presenting a lecture to adolescents to teach them how conception occurs. Which of the following statements by the nurse would accurately describe this process? Select one: A. "At the time of conception, the ovum determines the sex of the baby." B. "Conception usually occurs when the ovum is in the outer third of the fallopian tube." C. "Human life begins with the union of two cells: the zygote and the sperm." D. "The ovum carries the Y chromosome and the sperm carries an X or Y chromosome."
Conception usually occurs when the ovum is in the outer third of the fallopian tube (oviduct). Human life (conception) begins with the union of two cells: the ovum (female) and the sperm (male). At the time of conception, the sperm determines the sex. An ovum carries only one type of chromosome to determine sex: the X chromosome. A male sperm cell may carry either an X or Y sex chromosome. If a sperm cell carrying a Y chromosome fertilizes the ovum, a boy (XY) will result; if the sperm cell carries an X chromosome, the result will be a girl (XX). The correct answer is: "Conception usually occurs when the ovum is in the outer third of the fallopian tube."
The nurse is observing a newborn for respiratory status. Which of the following signs confirms that the respiratory status is normal? Select one: A. The chest should expand from side to side on inhalation. B. The baby should flare nostrils and make grunting noises when breathing. C. The muscles of the chest wall should show considerable effort with breathing. D. Movement of diaphragm and abdominal muscles should be synchronized.
D. Movement of diaphragm and abdominal muscles should be synchronized.
A pregnant woman undergoing amniocentesis asks her nurse why the baby needs this fluid. What would be an accurate response from the nurse? Select one: A. "Amniotic fluid supplies the food your baby needs to grow." B. "Amniotic fluid keeps the fetus from moving freely inside it to prevent injury." C. "Amniotic fluid provides fetal blood circulation." D. "Amniotic fluid cushions your baby to prevent injury."
D. "Amniotic fluid cushions your baby to prevent injury."
The nurse caring for a postpartum client explains the occurrence of lochia following delivery. Which of the following statements accurately describe a characteristic of this process? Select one: A. "Lochia alba, which is yellow or white, starts on about day 15. B. "Lochia alba has a pungent, foul odor." C. "Lochia ruba, which is mostly red and bloody, is seen for the first week." D. "Lochia serosa, which is pink or brown tinged, starts after the bleeding diminishes."
D. "Lochia serosa, which is pink or brown tinged, starts after the bleeding diminishes."
A client has just given birth. After ensuring that the newborn is stable, which of the following steps should the nurse perform while still in the delivery room to help the client bond with the infant? Select one: A. Administer vitamin K to the newborn B. Clear the newborn's mouth of secretions C. Attach identification bands to the newborn D. Allow the mother to breastfeed
D. Allow the mother to breastfeed
The mother of a 2-month-old infant complains to the nurse that the infant has been crying continuously all evening. On examination the nurse understands that the newborn is colicky. Which of the following is the most common reason for the onset of colic in an infant? Select one: A. Frequent breastfeeding by the newborn B. Consumption of caffeine by the nursing mother C. Consumption of alcohol by the nursing mother D. Consumption of cow's milk by the nursing mother
D. Consumption of cow's milk by the nursing mother
The obstetrical nurse is administering oxytocin for her client to induce labor. Which of the following is a recommended guideline for administration of the drug? Select one: A. For labor induction and labor augmentation: Maximum recommended dose is 25 mU/min. B. For postpartum: 15 to 25 mU IM or IV after delivery of the placenta. C. For labor augmentation: Initial dose: 1.5 to 2.0 mU; increased 1 to 2 mU/min until an adequate labor pattern is achieved. D. For labor induction: Initial dose of 1 to 2 mU; increased 1 to 2 mU/min until an adequate labor pattern is achieved.
D. For labor induction: Initial dose of 1 to 2 mU; increased 1 to 2 mU/min until an adequate labor pattern is achieved.
A nurse is educating a pregnant client on what food to eat and what to avoid during her pregnancy. Which of the following precautions should a pregnant client take regarding her nutritional requirements? Select one: A. Avoid starchy food B. Limit fluid intake C. Limit folic acid intake D. Limit caffeine intake
D. Limit caffeine intake
The nurse is advising a pregnant woman during her first prenatal visit regarding the frequency of future visits. Which of the following is the recommended schedule for prenatal care? Select one: A. Once every 4 weeks for the first 28 weeks, then every 3 weeks until 36 weeks, and then every 2 weeks until the birth. B. Once every 3 weeks for the first 28 weeks, then every 2 weeks until 36 weeks, and then weekly until the birth. C. Once every 4 weeks for the first 36 weeks, then weekly until the birth. D. Once every 4 weeks for the first 28 weeks, then every 2 weeks until 36 weeks, and then weekly until the birth.
