PrepU Level 8 Ch 10-18

When discussing the many changes the woman's body undergoes during pregnancy, the nurse may include that the woman's total blood volume will increase by approximately how much by the 32nd week of gestation? a) 1,500 ml b) 2,000 ml c) 500 ml d) 1,000 ml

a) 1,500 ml Blood volume increases by approximately 1,500 ml or 50% above nonpregnant levels by the 32nd week of gestation. This increase in blood volume is needed to provide adequate hydration of fetal and maternal tissues.

A nurse is assessing a client during the postpartum period. Which findings indicate normal postpartum adjustment? Select all that apply. a) nondistended abdomen b) abdominal pain c) tender abdomen d) passing gas e) active bowel sounds

e) active bowel sounds d) passing gas a) nondistended abdomen Finding active bowel sounds, verification of passing gas, and a nondistended abdomen are normal assessment results. The abdomen should be nontender and soft. Abdominal pain is not a normal assessment finding and should be immediately looked into.

The nurse has been asked to conduct a class to teach new mothers how to avoid developing stress incontinence. Which action would the nurse include in the discussion as possible strategies for the new mothers to do? Select all that apply. a) losing weight if obese b) avoiding smoking c) increasing fluid intake d) starting jogging e) performing Kegel exercises

e) performing Kegel exercises b) avoiding smoking a) losing weight if obese Postpartum women should consider low-impact activities such as walking, biking, swimming, or low-impact aerobics as they resume physical activity. They should also consider a regular program of Kegel exercises; losing weight, if necessary; avoiding smoking; limiting intake of alcohol and caffeinated beverages; and adjusting the fluid intake to produce a 24-hourly output of 1,000 ml to 2,000 ml.

A nurse is working with a group of new parents, assisting them in transitioning to parenthood. The nurse explains that this transition may take 4 to 6 months and involves four stages. Place the stages below in the order in which the nurse would explain them to the group. All options must be used. 1) commitment, attachment, and preparation for an infant 2) moving toward a new normal routine 3) acquaintance with and increasing attachment to the infant 4) achievement of the parental role

1, 3, 2, 4 commitment, attachment, and preparation for an infant acquaintance with and increasing attachment to the infant moving toward a new normal routine achievement of the parental role Although the stages overlap, and the timing of each is affected by variables such as the environment, family dynamics, and the partners, transitioning to parenthood (Mercer, 2006), involves four stages: commitment, attachment, and preparation for an infant during pregnancy; acquaintance with and increasing attachment to the infant, learning how to care for the infant, and physical restoration during the first weeks after birth; moving toward a new normal routine in the first 4 months after birth; and achievement of a parenthood role around 4 months.

A nurse is caring for a woman in labor and understands that as the fetus travels through the birth canal, the fetus makes positional changes that occur concurrently. Based on the nurse's conceptualization of their sequential occurrence, list the cardinal movements of labor in the correct order that the nurse would expect the fetus to move. All options must be used. 1) extension 2) internal rotation 3) flexion 4) engagement 5) expulsion

4, 3, 2, 1, 5 engagement flexion internal rotation extension expulsion The cardinal movements of labor describe the positional changes the fetus goes through as it travels through the passageway. They are deliberate, specific, and very precise; these movements allow the smallest diameter of the fetal head to pass through a corresponding diameter of the mother's pelvic structure. Although cardinal movements are conceptualized as separate and sequential, the movements are typically concurrent. They are engagement, descent, flexion, internal rotation, extension, external rotation, and expulsion.

The nurse discharging a newly delivered mother and her newborn infant needs to assess the mother's knowledge about how to take care of herself and her baby. This is her second child. Which approach would be best to verify the client's understanding of these topics? a) Ask her questions and observe her caring for the baby. b) Have her fill out a questionnaire on the subject. c) Since she has had a previous child, she should already know how to do most everything. d) Have her demonstrate how to do all the baby care tasks as well as her self-care tasks.

a) Ask her questions and observe her caring for the baby. The best way to determine if a mother understands the information given to her regarding caring for herself and her baby is to ask her and watch her as she cares for the newborn in the hospital.

A primigravida client at 39 weeks' gestation calls the OB unit questioning the nurse about being in labor. Which response should the nurse prioritize? a) Ask the woman to describe why she believes that she is in labor. b) Arrange for the woman to come to the hospital for labor evaluation. c) Emphasize that food and fluid should stop or be light. d) Tell the woman to stay home until her membranes rupture.

a) Ask the woman to describe why she believes that she is in labor. The nurse needs further information to assist in determining if the woman is in true or false labor. The nurse will need to ask the client questions to seek further assessment and triage information. Having the client wait until membranes rupture may be dangerous, as the client may give birth before reaching the hospital. The client should continue fluid intake until it is determined whether or not the client is in labor. The client may be in false labor, and more information should be obtained before the client is brought to the hospital.

The nurse is caring for a newborn of a mother with human immunodeficiency virus (HIV). What is the priority for the nurse to complete following delivery? a) Bathe the newborn thoroughly b) Assist the mother to breastfeed c) Test the newborn for HIV d) Administer zidovudine

a) Bathe the newborn thoroughly The newborn should have a thorough bath immediately after birth to decrease the possibility of HIV transmission. It is recommended the newborn be tested for HIV at 14 to 21 days after birth, at 1-2 months and again at 4-6 months. Zidovudine should be administered within 6-12 hours post-delivery to help prevent transmission of HIV from the mother to the newborn.

An infant born at 35 weeks' gestation is being screened for hypoglycemia. During the first 24 hours of life, when will the nurse screen this infant? a) Before feedings b) Every 8 hours c) Only if the infant is jittery d) After feedings

a) Before feedings To screen for hypoglycemia, a glucose level is obtained prior to the first feeding and then prior to feedings for 24 to 48 hours. Infants are screened even in the absence of symptoms; this is done before feeding to obtain a preprandial measure.

A nurse is caring for a client administered general anesthesia for an emergency cesarean birth. The nurse notes the client's uterus is relaxed upon massage. What would the nurse do next? a) Continue to massage the client's fundus. b) Administer oxygen to the client. c) Assess the client's vaginal bleeding. d) Continue to monitor the client.

a) Continue to massage the client's fundus. The nurse should monitor the client for uterine relaxation. If this is noted, the nurse would continually massage the client's fundus until it no longer felt boggy.

The nurse is monitoring an infant who was born at 0515 hrs. At 1315 hrs, the same day, the nurse determines the infant is starting to show yellowish staining on the head and face. Which action should the LPN prioritize? a) Document and report to RN. b) Repeat bilirubin levels. c) Start phototherapy. d) Continue monitoring, report if spreads.

a) Document and report to RN. Jaundice which appears in the first 24 hours may be a sign of excessive bilirubin in the blood and is now seeping into the tissues. This needs to be further evaluated and should be reported to the RN immediately so further assessments, including lab work, can be ordered. Jaundice in the first 24 hours is considered pathologic and needs to be evaluated immediately. Physiologic jaundice usually occurs on the second or third day after birth and is considered a normal event as the bilirubin levels rise. It should clear up with the use of phototherapy.

