Test #2 Maternal and Newborn
While observing a mother visiting her preterm son in the neonatal intensive care nursery, the nurse notes that she has not yet begun the bonding process. Which statement by the mother supports the nurse's conclusion? "It's such a tiny baby." "Do you think he'll make it?" "Why does he need to be in an incubator?" "My baby looks so much like my husband."
"It's such a tiny baby." By failing to acknowledge the infant as a person, the client indicates that she has not released her fantasy baby and accepted the real baby. Acknowledging the infant by using the word "he" denotes a relationship. Saying that the baby looks like her husband indicates that the mother has incorporated the infant into the family.
During their initial visit to the prenatal clinic a couple asks the nurse whether the woman should have an amniocentesis for genetic studies. Which factor indicates that an amniocentesis should be performed? Recent history of drug abuse Family history of genetic abnormalities A client history of more than three prior spontaneous abortions Maternal age older than 30 years at the time of the first pregnancy
Family history of genetic abnormalities One of the specific reasons for performing amniocentesis is the diagnosis of genetic problems. A recent history of drug abuse is not a reason to perform this invasive procedure. A history of more than three prior spontaneous abortions is not a reason to perform this invasive procedure. Amniocentesis is no longer performed routinely if the client is an older primigravida; a sonogram is performed first.
During a client's labor the fetal monitor reveals a fetal heart pattern that signifies uteroplacental insufficiency. What is the nurse's priority intervention? Inserting a urine retention catheter Administering oxygen by means of nasal cannula Helping the client turn to the side-lying position Encouraging the client to pant with her next contraction
Helping the client turn to the side-lying position Assisting the client to turn to the side-lying position will improve uterine blood flow, and fetal oxygenation will increase. Inserting a urine retention catheter is unnecessary; in addition, it requires a primary healthcare provider's prescription. Oxygen may be administered eventually if necessary, but this is not the first intervention. Encouraging the client to pant with her next contraction will not increase uterine blood flow or oxygen to the fetus.
A breast-feeding mother experiences redness and pain in the left breast, a temperature of 100.8° F (38.2° C), chills, and malaise. Which condition does the nurse suspect? Mastitis Engorgement Blocked milk duct Inadequate milk production
Mastitis Because of the presence of generalized symptoms, the nurse should suspect mastitis. Engorgement would involve both breasts, not one. A blocked milk duct is usually marked by swelling and pain in one area of the breast but does not have systemic symptoms. There is no indication of the volume of milk being produced.
The postpartum nurse has just received report on four clients. Which client should the nurse evaluate first? Client who vaginally delivered a 7-lb (3175 g) baby 1 hour ago Client who vaginally delivered a 9-lb (4082 g) baby 1 hour ago Client who vaginally delivered a preterm baby 4 hours ago Client who had a planned cesarean delivery of an 8-lb (3629 g) baby 2 hours ago
Client who vaginally delivered a 9-lb (4082 g) baby 1 hour ago The nurse should assess the client at risk for postpartum hemorrhage first. Uterine atony after a vaginal delivery is the main cause of postpartum hemorrhage. An overdistended uterus caused by a large fetus (9-lb; 4082 g) can result in uterine atony. Delivering a 7-lb baby (3175 g) or a preterm baby is not a risk factor. Uterine atony is minimized in a planned cesarean delivery.
A woman at 22 weeks' gestation is admitted with heavy bleeding and severe abdominal cramping. When told that no fetal heart sounds can be detected, the client says to the nurse, "We wanted this baby so badly." How should the nurse respond? "It must be difficult to lose this baby that was important to you both." "This is nature's way of dealing with babies that may have problems." "A curettage will give you a new start. I'll bet you'll get pregnant again soon." "You must be disappointed, but don't feel guilty. These things sometimes happen."
"It must be difficult to lose this baby that was important to you both." The response "It must be difficult to lose this baby that was important to you both" acknowledges the loss and the grieving process. It also encourages the expression of feelings. Suggesting that "this is nature's way" minimizes the loss and may reflect the nurse's beliefs. Predicting that another pregnancy will occur soon does not acknowledge the loss and cuts off communication. Guilt feelings were never expressed by the client.
A client in the high-risk postpartum unit has had a precipitous labor and birth. Which maternal complication should the nurse anticipate? Hypertension Hypoglycemia Chilling and shivering Bleeding and infection
Bleeding and infection Precipitate birth is associated with an increased maternal morbidity rate, because hemorrhage and infection may occur as a result of the trauma of a rapid, forceful birth in a contaminated field. Hypertension is anticipated in a client with preeclampsia. There are not enough data to indicate that this client has preeclampsia. A low blood glucose level is not expected after a precipitous birth. Chilling and shivering are common maternal responses after all types of births because of cardiovascular and vasomotor changes.
The nurse applies fetal and uterine monitors to the abdomen of a client in active labor. When the client has contractions, the nurse notes a 15 beats/min deceleration of the fetal heart rate below the baseline lasting 15 seconds. What is the next nursing action? Calling the primary healthcare provider Changing the maternal position Obtaining the maternal blood pressure Preparing the environment for an immediate birth
Changing the maternal position The fetus is responding to partial cord compression. Stimulation of the fetal sympathetic nervous system is evidenced by the fetal heart rate deceleration. It is an initial response to mild hypoxia that accompanies partial cord compression during contractions; changing the maternal position can alleviate the compression. This is a compensatory physiologic response by a healthy fetus; the nurse, not the practitioner, should intervene by alleviating cord compression. Taking the client's blood pressure delays nursing interventions to help the fetus. Variable decelerations are not indicative of the need for an immediate birth.