D. Once every 4 weeks for the first 28 weeks, then every 2 weeks until 36 weeks, and then weekly until the birth.
Following delivery, a client feels the urge to void, but is unable to do so after an extended period of time. What immediate action should the nurse take? Select one: A. Apply suprapubic pressure. B. Reassure the client. C. Catheterize the bladder. D. Report it to the practitioner.
D. Report it to the practitioner.
The neonatal nurse knows the challenges that face newborns when adapting to their new world. What is one of the first interventions performed during the delivery to ensure a safe transition? Select one: A. Assessing for congenital defects B. Testing the neonate's reflexes C. Facilitating maternal bonding D. Suctioning the neonate's airways
D. Suctioning the neonate's airways
A nurse is assessing a pregnant client. Which of the following would the nurse document as an abnormal finding in a pregnancy? Select one: A. Pedal edema B. Linea nigra C. Lordosis D. Visual changes
D. Visual changes
A nurse is monitoring the fetal heart rate of a client. What signs of fetal distress on the fetal monitor should the nurse report immediately? Select one: A. Fetal heart rate above 100 bpm B. Decreased variability C. Early decelerations D. Accelerations of 15 bpm
Decreased variability means little to no fluctuation in the FHR on an internal electronic monitor tracing, which is a danger sign. It may indicate an abnormality in the fetal nervous system. It might also indicate that the mother has taken or been given central nervous system depressants. Report this observation to the team leader for further evaluation. Accelerations are brief increases of the FHR of 15 bpm or more. It is a sign of a healthy fetus for the FHR to accelerate after movement or stimulation. Early decelerations are caused by vagal nerve stimulation resulting from pressure on the fetal head and are considered a normal response of the fetus to labor. A fetal heart rate above 100 bpm is normal. It should not fall below 100 bpm. The correct answer is: Decreased variability
A pregnant woman is having moderately strong contractions every 3 minutes lasting 50 seconds. Her cervix is dilated 6 cm. What state of labor is she experiencing? Select one: A. Stage I, active phase B. Stage II C. Stage I, latent phase D. Stage I, transitional phase
In the stage I active phase, the woman experiences regular, moderate to strong contractions: frequency 2 to 4 minutes, duration 45 to 60 seconds with dilation 4 to 8 cm. In the stage I latent phase, the woman experiences irregular, mild contractions: frequency 5 to 20 minutes, duration 30 to 50 seconds with dilation 0 to 4 cm. In the stage I transitional phase, the woman experiences regular, very strong contractions: frequency 2 to 3 minutes, duration 60 to 90 seconds with dilation 8 to 10 cm. During stage II, the woman's abdominal muscles and diaphragm join the uterine muscles to push the newborn out of the woman's body. The woman may say she feels "pushing pains" or a "bearing down" feeling. The correct answer is: Stage I, active phase
The nurse is providing prenatal care to a young couple that is pregnant with their first child. In what period of development would the nurse explain to the couple that most congenital defects would occur? Select one: A. The period of the embryo B. The period of the zygote C. All periods are equally vulnerable D. The period of the fetus
During the period of the embryo, which lasts until the eighth week after conception, the embryo is in what is called the critical phase of human development. During these weeks, all the organs and structures of the human are formed and are most susceptible to damage. The correct answer is: The period of the embryo
The nurse is teaching a pregnant client in her last trimester about interventions to help reduce risks of complications during pregnancy. Which of the following are recommended guidelines? Select one: A. If planning to breastfeed, bathe as normal using soap and water on the nipples. B. Sleep on your back to avoid supine hypotension syndrome. C. Take a daily shower, but avoid a tub bath because this could harm the fetus. D. During the last month, rest on the left side for at least an hour, morning and afternoon.
During the pregnancy's last months, the woman should rest on her left side for at least 1 hour in the morning and afternoon. This position relieves fetal pressure on the renal veins, helps the kidneys excrete fluid, and increases flow of oxygenated blood to the fetus. There is no proof that a tub bath is harmful to the fetus. If breastfeeding, the woman should bathe as normal, but avoid using soap on the nipples. The woman should also avoid sleeping on her back to avoid supine hypotension syndrome. The correct answer is: During the last month, rest on the left side for at least an hour, morning and afternoon.