A primiparous mother gave birth to an 8 lb 12 oz (3970 g) infant daughter yesterday. She is being bottle fed, is Rh positive, has a cephalohematoma, and received her hepatitis A vaccine last evening. Which factor places the newborn at risk for the development of jaundice? a) cephalohematoma b) formula feeding c) female gender d) Rh positive blood type e) hepatitis A vaccine

a) cephalohematoma Risk factors for the development of jaundice include bruising as seen in a cephalohematoma, male gender, and being breastfed. Blood type incompatibility is only an issue if the infant's blood type differs from the mother and the maternal blood type is not stated. Administering hepatitis A vaccine does not increase the risk of jaundice.

The nurse has just received the results of a pregnant client's MSAFP screening and notes the levels are elevated. The nurse should prioritize which discussion with the client? a) Further testing is required b) Risk for neural tube defects c) Test needs to be repeated d) Risk for Down syndrome

a) Further testing is required The maternal serum alpha-fetoprotein (MSAFP) measures the levels of alpha-fetoprotein, which is a protein manufactured by the fetus. The woman's blood contains small amounts of this protein during pregnancy. The blood test is run between 16 and 20 weeks' gestation; an abnormal level indicates a need for further testing to determine the risks her fetus may face. Higher levels can indicate multiple fetuses, death of the fetus, the presence of neural tube defects, and possibly Down syndrome; however, further testing such as ultrasound or amniocentesis is required to determine the exact cause of the elevation.

The parents of a newborn are upset that their newborn needs treatment for ophthalmia neonatorum. The nurse should explain this is related to which maternal infection? Select all that apply. a) Gonorrhea b) Chlamydia c) Candidiasis d) Syphilis e) Trichomonas

a) Gonorrhea b) Chlamydia Colonization of chlamydia and gonorrhea in the vaginal tract can lead to ophthalmia neonatorum in the newborn, which infants contract at birth. The treatment is the use of an antibiotic ophthalmic ointment that is usually applied within the first hour. Trichomonas, syphilis, and candidiasis do not cause ophthalmia neonatorum.

The nurse is preparing a client for an epidural block. Which intervention is a priority before the epidural anesthesia is started? a) IV fluid bolus b) Monitor temperature c) Monitor maternal apical pulse d) Increase oral fluids

a) IV fluid bolus The client will need to have a bolus of IV fluids prior to the epidural to prevent hypotension. The hypotensive event is transitory, and increasing oral hydration is unnecessary and may lead to nausea later. Monitor the mother's body temperature as per routine. The nurse should monitor the radial pulse not the apical pulse.

The nurse is inspecting a new mother's perineum. What actions would the nurse take for this client? Select all that apply. a) Inspect the episiotomy for sutures and to ensure that the edges are approximated. b) Note any hemorrhoids. c) Gently palpate for any hematomas. d) Place the patient in Trendelenburg position for inspection. e) Palpate the episiotomy for pain.

a) Inspect the episiotomy for sutures and to ensure that the edges are approximated. b) Note any hemorrhoids. c) Gently palpate for any hematomas. The client is placed in the Sims position, not Trendelenburg position, for inspection. The nurse will then use a light to look at the perineum, noting any hemorrhoids, inspecting the episiotomy (if present) and palpating for any hematomas. The episiotomy is not palpated due to the pain associated with it, and the nurse can visually inspect it.

The nurse is assessing a newborn, 4 hours old, weighing 9 lbs, 2 oz (4088 g). While doing the initial assessment the RN mentioned that the mother's history showed her to be morbidly obese. Which assessment findings should the nurse prioritize as the newborn is continued to be monitored? a) Jitteriness and irritability b) Low temperature and hypertonia c) Hypotonia and fever d) Frequent activity and jitteriness

a) Jitteriness and irritability Infants born to women who are morbidly obese are at a greater risk for developing hypoglycemia. Early signs of hypoglycemia in the newborn include jitteriness, poor feeding, listlessness (not frequent activity), irritability, low temperature (not fever), weak or high-pitched cry, and hypotonia (not hypertonia).

What would the nurse recommend to a pregnant client at 35 weeks' gestation who reports irregular contractions and lower backache? a) Lie down and rest and see if the contractions stop and pain subsides. b) Ask her if she is having urinary frequency that may indicate an infection. c) Suggest that she try some isometric exercises to relieve the back pain. d) Have a family member rub her back and place moist heat on it.

a) Lie down and rest and see if the contractions stop and pain subsides. If a client is less than 37 weeks and having contractions that will not go away, she may be in preterm labor and this needs to be reported. The first thing for her to do is lie down and rest to see if the contractions go away. Lower backache and cramping or pain need to be taken seriously and reported to the health care provider if they persist.

A nurse is assessing a newborn's vital signs 2 hours after delivery. The newborn had low Apgar scores at birth. Which finding would lead the nurse to notify the health care provider? a) Pulse rate 100 bpm b) Blood pressure 60/40 mm Hg c) Temperature 99°F (37.2°C) d) Respirations 40 breaths/min

a) Pulse rate 100 bpm A pulse rate between 110 and 160 bpm is considered within acceptable parameters. Therefore, a pulse rate of 100 bpm would be a cause for concern. Temperature typically ranges from 97.7°F to 99.5°F (36.5°C to 37.5°C); respirations typically range from 30 to 60 breaths/min; and blood pressure ranges from 50 to 75 mm Hg systolic and 30 to 45 mm Hg diastolic.

The results of a woman's quadruple marker screen show that her alpha-fetoprotein (AFP) blood level is more than twice the value of the mean for that gestational age. The nurse recognizes that this finding is most strongly associated with: a) a neural tube disorder. b) Down syndrome. c) a trisomy disorder. d) a chromosomal disorder.

a) a neural tube disorder. AFP in maternal blood is elevated more than twice the value of the mean for the gestational age if a neural tube disorder such as myelomeningocele is present; it is decreased in amount if the fetus has a chromosomal disorder such as trisomy 21. Lower than normal levels of unconjugated estriol may also indicate a woman is at high risk for having a baby with Down syndrome. An elevated level of human chorionic gonadotropin (hCG) indicates presence of a trisomy disorder.

The nurse has just informed a client that her pregnancy test is positive and she will need further assessment to determine the complete status of the situation. Which initial emotional response does the nurse expect the client to exhibit? a) ambivalence b) emotional lability c) introversion d) acceptance

a) ambivalence Initially, the pregnant woman commonly experiences ambivalence, with conflicting feelings at the same time. Introversion heightens during the first and third trimesters when the woman's focus is on behaviors that will ensure a safe and healthy pregnancy outcome. Acceptance usually occurs during the second trimester. Emotional lability (mood swings) is characteristic throughout a woman's pregnancy.

A group of nursing students are preparing a presentation for a health fair illustrating the structures found during a pregnancy. Which structures should the students point out form a protective barrier around the developing fetus? a) chorion and amnion b) chorion and endoderm c) ectoderm and amnion d) amnion and mesoderm

a) chorion and amnion The chorion and amnion are the two fetal membranes. The ectoderm, mesoderm, and endoderm are layers in the developing blastocyst.