The obstetrical nurse checks the station of a laboring pregnant woman and documents +5 on the patient chart. What does this number mean in terms of the delivery? Select one: A. The presenting part is 5 cm above the level of the ischial spines. B. The fetal head is at the vaginal opening. C. The lowest part of the fetal skull is at the level of the mother's ischial spines. D. The baby is "floating" above the mother's ischial spines.
Feedback A station of +5 means the fetal head is at the vaginal opening. A station of -5 is considered "floating," or the presenting part is 5 cm above the level of the ischial spines. The station at which the fetus is said to be fully engaged is called station 0; that is, the widest part of the presenting part of the fetus has lodged in the pelvic inlet, and the lowest part of the fetal skull is at the level of the mother's ischial spines. The correct answer is: The fetal head is at the vaginal opening.
A nurse is asked to auscultate the fetal heart sounds in a pregnant client. Which of the following equipment is most appropriate when auscultating fetal heart sounds at the 12th week? Select one: A. Doppler B. Fetoscope C. Tocodynometer D. Stethoscope
Fetal heart sounds are best heard with the Doppler from the 10th week onward. They can be heard with the fetoscope by about the 18th to 20th week only. A tocodynometer is used to record uterine contractions and not to auscultate fetal heart tones. Fetal heart tones may not be audible with an ordinary stethoscope at the 12th week. The correct answer is: Doppler
A pregnant client complains to the nurse about the discomforts of pregnancy. Which of the following should the nurse assure her is a common discomfort of pregnancy? Select one: A. Persistent vomiting B. Frequent urination C. Burning micturition D. Severe headaches
Frequent urination is a common discomfort of pregnancy. This is because the enlarging uterus presses against the bladder, causing the need to urinate more frequently than usual. Persistent vomiting, burning micturition, and severe headaches are danger signs of pregnancy and should be immediately reported to the physician. The correct answer is: Frequent urination
A nurse is classifying the pregnancy history of a woman who has had five pregnancies: three full-term, one preterm, and one abortion. How would the nurse document this information on the patient chart? Select one: A. G4 P3115 B. G5 P1135 C. G5 P3114 D. G5 P3115
G = gravida or the total number of pregnancies, which in this case equals five. P = para is the outcome of the pregnancies in the following order: full term, preterm, abortions, and living as of today. In this case, P3114. The correct answer is: G5 P3114
A multigravida client is pregnant for the third time. Her previous two pregnancies ended in an abortion in the first and third month of pregnancy. How will the nurse classify her pregnancy history? Select one: A. G2 P1020 B. G3 P0021 C. G3 P0020 D. G2 P0020
Gravida (G) is the total number of pregnancies she has had, including the present one. Therefore she is G3 and not G2. Para (P), the outcome of her pregnancies, is further classified by the FPAL system as follows: F = Full term: number of babies born at 37 or more weeks of gestation, which is 0 and not 1 in this case. P = Preterm: number of babies born between 20 and 37 weeks of gestation, which is 0 in this case. A = Abortions: total number of spontaneous and elective abortions, which is 2 in this case. L = Living children, as of today. She has no living children; therefore, it is 0 and not 1. The correct answer is: G3 P0020
The obstetrical nurse records the expulsion of the placenta in stage III labor as a Duncan presentation. What does this data represent? Select one: A. The placenta is expelled with the dull side out. B. The placenta is not fully expelled. C. The placenta contains placental fragments. D. The placenta is expelled with the shiny side out.
If the placenta is expelled with the dull side out, it is called a Duncan presentation ("dirty Duncan"). This is the maternal side, which is rough and irregular. Excessive bleeding is more likely with this type of placental presentation. If the placenta is expelled with the shiny (membranous) side out, it is called a Schultze presentation ("shiny Schultze"); this is the fetal side of the placenta. Schultze presentation occurs in approximately 80% of births. The birth attendant examines the expelled placenta and membranes to determine if the placenta is intact. Retained placental fragments are a major cause of hemorrhage following delivery. The correct answer is: The placenta is expelled with the dull side out.