A female client has the Huntington's disease gene. She and her husband want to have a child but are apprehensive about possibly transmitting the disease to their newborn child. They have strong views against abortion. They would also like to have their "own" child and would consider adopting only as a last resort. Which action would be most appropriate in this situation? a) opting for a preimplantation genetic diagnosis b) chancing the conception and birth of a child c) undergoing prenatal diagnosis with prenatal choice of continuing pregnancy d) using donor gametes for conception of a child

a) opting for a preimplantation genetic diagnosis The most appropriate choice would be opting for a preimplantation genetic diagnosis (PGD). A PGD is a genetic evaluation of the embryo created through IVF which will reveal whether the Huntington's disease gene is present in the embryo. Undergoing prenatal diagnosis with prenatal choice of continuing pregnancy is not an option because the client and her husband are against abortion. Chancing the conception and birth of a child involves the risk of passing the gene to the newborn child. Using donor gametes may reduce the risk, but it is against the client's preferences.

A woman comes to the clinic for her first postpartum visit. She gave birth to a healthy term neonate 2 weeks ago. As part of this visit, the woman has a complete blood count drawn. Which result would the nurse identify as a potential problem? a) white blood cell count 14,000/mm3 (14 ×109/L) b) platelets 350,000/µL (350 ×109/L) c) hemoglobin 12.5 g/dL (125 g/L) d) hematocrit 42% (0.42)

a) white blood cell count 14,000/mm3 (14 ×109/L) The white blood cell count, which increases in labor, remains elevated for the first 4 to 6 days after birth but then falls to 6,000 to 10,000/mm3 (6 to 10 ×109/L). An elevated white blood cell count would be suspicious for infection. The hemoglobin, hematocrit and platelet levels are within normal parameters for this woman.

The nurse is teaching a new mother about the changes in her newborn's gastrointestinal tract. The nurse determines that additional teaching is needed when the mother makes which statement? a) "The muscle opening that leads into the stomach is not mature." b) "His stomach can hold approximately 10 ounces." c) "The newborn's gut is sterile at birth." d) "He needs to get food orally to make vitamin K."

b) "His stomach can hold approximately 10 ounces." A newborn's stomach capacity is approximately 30 to 90 mL or 1 to 3 ounces. The gut is sterile at birth but changes rapidly depending on what feeding is received. Colonization of the gut is dependent on oral intake; oral intake is required for the production of vitamin K. The cardiac sphincter that leads into the stomach and nervous control of the stomach are immature.

The nurse in an obstetric clinic is conducting client education with a group of expectant mothers. One young woman asks the nurse to tell the group what labor pain is like. What would be the nurse's best response? a) "It is best evaluated by talking with visitors in the labor room because they know you best." b) "The pain of labor is unique and multidimensional. It originates from different places depending on what stage of labor you are in." c) "It has been described as the worst pain you will ever feel." d) "It comes in waves."

b) "The pain of labor is unique and multidimensional. It originates from different places depending on what stage of labor you are in." Pain sensations associated with labor originate from different places, depending on the stage of labor.

During a home visit, the client mentions she is still having significant of joint pain. The nurse explains that the changes that softened the pelvic joints to allow for the birth were due to the hormone relaxin. The nurse informs the client that it takes approximately how long for the joints to return to prepregnancy status? a) 8 to 10 weeks after pregnancy b) 6 to 8 weeks after pregnancy c) 4 to 6 weeks after pregnancy d) 2 to 4 weeks after pregnancy

b) 6 to 8 weeks after pregnancy During pregnancy, the hormones relaxin, estrogen, and progesterone relax the joints. After birth, levels of these hormones decline, resulting in a return of all joints to their prepregnant state. Within 6 to 8 weeks after delivery, joints are completely stabilized and return to normal.

The client states that the first day of her last menstrual period is March 23. The nurse is most correct to calculate using Naegele rule that the estimated date of delivery is: a) January 30 b) December 30 c) November 23 d) December 16

b) December 30 Using Naegele rule, since the first day of the client's last menstrual period is March 23, 7 days are added leading to the 30th. Subtracting 3 months from March is December. Thus, December 30 is the estimated date of delivery.

A pregnant woman is concerned about the recent onset of a midline swelling that is soft and nontender. The nurse should point out this is most likely related to which condition? a) Linea nigra b) Diastasis recti c) Round ligament pain d) Chadwick sign

b) Diastasis recti In advanced pregnancy muscle tone diminishes, which may aid in the separation of the rectus abdominis muscles. This benign finding does not usually cause other symptoms. The nurse may palpate the fetus well through this opening. Linea nigra is a hyperpigmentation along the midline. Chadwick sign is the bluish tinge to the cervix and vaginal walls seen early in pregnancy, and round ligament pain occurs as the uterus enlarges. This discomfort is usually found in the right more often than the left.

The nurse is preparing to administer the ordered injections to a newborn. After noting the mother tested positive for HbsAG, which nursing intervention should the nurse prioritize for the infant? a) Hepatitis B vaccination and 1 dose of hepatitis B immunoglobulin within 24 hours of birth b) Hepatitis B vaccination and 1 dose of hepatitis B immunoglobulin within 12 hours of birth c) Hepatitis B vaccination and 2 doses of hepatitis B immunoglobulin within 24 hours of birth d) Two doses of the hepatitis B immunoglobulin within 24 hours of birth

b) Hepatitis B vaccination and 1 dose of hepatitis B immunoglobulin within 12 hours of birth If a mother has hepatitis B (HbsAG) or is suspected of having hepatitis B, the newborn should be bathed and then should receive 1 dose of the hepatitis B vaccine and 1 dose of the hepatitis B immunoglobulin within 12 hours of birth. The other choices are the wrong dosages and/or times.

A nurse places an external fetal monitor on a woman in labor. Which instruction would be best to give her? a) Lie supine so the tracing does not show a shadow. b) Lie on her side so she is comfortable. c) Avoid using her call bell to reduce interference. d) Avoid flexing her knees so her abdomen is not tense.

b) Lie on her side so she is comfortable. The best position for all women during labor is on their side.

The nurse is caring for a client having chorionic villus sampling using the transcervical approach. When preparing the client for the procedure, in which position is the client placed? a) Supine position b) Lithotomy position c) Recumbent position d) Sims position

b) Lithotomy position The lithotomy position with the legs in stirrups is the best position to access the cervical region. The other options make it difficult, if not impossible, to access.

The nurse is admitting to the floor a woman who just gave birth. What medical and pregnancy history would the labor and delivery nurse include in the report? a) Apgar scores b) Maternal blood type c) The newborn's weight d) Length of labor

b) Maternal blood type Medical and pregnancy history would include information pertinent to the mother, which would be the mother's blood type, Rh, and rubella status. History of the length of labor are part of the labor and birthing history. The infant's Apgar scores and birth weight are part of the newborn history.