The nurse practitioner examining a pregnant woman in labor notes that the fetal spine is parallel to the woman's spine. What is the term for this relationship of the fetal body to the maternal body? Select one: A. Lie B. Presentation C. Engagement D. Station
Lie is a term used to compare the position of the fetal spinal cord (the "long part") to that of the woman. The normal lie of the fetus is longitudinal (up and down), which means that the fetal spine is parallel to the woman's. Presentation refers to the body part of the fetus that lies closest to the pelvis and will enter the birth canal first. Station refers to the level of descent of the fetal presenting part into the birth canal. Engagement is the term used when the fetal head has moved downward in the birth canal until it can no longer be pushed up and out of the pelvis. The correct answer is: Lie
During assessment of the reflexes in the newborn, the nurse notices that the newborn baby turns her head in the direction of the touch when the cheek is stroked. What is this reflex called? Select one: A. Stepping reflex B. Rooting reflex C. Moro's reflex D. Babinski's reflex
Newborns exhibit the rooting reflex by turning the head toward the direction of the stimulus when the lip or cheek is stroked. Babinski's reflex can be elicited when the sole of the foot is scraped from heel to toe, resulting in the big toe fanning out. Moro's reflex is elicited when sudden noises or jarring movements cause the newborn to throw out the arms and draw up the legs. Stepping reflex occurs when the newborn is held upright with the feet touching a surface, resulting in the newborn stepping with one foot and then the other. The correct answer is: Rooting reflex
The nurse caring for newborns with congenital heart defects knows that these defects occur when certain events do not take place after birth. Which of the following describes one of these events? Select one: A. The ductus arteriosus expands. B. The foramen ovale opens. C. The ductus venosus becomes a ligament. D. The lungs retract.
Normally, with the newborn's first few respirations, the lungs expand as soon as the pressure within the chest alters. The foramen ovale closes, and the ductus arteriosus and ductus venosus shrivel and become fibrous ligaments. Congenital heart defects in a child occur when these events do not take place after birth. The correct answer is: The ductus venosus becomes a ligament.
The nurse performing a postpartum assessment on a client elicits the Homan's sign. For what condition is the nurse assessing? Select one: A. Soft, boggy uterus B. Hematoma C. Thrombophlebitis D. Urinary distention
Pain behind the knee on flexion of the feet indicates a positive Homans' sign and suggests thrombophlebitis. The nurse would palpate the bladder for a rounded bulge in the suprapubic region, which indicates distention, and palpate the fundus to determine if the uterus is soft or boggy. A hematoma is a complication that may be observed at the site of an episiotomy. The correct answer is: Thrombophlebitis
A nurse cleansing a newborn in the delivery room notices small purple dots on the face of the newborn. How should the nurse record this finding? Select one: A. Petechiae B. Erythema toxicum C. Port-wine stain D. Mongolian spots
Petechiae are small purplish dots on the skin caused by pressure during labor; they usually fade away. Mongolian spots are dark blue areas of discoloration often appearing on the buttocks, lower back, or upper legs of nonwhite babies. These spots usually disappear by early childhood. Erythema toxicum may develop as a red, raised rash on the skin of certain sensitive infants. A port-wine stain is a permanent birthmark; it is a flat purple-red area with sharp borders. The correct answer is: Petechiae
The nurse is examining a woman who came to the clinic because she thinks she is pregnant. Which data collected by the nurse are presumptive signs of her pregnancy? Select all that apply. Select one or more: A. Fetal heartbeat B. Ultrasound pictures C. Morning sickness D. Hydatidiform mole E. Amenorrhea
Presumptive signs are possible signs of pregnancy that appear in the first trimester, often only noted subjectively by the mother (e.g., breast changes, amenorrhea, morning sickness). Probable signs are signs that appear in the first and early second trimesters, seen via objective criteria, but can also be indicators of other conditions (e.g., hydatidiform mole). Positive signs affirm that proof exists that there is a developing fetus in any trimester and are objective criteria seen by a trained observer or diagnostic study, (e.g., ultrasound.) The correct answer is: Amenorrhea, Morning sickness
The nurse assisting with deliveries is aware that which of the following clients is most at risk for having a difficult delivery and possibly cesarean section. Select one: A. A woman whose baby has engaged prior to labor B. A woman whose baby has a cephalic presentation C. A woman whose baby is in a longitudinal lie D. A woman whose baby is in the footling breech position
Some positions of the fetus make delivery difficult or dangerous. For example, in a footling breech position, there is a chance the umbilical cord could prolapse because there is so much empty space within the uterus. This could cut off the blood and oxygen supply to the fetus before it is born. The other examples are normal fetal body to maternal body presentations. The correct answer is: A woman whose baby is in the footling breech position
The nurse is assessing a neonate to obtain an Apgar score. The nurse records the following data: heart rate: 120 bpm, good respiratory effort, neonate crying vigorously, some flexion of extremities, body color: pink, extremities blue. What would be the Apgar score for this neonate? Select one: A. 4 B. 10 C. 8 D. 6