A nurse is providing care to a pregnant woman in her first trimester who has come to the clinic for a follow-up visit. During the visit, the nurse teaches the woman about some of the changes that she will be experiencing during her pregnancy. Which information would the nurse include when describing changes in the breast? a) The areolas becomes lighter in color. b) Montgomery glands (Montgomery tubercles) become more prominent. c) Prolactin, an anterior pituitary hormone, stimulates the breasts to grow. d) Estrogen causes the breasts to feel nodular.

b) Montgomery glands (Montgomery tubercles) become more prominent. Montgomery glands (Montgomery tubercles), sebaceous glands on the areolas, produce secretions that lubricate the nipple. Montgomery glands become more prominent during pregnancy. The other listed phenomena do not happen.

The nurse is teaching new parents how to clear the secretions from their infant's mouth and nose. The nurse determines they are prepared when they correctly perform which initial step? a) Position the newborn on side, and suction with a bulb syringe. b) Position the newborn on side with head slightly below body; use a bulb syringe to clear mouth. c) Position the newborn on side with head slightly below body; use a small suction catheter to clear nose. d) Position the newborn on side with head slightly below body; use a bulb syringe to clear nose.

b) Position the newborn on side with head slightly below body; use a bulb syringe to clear mouth. The infant needs to have bulb suction used to remove the secretions from the mouth first; the head should be held slightly lower than the body to facilitate use of gravity. A bulb syringe, not a small suction catheter, is used to suction the mouth and nose of a newborn. The mouth should be cleared first to prevent possible aspiration of secretions. Suctioning the nose first could cause the infant to inhale the secretions in the mouth.

The nurse wants to maintain a neutral thermal environment for her assigned neonatal clients. Which intervention would best ensure that this goal is met? a) Avoid skin-to-skin contact with the mother until the infants are 8 hours old. b) Promote early breastfeeding for the infants. c) Keep the infant transporter temperature between 80° and 85°F (27° and 29°C). d) Avoid bathing the newborn until he or she is 24 hours old.

b) Promote early breastfeeding for the infants. The nurse should promote early breastfeeding to provide fuels for nonshivering thermogenesis. The nurse can bathe the newborn if he or she is medically stable. The nurse can also use a radiant heat source while bathing the newborn to maintain the temperature. Skin-to-skin contact with the mother should be encouraged, not discouraged, if the newborn is stable. The infant transporter should be kept fully charged and heated at all times.

A nurse is conducting a parenting class on infant skin care. What information should the nurse include when preparing materials on the characteristics of the skin of infants? Select all that apply. a) Sweat glands are fully functioning at birth. b) Substances are easily absorbed. c) It is thinner and more fragile than an adult's d) The epidermis is thicker than in adults. e) Skin is less susceptible to the sun.

b) Substances are easily absorbed. c) It is thinner and more fragile than an adult's An infant's skin is more fragile than that of adult's and is more susceptible to breakdown as well as the effects of the sun. The epidermis of an infant's skin is much thinner than an adult's and does not reach the thickness of adult skin until late adolescence. Sweat glands are immature at birth, contributing to the difficulty infants have in regulating temperature. Sweat glands do mature as the infant grows.

A mother who is 4 days postpartum and is breastfeeding expresses to the nurse that her breast seems to be tender and engorged. Which suggestions should the nurse give to the mother to relieve breast engorgement? Select all that apply. a) Feed the newborn in the sitting position only. b) Take warm-to-hot showers to encourage milk release. c) Express some milk manually before breastfeeding. d) Massage the breasts from the nipple toward the axillary area. e) Apply warm compresses to the breasts prior to nursing.

b) Take warm-to-hot showers to encourage milk release. c) Express some milk manually before breastfeeding. e) Apply warm compresses to the breasts prior to nursing. To relieve breast engorgement in the client, the nurse should educate the client to take warm-to-hot showers to encourage milk release, express some milk manually before breastfeeding, and apply warm compresses to the breasts before nursing. The mother should be asked to feed the newborn in a variety of positions—sitting up and then lying down. The breasts should be massaged from under the axillary area, down toward the nipple.

The nurse is caring for four clients in labor. Which client would the nurse anticipate having continuous internal electronic fetal monitoring? a) The client who is having an uncomplicated labor b) The client who is very restless and is moving around in the bed c) The client who has had a previous cesarean section d) The client who is having back labor and desires to lay on her side

b) The client who is very restless and is moving around in the bed The client who is restless and frequently changing positions is more likely to have continuous internal electronic fetal monitoring. This method provides data on the fetal heart rate. Depending upon the obstetric history, the client having back labor and the client with an uncomplicated labor may have intermittent fetal heart rate auscultation or external electronic fetal monitoring. The client who had a previous cesarean section would also have monitoring of uterine contraction intensity.

Which psychosocial state is anticipated when the client enters the active phase of labor? a) The client will become tired and want the process over. b) The client will become more quiet and introverted. c) The client will become more talkative and excited about the birth. d) The client will become angry and begin to scream.

b) The client will become more quiet and introverted. The woman's psychosocial state typically changes as she enters the active phase of labor. As the contractions are increasing in amount and intensity, the woman becomes more quiet and introverted as she is focused on the work of labor. The other options may occur but are not anticipated.

A nurse is describing what happens at fertilization as the zygote begins life. Which statement is most accurate? a) The zygote begins life with its first meiotic division before ovulation. b) The zygote begins life with the diploid number of chromosomes c) The zygote begins life with the haploid number of chromosomes d) The zygote begins life with its second meiotic division just before ovulation.

b) The zygote begins life with the diploid number of chromosomes Because each nucleus contains a haploid number of chromosomes (23), this union restores the diploid number of (46). Because each nucleus contains a haploid number of chromosomes (23), this union restores the diploid number (46). The primary oocyte completes its first meiotic division before ovulation. The secondary oocyte begins its second meiotic division just before ovulation.

A woman is aware that she is the carrier of a sex-linked recessive disease (hemophilia A); her husband is free of the disease. What frequency of this disease could she expect to see in her children? a) All female children will be carriers like she is. b) 50% of her male children will inherit the disease. c) 50% of her female children will inherit the disease. d) All male children will inherit it.

b) There is a 50% chance her male children will inherit the disease. With X-linked inheritance, there is a 50% chance male children will be affected. There is a 50% chance female children will be carriers of the disease.

During pregnancy, one of progesterone's actions is to allow sodium to be "wasted" or lost in the urine. The nurse would expect to see which hormone increased to help counteract this loss? a) glycogen b) aldosterone c) cortisol d) ADH

b) aldosterone Aldosterone is secreted by the adrenal glands, and it normally regulates the absorption of sodium in the kidney. During pregnancy, aldosterone is a key regulator of electrolyte and water homeostasis and plays a central role in blood pressure regulation. ADH (antidiuretic hormone) is secreted by the kidneys and aids in resorption of fluids in the kidneys. Glycogen assists in the balancing of blood glucose, breaking down to glucose when needed by the body. Cortisol is important in helping the body handle stress.

Which finding is most worrisome in a client in her 26th week of pregnancy? a) generalized hair loss b) facial edema c) a hyperpigmented rash over the maxillary region bilaterally d) nosebleeds

b) facial edema Generalized hair loss, hyperpigmented maxillary rash (chloasma), and nosebleeds are usually benign and common in pregnancy. Facial edema after the 24th week of gestation may indicate gestational hypertension.