The Apgar score is determined by the following: Heart rate: absent = 0, <100 = 1, >100 = 2. Respiratory effort: absent = 0, slow, irregular = 1, good, crying = 2. Muscle tone: flaccid = 0, some flexion of extremities = 1, active crying = 2. Reflexes, irritability: no response = 0, weak cry or grimace = 1, vigorous crying = 2. Color: blue, pale = 0, body pink, extremities blue = 1, and completely pink = 2. This neonate receives 2 for heart rate, 2 for respiratory effort, 2 for reflexes, and 1 for muscle tone and color, which equals a score of 8. The correct answer is: 8
The nurse is using the LATCH Breastfeeding Charting System to evaluate the effectiveness of a newborn's breastfeeding experience. The nurse documents the following on the chart: L = repeated attempts; A = a few audible swallows with stimulation, T = everted nipple; C = engorged nipples; H = holding without assist from staff. What number would the nurse document using this data? Select one: A. 6 B. 4 C. 10 D. 8
The client would receive 1 for Latch, 1 for audible swallowing, 2 for everted nipple, 0 for engorgement, and 2 for holding without assistance; totaling 6 of a possible 10. The correct answer is: 6
The obstetrical nurse knows that a woman's hormone levels change dramatically during pregnancy. Which hormonal actions accurately represent these changes? Select all that apply. Select one or more: A. Causing changes in the mother's metabolism so that nutrients are available for both B. Maintaining the endometrium so that the embryo can implant C. Decreasing the blood supply to the gastrointestinal tract and slowing peristaltic waves D. Relaxing the ligaments that connect the pelvic bones, allowing them to spread slightly E. Decreasing the mother's blood volume and red blood cell mass to increase oxygen I F. Preparing the breasts for lactation, keeping the milk from coming in until birth occurs
The correct answer is: Maintaining the endometrium so that the embryo can implant, Causing changes in the mother's metabolism so that nutrients are available for both, Relaxing the ligaments that connect the pelvic bones, allowing them to spread slightly, Preparing the breasts for lactation, keeping the milk from coming in until birth occurs
The nurse is teaching a class of new mothers how to provide care for their babies' cord and genitals. Which of the following is a recommended guideline for this care? Select one: A. Do not use alcohol to swab the stump during diaper change. B. For a male baby, stretch the foreskin over the glans penis for cleaning once a day. C. For a female baby, clean folds of the labia wiping from back to front. D. When bathing the infant, submerge the cord and clean with soap and water.
The following are recommended guidelines for cord and genital care: If circumcision is not performed, the physician may order that the foreskin be gently stretched and retracted over the glans penis for cleaning once every day. The cord stump is usually swabbed with alcohol with each diaper change. When bathing, do not submerge the baby in tub water until the cord falls off. In female babies, gently clean between all the folds of the labia, wiping from front to back. The correct answer is: For a male baby, stretch the foreskin over the glans penis for cleaning once a day.
The nurse who assisted in the delivery of a newborn is giving a report to the nurse receiving the newborn in the labor-delivery-recovery room (LDR). What information must the nurse report to the healthcare personnel who take responsibility for the care of this infant? Select all answers that apply. Select one or more: A. Length of the first and second stages of labor B. Whether immunizations were given C. Newborn's vital signs D. Condition of the placenta E. Whether vitamin K was given F. Whether the baby passed the meconium plug
The following information must be reported to the new caretakers: • Length of first and second stages of labor • Length of time the membranes were ruptured • Type of delivery and any difficulties; use of forceps or vacuum extraction • Analgesics and anesthetics that were used in delivery • Newborn's condition at delivery • Newborn's Apgar scores • Whether resuscitation was needed • Newborn's vital signs • Whether vitamin K was given • Whether eye prophylaxis was performed • Whether or not the baby voided or passed the meconium plug or stool The correct answer is: Length of the first and second stages of labor, Whether vitamin K was given, Whether the baby passed the meconium plug, Newborn's vital signs
The nurse is examining a newborn male client's genitalia and notes that the opening of the foreskin is so small that it cannot be pulled back at all. What condition would the nurse document on the client record? Select one: A. Prepuce B. Phimosis C. Hypospadias D. Epispadias
The foreskin, or prepuce, covers the glans of the penis and is often adherent at birth. If the opening of the foreskin is so small that it cannot be pulled back at all, the condition is called phimosis. The penis should be inspected to determine the location of the urinary meatus, which should be at the very tip of the penis. If it is located on the underside of the penis (near the scrotum), it is termed hypospadias. A less common location is on the upper side of the penis; this is called epispadias The correct answer is: Phimosis
Following the 1-minute Apgar score of a neonate, the nurse records the number 5. What is the implied meaning of this number? Select one: A. The newborn is in good condition. B. The newborn is in danger. C. The newborn does not need resuscitation. D. The newborn needs emergency resuscitation.