A new mother is concerned that the infant is not eating enough and will not have enough energy. The nurse explains that storage of which substance will provide energy for the first 24 hours after birth? a) protein b) glucose c) carbohydrate d) brown fat

b) glucose Glucose is the main source of energy for the first several hours after birth. With the newborn's increased energy needs after birth, the liver releases glucose from glycogen stores for the first 24 hours. Stored protein, brown fat, or carbohydrate are not associated with energy production in the newborn.

A nurse working on the postpartum floor is mentoring a new graduate and instructs the new nurse to make sure that clients empty their bladders. A full bladder can lead to which complication? a) permanent urinary incontinence b) increased lochia drainage c) fluid volume overload d) ruptured bladder

b) increased lochia drainage If the bladder is full in a postpartum mother, lochia drainage will be more than normal because the uterus cannot contract to suppress the bleeding. The other options do not happen if a woman has a distended bladder.

The nurse is making a home visit to a woman who is 5 days' postpartum. Which finding would concern the nurse and warrant further investigation? a) diaphoresis b) lochia rubra c) uterus 5 cm below umbilicus d) edematous vagina

b) lochia rubra Lochia serosa is normal from days 3 to 10 postpartum. However, lochia rubra is present for about the first 3 days and is considered abnormal on the 5th postpartum day. By the fifth postpartum day, the uterus should be approximately 5 cm below the umbilicus. After birth the vagina is edematous and thin with few rugae. It eventually thickens and rugae return in approximately 3 weeks. Diaphoresis is common during the early postpartum period, especially in the first week. It is a mechanism to reduce fluids retained during pregnancy and restore prepregnant body fluid levels.

Which medication is administered to reverse the depressant effects of opioids? a) meperidine b) naloxone c) butorphanol d) nalbuphine

b) naloxone Naloxone is an opioid antagonist. Butorphanol, nalbuphine, and meperidine are opioids.

A woman dilated to 10 cm and feeling the urge to "have a bowel movement" is refusing to push and is screaming, "It hurts down there too much to push." What option should the nurse suggest at this point for pain management to facilitate pushing? a) epidural anesthesia b) pudendal block c) paracervical block d) parenteral medication

b) pudendal block The client is too far dilated to have any parenteral medication or an epidural block. The best option is a local block or a pudendal block that will numb the vaginal wall to block the pain sensation to the pudendal nerve. The paracervical block is only used in the first stage of labor, and this client is in the second stage.

A nurse is counseling a couple who report that they are both carriers for a condition. The medical history reveals neither of them have symptoms of the condition. In the event this couple conceives a child, what is the likelihood they will have a child who will have the disorder? a) 100% b) 75% c) 25% d) 50%

c) 25% When an individual is a carrier for a disorder they have one normal gene and one abnormal gene. They do not demonstrate the symptoms of the disorder. In the event they reproduce with an individual with the same pattern they will have a 25% chance of conceiving a child with the disorder. There is a 50% chance they will conceive a child who like them is a carrier for the disorder.

The nurse is caring for a client at the prenatal clinic. The client reports that she has felt some fluttering sensations in her lower abdomen and she noticed that her waistline is now totally gone. Additionally, she shows the nurse her nipples and the areola are much darker. Based upon this assessment, in which month of pregnancy is this client? a) 5th month b) 2nd month c) 4th month d) 3rd month

c) 4th month Based upon the presenting findings, the mother is in her 4th month of pregnancy. This is when quickening occurs—the beginning of feeling fetal movement. Also, the mother now has lost her waistline and the breast areola has begun to darken.

Which would be a normal finding by the nurse during a physical exam of a woman in her third trimester? a) Kyphosis b) Increased hematocrit c) Dyspnea d) Ptyalism

c) Dyspnea In the third trimester, a women experiences dyspnea from the uterus pushing up into the diaphragm. A pregnant woman will experience lordosis, not kyphosis. Ptyalism is excessive saliva production and is often seen in the first trimester of pregnancy. The hematocrit of a pregnant woman will decrease in the third trimester, not increase.

The nurse is inspecting the mouth of a newborn and finds small, white cysts on the gums and hard palate. The nurse documents this finding as: a) vernix caseosa. b) milia. c) Epstein pearls. d) oral candidiasis (thrush).

c) Epstein pearls. Epstein pearls are small, white epidermal cysts on the gums and hard palate that disappear in weeks. Oral candidiasis (thrush) is white plaque inside the mouth caused by exposure to Candida albicans during birth, which cannot be wiped away with a cotton-tipped applicator. Milia are multiple pearly-white or pale yellow unopened sebaceous glands frequently found on a newborn's nose. Vernix caseosa is a thick white substance that protects the skin of the fetus. It is formed by secretions from the fetus's oil glands and is found during the first 2 or 3 days after birth in body creases and the hair.

New parents report to the nurse that their newborn has "crying jags" in the afternoon each day. They are worried that if they hold the newborn every time she cries, she will become spoiled. What advice would the nurse give these parents? a) Crying indicates that the newborn has a need, so changing the diaper and feeding the infant should help. b) Rocking the newborn may soothe her but the time needs to be limited to 30 minutes per session. c) Holding and comforting the newborn will not cause the infant to become spoiled. d) Try walking with the newborn around the house then place her back in the crib to let her cry for a while.

c) Holding and comforting the newborn will not cause the infant to become spoiled. Newborns often have periods of crying; the parents should first check for a physical reason for crying such as hunger or a soiled diaper. If this is not the cause, then the parents need to try to soothe the newborn by holding, walking, rocking the newborn or even taking the infant for a ride in the car. Reassure the parents that they will not spoil the newborn by meeting its needs.

The nurse explains to the parents of a 2-day-old newborn that decreased life span of neonatal red blood cells has contributed to which complication? a) Polycythemia b) Transient tachypnea c) Hyperbilirubinemia d) Respiratory distress syndrome

c) Hyperbilirubinemia Neonatal red blood cells have a life span of 80 to 100 days and normally have a higher count at birth. This combination leads to an increased hemolysis. Complications of this process include hyperbilirubinemia.

Which assessment finding 1 hour after birth should be reported to the health care provider? a) Large, bruised hemorrhoids are protruding from the anal opening. b) Fundus of uterus is palpable at the level of the umbilicus. c) Lochia rubra is saturating a pad every 45 to 60 minutes. d) Fundus is displaced to the right, and bladder is hard.

c) Lochia rubra is saturating a pad every 45 to 60 minutes. The nurse should ask the woman to turn over so her buttocks can be inspected in order to ensure that blood is not pooling beneath her. If the nurse observes a constant trickle of vaginal flow or the woman is soaking through a pad every 60 minutes, she is losing more than the average amount of blood. She needs to be examined by her health care provider to be certain there is no cervical or vaginal tear, or that poor uterine contraction is not causing excessive bleeding. Following perineal assessment, the nurse should assess the rectal area for the presence of hemorrhoids. If any are present, the nurse should document their number, appearance, and size in centimeters. Fundus of uterus palpable at the level of the umbilicus is a normal finding immediately after birth. When the fundus is displaced to right and bladder is hard to palpation, the bladder is full, and the nurse needs to assist the client in emptying the bladder. The health care provider should be notified if a catheter needs to be inserted and there are no standing prescriptions for an in-and-out cath following birth.

What effect does progesterone have on normal gallbladder function? a) It has no effect on the gallbladder. b) Bile will be produced at a more rapid rate due to the progesterone. c) Progesterone interferes with gallbladder contraction, leading to stasis of bile. d) The gallbladder will hypertrophy.

c) Progesterone interferes with gallbladder contraction, leading to stasis of bile. Progesterone interferes with normal gallbladder contractions, which leads to stasis of bile. This stasis results in cholestasis, either seen in the gallbladder or the liver.

A mother who just given birth has difficulty sleeping despite her exhaustion from labor. What are the causes of this inability to rest? Select all that apply. a) bottle feeding b) inability to get adequate pain relief c) crying baby d) excess fatigue and overstimulation by visitors e) frequent trips to the bathroom due to diuresis

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

The student nurse is learning about normal labor. The teacher reviews the cardinal movements of labor and determines the instruction has been effective when the student correctly states the order of the cardinal movements as follows: a) internal rotation, descent, extension, flexion, external rotation, expulsion b) internal rotation, flexion, descent, extension, external rotation, expulsion c) descent, flexion, internal rotation, extension, external rotation, expulsion d) descent, flexion, external rotation, extension, internal rotation, expulsion

c) descent, flexion, internal rotation, extension, external rotation, expulsion The six cardinal movements of the fetus, in order, are descent, flexion, internal rotation, extension, external rotation, and expulsion.

A nurse is describing to a group of young parents the many changes that will occur during the early postpartum period. The nurse reviews common reports experienced as the woman's body returns to her prepregnancy state. The nurse determines that the teaching was successful when the participants identify which report as being most common during the first week (indicating that fluid volume is returning to normal)? a) urinary frequency b) nocturia c) diaphoresis d) urinary urgency

c) diaphoresis The profuse diaphoresis is common during the early postpartum period. Many women will wake up drenched with perspiration. This diaphoresis is a mechanism to reduce the amount of fluids retained during pregnancy and restore prepregnant body fluid levels. It is common, especially at night during the first week after birth. Nocturia, urinary frequency, or urinary urgency are not associated with this fluid shift.

The nurse is describing fetal circulation to new parents and how the circulation changes after birth. The nurse describes a structure that allows the pulmonary circulation to be bypassed, but that shortly after birth this structure should close. Which structure is the nurse describing? a) umbilical vessels b) ductus venosus c) ductus arteriosus d) foramen ovale

c) ductus arteriosus During fetal life, the ductus arteriosus protects the lungs against circulatory overload by shunting blood into the descending aorta, bypassing the pulmonary circulation. The foramen ovale is located in the septum between the atria and allowed blood to flow from the right atrium directly the left atrium. The ductus venous allowed the majority of the blood to bypass the liver. The umbilical vessels carried oxygenated blood to the fetus and removed deoxygenated blood and waste products from the fetus.

A pregnant client tells the nurse that she has a 2-year-old child at home who was born at 38 weeks; she had a miscarriage at 9 weeks; and she gave birth to a set of twins at 34 weeks. Which documentation would be appropriate for the nurse? a) gravida 3, para 4 b) gravida 2, para 1 c) gravida 4, para 2 d) gravida 2, para 4

c) gravida 4, para 2 Gravida (G) indicates the number of pregnancies. When a nurse calculates the GP of a pregnant client, the current pregnancy counts as one, the twin pregnancy counts as one, and the previous pregnancies count as two for a gravida of 4. Para (P) indicates the number of pregnancies that result in birth at a viable gestational age. The birth of multiples count as one. Thus, this client has a 2-year-old and one set of twins, for a para of 2.

When educating a group of nursing students about the different types of pelves, the nurse describes one type as being flat, having a wider transverse diameter than anterior-posterior diameter, with ischial spines that are wide apart, and a short sacrum. The students are correct when they identify this description with which type? a) gynecoid b) anthropoid c) platypelloid d) android

c) platypelloid A platypelloid pelvis is a flat pelvis with a wider transverse diameter than anterior-posterior diameter, ischial spines are wide apart, and the sacrum is short. In a gynecoid pelvis, the inlet is oval, the pubic arch is wide, it has dull ischial spines, and the sacrum has no anterior or posterior inclinations. In an android pelvis, the inlet is heart shaped, the ischial spines are prominent, and the sacrum is straight. In an anthropoid pelvis, the anterior-posterior diameter is longer than the transverse diameter, the ischial spine is somewhat prominent, and the sacrum is inclined posteriorly.

The placenta is the site where antibodies in the mother's blood pass into the fetal circulation. These antibodies give passive immunity to the fetus for several common childhood diseases. There are some infections for which the mother does not provide antibodies to the fetus. What infection is the fetus not protected from? a) diphtheria b) rubeola c) rubella d) smallpox

c) rubella The fetus does not receive immunity to rubella, cytomegalovirus (CMV), varicella, or measles. If the woman encounters these pathogens during her pregnancy, fetal infection may ensue.

The nurse is monitoring a client and notes: contractions causing urge to push, strong intensity, cervix 10 cm, 100% effaced, fetal head crowns when client pushes. The nurse determines the client is currently in which stage or phase of labor? a) active b) transition c) second d) third

c) second The second stage of labor is between full dilation (dilatation) and birth of the infant. This woman has completed transition and is in the second stage of labor. The third stage begins with the birth of the baby and ends with delivery of the placenta. The active phase begins at 4 cm cervical dilation and ends when the cervix is dilated 8 cm. During the transition phase, contractions reach their peak of intensity, occurring every 2 to 3 minutes with a duration of 60 to 70 seconds, and a maximum cervical dilatation of 8 to 10 cm occurs. Both the active and transistion phases ocur during the first stage of labor.

Review of a woman's labor and birth record reveals a laceration that extends through the anal sphincter muscle. The nurse identifies this laceration as which type? a) fourth-degree laceration b) first-degree laceration c) third-degree laceration d) second-degree laceration

c) third-degree laceration A third-degree laceration extends through the anal sphincter muscle. A first-degree laceration involves only skin and superficial structures above the muscle. A second-degree laceration extends through the perineal muscles. A fourth-degree laceration continues through the anterior rectal wall.

A nurse is working with the parents of a newborn girl. The parents have a 2-year-old boy at home. Which statement would the nurse include when teaching these parents? a) "Expect to see your 2-year-old become more independent when the baby gets home." b) "Have your 2-year-old stay at home while you're here in the hospital." c) "Talk to your 2-year-old about the baby when you're driving him to day care." d) "Ask your 2-year-old to pick out a special toy for his sister."