The meanings of the Apgar scores are as follows: if the total score is 10, the newborn is in the best possible condition, if the score is 7 to 9, the newborn usually does not need resuscitation, if the score is 4 to 6, the newborn is in danger, and if the score is 0 to 3, the newborn needs emergency resuscitation. The correct answer is: The newborn is in danger.
A nurse is educating a client who is primigravida about the expected changes during pregnancy. Which of the following are examples of anticipatory guidance about pregnancy? Select one: A. Avoid consuming too much fiber in the diet. B. Eat sweets at bedtime to avoid waking up feeling hungry. C. Avoid wearing high heels, especially during late pregnancy. D. Inform healthcare provider if bleeding is more than just spotting.
The nurse should ask the client to avoid wearing high heels, especially during late pregnancy because the ligaments relax and the pregnant woman's center of gravity changes; thus, she may lose her balance. The nurse should ask the client to inform the healthcare provider if any bleeding, including a spot or two, occurs. The nurse should ask the pregnant woman to consume plenty of fiber and water to prevent constipation and hemorrhoids. If she wakes up feeling very hungry, it could help to eat starchy food, such as a baked potato, just before bedtime. If she eats sweets, she will probably have a rapid rise in blood sugar, followed by a sharp drop. Either of these changes can cause uncomfortable symptoms. The correct answer is: Avoid wearing high heels, especially during late pregnancy.
A nurse is performing fundal massage for a client. What precaution should the nurse take when giving a fundal massage? Select one: A. Never massage a contracted fundus. B. Avoid placing a hand over the symphysis pubis. C. Report cramps immediately to physician. D. Avoid applying heat to relieve cramps.
The nurse should never massage a contracted fundus because massage of an already contracted uterus may cause it to invert, which can become an emergency situation. A hand should be placed over the symphysis pubis to stabilize the uterus. The mother may have painful cramps as the uterine muscles contract. These cramps are called after-pains and are more likely to occur in multigravidas; they need not be reported. Heat application helps to relieve cramps. The correct answer is: Never massage a contracted fundus.
A client is in the second stage of labor. The nurse should record the following information in the second stage: Select one: A. The type of episiotomy on the client's chart B. The exact time of placental delivery C. The nature of placental delivery D. The side of placental presentation
The nurse should note the type of episiotomy on the client's chart in the second stage. The nurse should record the information about the exact time of placental delivery, whether spontaneous or manual placental delivery and the side of placental presentation, in the third stage. The correct answer is: The type of episiotomy on the client's chart
The nurse is performing a focused health assessment of a pregnant woman in her second trimester who is brought to the ER by her husband with complaints of spotting. At about how many weeks gestation could the fetus be viable? Select one: A. 35 weeks B. 20 weeks C. 30 weeks D. 25 weeks
The period of the fetus lasts from the beginning of the ninth week after fertilization through birth, which is usually at about the end of the 40th week of pregnancy. This is a period of increasing growth, differentiation, and functional development of the tissues that appeared during the embryonic period. At about 20 weeks of gestation, the fetus becomes viable (having some chance of life outside the uterus). The correct answer is: 20 weeks
During the development of the fetus, its chorionic villi eventually meet with an area of uterine tissue to form the placenta. Which statements accurately describes a function of the placenta? Select all answers that apply. Select one or more: A. It carries waste away for excretion by the mother. B. It protects the umbilical cord. C. It produces hormones that help maintain the pregnancy. D. It permits blood to bypass the right ventricle. E. It cushions the fetus against injury.