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

A nurse is making a home visit to a new mother who gave birth vaginally 5 days ago. The woman tells the nurse that she has lost some weight but still feels as if she has a long way to go to return to her prepregnancy weight. The woman asks the nurse about the average weight loss for 5 days postpartum. Which information would the nurse incorporate into the response? a) 24 lb b) 14 lb c) 9 lb d) 19 lb

d) 19 lb The rapid diuresis and diaphoresis during the second to fifth days after birth usually result in a weight loss of 5 lb (2 to 4 kg), in addition to the approximately 12 lb (5.8 kg) lost at birth. Lochia flow causes an additional 2- to 3-lb (1-kg) loss, for a total weight loss of about 19 lb.

A 35-year-old client has been told to keep her pulse rate below 140 bpm during workouts because she is pregnant. This means that the client will be working roughly what percentage of the suggested pulse rate? a) 65% b) 60% c) 70% d) 75%

d) 75% 220 - 35 = 185 x 0.75 = 138.75 (round to 139)

The nurse is monitoring a postpartum client who says she's concerned because she feels mildly depressed. The nurse recognizes that she is most likely experiencing "postpartum blues," and reassures the client that this symptom is experienced by approximately what percentage of women? a) 100% b) 40% c) 25% d) 85%

d) 85% Postpartum blues, or mild depression during the first 10 days after giving birth, affects up to 85% of women who give birth. More intense depression during this period is referred to as postpartum depression, which affects approximately 10% to 15% of postpartum clients. Postpartum depression can be severe with negative implications for maternal and neonatal well-being.

Rho(D) immune globulin is administered to which clients? Select all that apply. a) A newborn with type O-negative blood and a negative Coombs test b) A Rh negative woman who gives birth at 32 weeks gestation to a baby with A+ blood c) A client who is Rh-positive and gave birth to a 7-pound baby d) An Rh-negative woman who had a spontaneous abortion (miscarriage) yesterday e) An Rh-negative woman following an ectopic pregnancy

d) An Rh-negative woman who had a spontaneous abortion (miscarriage) yesterday e) An Rh-negative woman following an ectopic pregnancy b) A Rh negative woman who gives birth at 32 weeks gestation to a baby with A+ blood Rho(D) immune globulin is never given to an individual with Rh positive blood, and it is never given to the neonate following birth. Rho(D) immune globulin is given to women with Rh negative blood following an ectopic pregnancy, a spontaneous abortion (miscarriage), and the birth of an Rh positive neonate.

The nursing instructor is conducting a class discussion on the various agents used during labor and delivery to assist the client. The instructor determines the class is successful after the students correctly choose which factor as true about the use of systemic analgesia? a) Opioids are more effective if given PO. b) Barbiturates are used primarily in active labor and during transition. c) Ataractics are used for pain relief but may cause nausea and vomiting. d) Benzodiazepines enhance pain relief attained with opioids and cause sedation.

d) Benzodiazepines enhance pain relief attained with opioids and cause sedation. Barbiturates are used in latent labor for their minor tranquilizing and sedative effects. They can also be used just before general anesthesia, if required. Ataractics are opioid agonists used to decrease anxiety, nausea, and vomiting. Opioids may be given IV, intrathecally, or epidurally.

A nurse is teaching a preconception class discussing the process of conception. Which information would the nurse likely include? a) Conception occurs when the sperm travels through the vagina to unite with the ovum. b) Conception occurs when an ovum passes into the uterus to unite with sperm. c) Conception occurs when a zygote travels through the vagina to meet the sperm. d) Conception occurs when an ovum passes into a fallopian tube to unite with sperm.

d) Conception occurs when an ovum passes into a fallopian tube to unite with sperm. For conception to occur, a healthy ovum from the woman is released from the ovary and passes into an open fallopian tube. Sperm from the male is deposited into the vagina and swims approximately 7 inches to meet the ovum at the outermost portion of the fallopian tube, the area where fertilization takes place. The sperm does not unite with the ovum in the vagina. A zygote is the product of fertilization. Conception occurs in the fallopian tube, not in the uterus.

A pregnant client has opted for hydrotherapy for pain management during labor. Which measure should the nurse consider when assisting the client during the birthing process? a) Ensure that the water temperature exceeds body temperature. b) Allow the client into the water only if her membranes have ruptured. c) Do not allow the client to stay in the bath for long. d) Initiate the technique only when the client is in active labor.

d) Initiate the technique only when the client is in active labor. The recommendation for initiating hydrotherapy is that women be in active labor (>5 cm dilated) to prevent the slowing of labor contractions secondary to muscular relaxation. Women are encouraged to stay in the bath or shower as long as they feel they are comfortable. The water temperature should not exceed body temperature. The woman's membranes can be intact or ruptured.

A nurse is aware that the newborn's neuromuscular maturity assessment is typically completed within 24 hours after birth. Which assessment would the nurse be least likely to complete to determine the newborn's degree of maturity? a) popliteal angle b) square window c) scarf sign d) Moro reflex

d) Moro reflex There are six activities or maneuvers that are evaluated to determine the newborn's degree of neuromuscular maturity: posture, square window, arm recoil, popliteal angle, scarf sign, heel-to-ear. The Moro reflex is an indication of the newborn's neurologic status.

A client in labor has been admitted to the labor and birth suite. The nurse assessing the woman notes that the fetus is in a cephalic presentation. Which description should the nurse identify by the term presentation? a) Relation of the different fetal body parts to one another b) Relationship of the presenting part to the maternal pelvis c) Relation of the fetal presenting part to the maternal ischial spine d) Part of the fetal body entering the maternal pelvis first

d) Part of the fetal body entering the maternal pelvis first The term presentation is the part of the fetal body that is entering the maternal pelvis first. The relationship of the presenting part to the sides of the maternal pelvis is called the position. Attitude is the term that describes the relation of the different fetal body parts to one another. The relation of the fetal presenting part to the maternal ischial spine is termed the station.

The nurse is conducting an assessment of a pregnant client at a routine second trimester prenatal visit. Which lower extremity assessment should the nurse prioritize? a) Blanching and refilling of toenails b) Diameter of the calf muscle c) Lateral movement of the kneecap d) Presence of varicosities

d) Presence of varicosities During pregnancy, women are prone to develop varicosities because of uterine pressure on lower-extremity veins. Evaluating the diameter of the calf would be important if a deep vein thrombosis was suspected. Capillary refill of the toenails would be a routine evaluation. Lateral movement of the kneecap would not be a priority.

The nursing instructor is teaching a class on the various hormones necessary for a successful pregnancy and birthing process. The instructor determines the session is successful when the students correctly choose which hormone as being necessary after birth to ensure growth of the newborn? a) Oxytocin b) Progesterone c) Estrogen d) Prolactin

d) Prolactin Prolactin is the hormone responsible for the initiation of lactation, the production of breast milk. Oxytocin is responsible for the letdown of milk and uterine contractions enabling the infant to be born, and estrogen and progesterone are responsible for uterine and pregnancy maintenance.