The placenta supplies the developing organism with food and oxygen, carries waste away for excretion by the mother, slows the maternal immune response so that the mother's body does not reject the fetal tissues, and produces hormones that help maintain the pregnancy. Wharton's jelly protects the umbilical cord and the foramen ovale permits most of the blood to bypass the right ventricle. The amniotic fluid cushions the fetus against injury. The correct answer is: It produces hormones that help maintain the pregnancy., It carries waste away for excretion by the mother.
A nurse is assessing a newborn baby boy. Which of the following findings indicates a strong possibility of congenital defects in the newborn? Select one: A. Presence of cyanotic discoloration of the newborn's arms and legs B. Enlargement and darker pigmentation of the scrotum C. Presence of two blood vessels on the umbilical cord D. Absence of indentation over the xiphoid process during breathing
The presence of two blood vessels on the umbilical cord indicates a strong possibility of congenital defects in the newborn. Normally, the umbilical cord has three visible vessels: two arteries and one vein. The presence of cyanotic discoloration of the newborn's arms and legs is caused by slowed peripheral circulation. This condition is called acrocyanosis and is common in the first 24 hours of life; it is more prominent when the newborn is exposed to cold. The xiphoid process (lower tip of the sternum) should not indent during breathing, as any degree of indentation is a sign of distress. In male newborns, the scrotum usually appears relatively larger and may have darker pigmentation than the parents expect. This is caused by the hormones of the mother, and will decrease within a few weeks. The correct answer is: Presence of two blood vessels on the umbilical cord
The nurse is providing preconceptional care for a primigravida client. Which of the following statements accurately represent the seven areas that need to be addressed in preconceptional care? Select all answers that apply. Select one or more: A. Referring a couple at risk of having a baby with a genetic defect for genetic testing B. Eating a healthy diet, including 200 mcg (micrograms) of folic acid a day C. Referring a couple who is having difficulty getting pregnant to a fertility specialist D. For the diabetic woman, changing to an oral diabetic agent instead of insulin E. Stopping harmful or addictive behaviors, such as smoking, drinking alcohol, and drugs
The seven areas that need to be addressed in preconceptional care are eating a healthy diet, including 400 mcg (micrograms) of folic acid a day; stopping harmful or addictive behaviors, such as smoking, drinking alcohol, and drugs; obtaining prescriptions for alternate drugs that are safer during pregnancy; for the diabetic woman, changing to an insulin instead of an oral diabetic agent; referring a couple at risk of having a baby with a genetic defect for genetic testing; testing the mother to be for infections diseases; and reducing psychosocial risk factors. Referring a couple that is having difficulty getting pregnant to a fertility specialist may occur, but is not one of the stated seven areas to be addressed. The correct answer is: Stopping harmful or addictive behaviors, such as smoking, drinking alcohol, and drugs, Referring a couple at risk of having a baby with a genetic defect for genetic testing
The nurse is explaining to a primigravida how the zygote becomes implanted into the uterus. How would the nurse describe the structure formed in this process known as the blastocyst? Select one: A. A group of cells is forming what will become the embryo. B. A ball of about 16 identical cells is formed when the zygote divides. C. The endometrium is enriched in nutrients in preparation for pregnancy. D. First one, then two layers of cells surround a fluid-filled space.
The zygote divides rapidly, until it forms a ball of about 16 identical cells, which is then called a morula. The morula is then swept down the fallopian tube and into the uterus, a process that takes approximately 7 to 9 days. The lining of the uterus, or endometrium, has become rich in nutrients in preparation for the pregnancy. Just before the morula reaches the uterus, the cells begin to form layers; first one, then two layers surround a fluid-filled space, called a blastocyst. Another group of cells form what will become the embryo. The correct answer is: First one, then two layers of cells surround a fluid-filled space.
The husband of a pregnant woman in labor is coaching her to perform breathing exercises to distract her from the pain. Which of the four P's of labor would the parents be? Select one: A. Powers B. Passage C. Passenger D. Psyche
There are common variables of labor, known as the 4 P's of labor: passage, passenger, powers, and psyche. The passage includes the diameter of the body pelvis and its soft tissues. The passenger includes the fetus, umbilical cord, and placenta. The powers are the uterine contractions. The psyche includes the process of birthing, the attitude and behaviors of the parents, and the evaluation process of the stages of labor. The correct answer is: Psyche
The nurse assessing a laboring client documents that the client is in stage II of labor. What typically occurs during this stage? Select one: A. Delivery of the placenta following delivery of the newborn B. Delivery of the baby through the vaginal opening C. Movement of fetus to the birth canal D. Dilation of the cervix
There are four stages of labor: In stage II, expulsion: Uterine contractions continue and increase in intensity until the baby is delivered through the vaginal opening. In stage I, dilation: Uterine contractions cause the cervical os (mouth) of the cervix to open (dilate) and move the fetus downward into the birth canal. In stage III, placental: Uterine contractions expel the placenta after the delivery of the newborn. In stage IV, recovery: Uterine contractions continue and close off open blood vessels to prevent excessive blood loss. The correct answer is: Delivery of the baby through the vaginal opening
The nurse is measuring a newborn who experienced molding during a vaginal delivery. The nurse documents: head circumference: 13.5 inches and chest: 11.7 inches. What do these numbers mean? Select one: A. The newborn is within the normal parameters for head, but body size is small. B. The newborn's head is larger than the body due to molding occurring during delivery. C. The newborn is within the normal parameters for head and body size. D. The newborn is within the normal parameters for body, but the head size is small.
This newborn is within normal parameters for head and body size. The newborn has a large head, averaging 13 to 14 inches (33 to 35.5 cm) in circumference. A short neck supports it. The chest is somewhat smaller than the head, 10 to 12 inches (25.5 to 30.5 cm) in circumference. The head usually measures 1 to 2 inches (2.5 to 5 cm) more than the chest. If the newborn was delivered vaginally, the head may show temporary molding (elongation) because of the overlap of skull bones during the birth process, but it is not larger because of this fact. The correct answer is: The newborn is within the normal parameters for head and body size.
A fetus is experiencing variable decelerations in the fetal heart rate during contractions. What is the appropriate nursing intervention for this situation? Select one: A. Have the pregnant woman walk around the room. B. Administer prescribed pain medications. C. Notify the healthcare practitioner immediately. D. Change the woman's position and give oxygen.
Variable decelerations in fetal heart rate occur anytime during or after contractions. They usually indicate umbilical cord compression and can usually be altered by changing the woman's position or by giving her oxygen. Late decelerations begin late in the contraction, and the fetal heart rate recovery occurs after the contraction is over. Decelerations are related to placental insufficiency and indicate fetal distress. The fetal heart rate should not fall below 100 bpm. The correct answer is: Change the woman's position and give oxygen
A client is in labor, and the nurse palpates her abdomen to assess the presentation of the fetus. Which of the following presentations indicates normal labor? Select one: A. Shoulder presentation B. Breech presentation C. Vertex presentation D. Brow presentation
Vertex presentation occurs when the fetal head is flexed well against the fetal chest and the top of the fetal head is the presenting part. In normal labor, there is a vertex presentation. Complicated labor often occurs when body parts other than the top (crown) of the fetal head present. When the buttocks, foot, or knee is the presenting (lowest) part, it is called a breech presentation. The shoulder may be the presenting part if the fetus is lying in a transverse position. If the head is partially extended, then the brow presents. The correct answer is: Vertex presentation
The nurse helping to deliver newborns institutes measures to protect the mother and infant as well as the staff from infection or disease. Which of the following accurately describes a form of infection/disease control utilized in the delivery or birthing room? Select one: A. Universal Precautions are used when handling the baby or caring for the mother. B. Vitamin K is given to prevent bleeding problems. C. The first vaccination against hepatitis C is given. D. Eye prophylaxis is used for infants born to mothers with diabetes mellitus
Vitamin K is given to prevent bleeding problems. Eye prophylaxis is used for infants born to mothers with gonorrhea or chlamydia affecting her reproductive organs. Also, the first vaccination against hepatitis B is given, and Standard Precautions are used when handling the baby or caring for the mother. The correct answer is: Vitamin K is given to prevent bleeding problems.
The nurse is providing teaching to a new mother regarding changing her perineal pad. Which of the following client statement indicates effective teaching? Select one: A. "I will apply the new pad by hooking it to the back first." B. "I will remove the pad from the back to the front." C. "I will unhook my pad from the front first." D. "I will pull my underwear down and to the front."
When removing a soiled pad, the client should pull her panties straight down. If using a sanitary belt, she should unhook the pad from the front first. The nurse should advise the client always to start removal of the perineal pad by first removing the pad from "clean" areas in the front and then removing the pad from the "dirty" area near the rectum. When applying a clean pad, she should hook it onto the front first, which helps prevent infection. The correct answer is: "I will unhook my pad from the front first."