A client in labor is agitated and nervous about the birth of her child. The nurse explains to the client that fear and anxiety cause the release of certain compounds that can prolong labor. The nurse is referring to which compounds? a) relaxin b) oxytocin c) prostaglandins d) catecholamines

d) catecholamines Fear and anxiety cause the release of catecholamines, such as norepinephrine and epinephrine, which stimulate the adrenergic receptors of the myometrium. This in turn interferes with effective uterine contractions and results in prolonged labor. Estrogen promotes the release of prostaglandins and oxytocin. Relaxin is a hormone that is involved in producing backache by acting on the pelvic joints. Prostaglandins, oxytocin, and relaxin are not produced due to fear or anxiety in clients during labor.

The nurse realizes that accommodating for the various cultural differences in her clients is an important aspect in providing their care. When caring for a postpartum woman of Japanese descent, which action would be a priority? a) allowing time for the numerous visitors who come to see the woman and newborn b) assigning a female nurse to care for her c) providing time for prayers to be performed at the bedside d) ensuring that the newborn receives a daily bath

d) ensuring that the newborn receives a daily bath In the Japanese American culture, cleanliness and protection from cold are essential components of newborn care. Nurses should bathe the infant daily. Muslims prefer the same-sex health care provider; male-female touching is prohibited except in emergency situations. Numerous visitors can be expected to visit some women of the Filipino American culture because families are very close-knit. Bedside prayer is common due to the strong religious beliefs of the Filipino American culture.

A pregnant client states she was unable to breastfeed her last child because her breasts did not produce milk. She desires to breastfeed this child. Which hormones would the nurse monitor to during this pregnancy? a) relaxin and human chorionic gonadotropin (hCG) b) progesterone and relaxin c) oxytocin and progesterone d) estrogen and human placental lactogen (hPL)

d) estrogen and human placental lactogen (hPL) Estrogen aids in developing the ductal system of the breasts in preparation for lactation during pregnancy. hPL prepares the mammary glands for lactation. Progesterone supports the endometrium of the uterus to provide an environment conducive to fetal survival. Oxytocin is responsible for uterine contractions, both before and after birth. Oxytocin is also responsible for milk ejection during breastfeeding.

The nurse is preparing the client for the routine laboratory tests that will be obtained at the first prenatal visit. Which test will the nurse prioritize at this visit? a) rubeola titer b) magnesium level c) prolactin levels d) hepatitis screen

d) hepatitis screen The woman will undergo tests for hepatitis B, HIV, syphilis, gonorrhea, and chlamydia. Each of these infections can cause serious fetal problems unless they are treated. Rubella is more concerning than rubeola and a titer may be completed to assess the woman's immunity to rubella. Other blood tests will include a complete blood count to evaluate anemia, blood type and antibody screen, and possibly thyroid screen to evaluate for hypothyroidism.

A nursing instructor informs the student that which stimuli initiate respirations in the newborn? Select all that apply. a) acidosis b) hypoxia c) alkalosis d) hypercapnia e) decreased CO2

d) hypercapnia b) hypoxia a) acidosis The first breath of life is a gasp that generates an increase in transpulmonary pressure and results in diaphragmatic descent. Hypercapnia, hypoxia, and acidosis resulting from normal labor become the stimuli for initiating respirations.

A nurse is educating a group of nursing students about the molding of the fetal skull during the birth process. What would the nurse include as the usual cause of molding? a) rigid bones at the base of the skull b) well-ossified bones of the face c) tight membranous attachments d) poorly ossified bones of the cranial vault

d) poorly ossified bones of the cranial vault Molding is an adaptive process in which there is overriding and movement of the bones of the cranial vault to adapt to the maternal pelvis. The poorly ossified bones of the cranial vault, along with loosely attached membranous attachments, allow for the process of molding in the fetal skull. The bones of the face and the base of the skull are completely ossified and united. Hence they cannot allow for movement or overriding. The membranous attachments are loosely (not tightly) bound to the cranial vault, which allows for molding of the fetal skull.

The assessment of a pregnant client who is toward the end of her third trimester reveals that she has increased prostaglandin levels. For which factors should the nurse assess the client? Select all that apply. a) myometrial contractions b) softening and thinning of the cervix c) boggy appearance of the uterus d) reduction in cervical resistance e) hypotonic character of the bladder

d) reduction in cervical resistance a) myometrial contractions b) softening and thinning of the cervix Upon seeing the increased prostaglandin levels, the nurse should assess for myometrial contractions, leading to a reduction in cervical resistance and subsequent softening and thinning of the cervix. The uterus of the client will appear boggy during the fourth stage of labor, after the completion of pregnancy and birth. Hypotonic character of the bladder is also marked during the fourth stage of pregnancy, not when the prostaglandin levels rise, marking the onset of labor.

A nurse is conducting a presentation at a community health center about congenital malformations. The nurse describes that some common congenital malformations can occur and are recognized to be caused by multiple genetic and environmental factors. Which example would the nurse most likely cite? a) color blindness b) hemophilia c) cystic fibrosis d) spina bifida

d) spina bifida Spina bifida is a multifactorial inherited disorder thought to be due to multiple genetic and environmental factors. Cystic fibrosis is considered an autosomal recessive inherited disorder, while color blindness and hemophilia are considered X-linked inheritance disorders.

A nurse is meeting with a client who developed overdistention of the abdominal muscles during her pregnancy. Which action should the nurse prioritize to best assist this client recover from this situation? a) apply moist heat b) massage the muscles c) apply warm compresses d) suggest proper exercise

d) suggest proper exercise This client developed diastasis recti, a condition in which the abdominal muscles separate during the pregnancy, leaving part of the abdominal wall without muscular support. Exercise can improve muscle tone when this condition occurs. Application of warm compresses, application of moist heat, and massaging the muscles gently will not correct this situation.

A client in the third stage of labor has experienced placental separation and expulsion. Why is it necessary for a nurse to massage the woman's uterus briefly until it is firm? a) to reduce boggy nature of the uterus b) to lessen the chances of conducting an episiotomy c) to remove pieces left attached to uterine wall d) to constrict the uterine blood vessels

d) to constrict the uterine blood vessels The nurse must massage the client's uterus briefly after placental expulsion to constrict the uterine blood vessels and minimize the possibility of hemorrhage. Massaging the client's uterus will not lessen the chances of conducting an episiotomy. In addition, an episiotomy, if required, is conducted in the second stage of labor not the third. The client's uterus may appear boggy only in the fourth stage of labor not in the third stage. Ensuring that all sections of the placenta are present and that no piece is left attached to the uterine wall is confirmed through a placental examination after expulsion.

As part of her physical examination of a pregnant client, the nurse examines the woman's breasts. Which are healthy breast changes that indicate pregnancy? Select all that apply. a) Montgomery glands (Montgomery tubercles) become prominent b) blue streaking of veins becomes prominent c) overall breast size increases d) breasts become softer in consistency e) areolae darken f) hard, painless lumps form

e) areolae darken c) overall breast size increases b) blue streaking of veins becomes prominent a) Montgomery glands (Montgomery tubercles) become prominent Healthy breast changes that occur during pregnancy include the areolae darkening, overall breast size increasing, blue streaking of veins becoming prominent, and Montgomery glands becoming prominent. Breasts tend to have a firmer consistency during pregnancy, not softer. Hard, painless lumps indicate possible tumors, which are not normal, healthy breast changes.