A client is scheduled for a sonogram at 36 weeks' gestation. Shortly before the test she tells the nurse that she is experiencing severe abdominal pain. Assessment reveals heavy vaginal bleeding, a drop in blood pressure, and an increased pulse rate. Which complication does the nurse suspect? Hydatidiform mole Vena cava syndrome Marginal placenta previa Complete abruptio placentae
Complete abruptio placentae Severe pain accompanied by bleeding at term or close to it is symptomatic of complete premature detachment of the placenta (abruptio placentae). A hydatidiform mole is diagnosed before 36 weeks' gestation; it is not accompanied by severe pain. There is no bleeding with vena cava syndrome. Bleeding caused by placenta previa should not be painful.
Several hours after delivery, a new mother expresses ambivalence regarding her infant. How will the nurse promote bonding between this mother and her newborn? Having the mother feed the infant Removing the infant from the mother's arms if it cries Positioning the infant so its head rests on the mother's shoulder Encouraging the mother to sleep for 4 to 6 hours before interacting with the infant
Having the mother feed the infant Feeding the infant promotes bonding through physical interaction, and positioning the infant in a face-to-face position facilitates eye contact. Removing the infant decreases the pair's time together. Positioning the infant on the mother's shoulder prevents the face-to-face contact that promotes bonding. It is important to have the parent and infant interact as soon as possible after birth to promote bonding.
The nurse is counseling a pregnant client with type 1 diabetes regarding medication changes as pregnancy progresses. Which medication will be needed in increased dosages during the second half of her pregnancy? Insulin Antihypertensives Pancreatic enzymes Estrogenic hormones
Insulin
A nurse is assessing a woman with a probable ruptured tubal pregnancy. What clinical manifestation requires immediate intervention? Abdominal distention Intermittent abdominal contractions Dull, continuous upper-quadrant abdominal pain Sudden onset of knifelike pain in one of the lower quadrants
Sudden onset of knifelike pain in one of the lower quadrants One symptom of sudden rupture of a fallopian tube is pain on the affected side, usually sudden, excruciating, and radiating over the lower abdomen and to the shoulder; sometimes the pain is associated with nausea, vomiting, and diarrhea. Abdominal distention is not a classic sign of a ruptured fallopian tube. There are no contractions, because the pregnancy is not uterine. The pain is exquisite, sharp (not dull) and sudden in the lower abdomen when the fallopian tube ruptures.
A nurse on the high-risk unit is caring for a client with severe preeclampsia. Which intervention is the most effective in preventing a seizure? Providing a plastic airway Controlling external stimuli Having emergency equipment available Keeping calcium gluconate at the bedside
Controlling external stimuli Reducing lights, noise, and stimulation minimizes central nervous system irritability, which can trigger a seizure. A plastic airway will not prevent a seizure. Available emergency equipment will not prevent a seizure, although oxygen and suction equipment may be useful after a seizure. Calcium gluconate is the antidote for magnesium sulfate toxicity; it does not prevent seizures.
The nurse is caring for a client who has had a spontaneous abortion. Which complication should the nurse assess this client for? Hemorrhage Dehydration Hypertension Subinvolution
Hemorrhage Hemorrhage may result if placental tissue is retained or uterine atony occurs. There is no indication that the client has been deprived of fluids. Hypotension, not hypertension, may occur with postabortion hemorrhage. Subinvolution is more likely to occur after a full-term birth.
The nurse is counseling a woman who has just been identified as having a multiple gestation. Why does the nurse consider this pregnancy high risk? Postpartum hemorrhage is an expected complication. Perinatal mortality is two to three times more likely in multiple than in single births. Optimal psychological adjustment after a multiple birth requires 6 months to 1 year. Maternal mortality is higher during the prenatal period in the setting of multiple gestation.
Perinatal mortality is two to three times more likely in multiple than in single births. Perinatal morbidity and mortality rates are higher with multiple-gestation pregnancies, because the greater metabolic demands and the possibility of malpositioning of one or more fetuses increases the risk for complications. Although postpartum hemorrhage does occur more frequently after multiple births, it is not an expected occurrence. Adjustment to a multiple gestation and birth is individual; the time needed for adjustment does not place the pregnancy at high risk. Maternal mortality during the prenatal period is not increased in the presence of a multiple gestation.
A client at 12 weeks' gestation arrives in the prenatal clinic complaining of cramping and vaginal spotting. A pelvic examination reveals that the cervix is closed. Which probable diagnosis should the nurse expect? Missed abortion Inevitable abortion Incomplete abortion Threatened abortion
Threatened abortion Because the cervix is closed, this is considered a threatened abortion. The lifeless products of conception are retained in a missed abortion. Once the cervix is dilated the abortion is inevitable. Portions of the products of conception will have to be passed for a diagnosis of incomplete abortion.
A client in the thirty-eighth week of gestation exhibits a slight increase in blood pressure. The primary healthcare provider advises her to remain in bed at home in a side-lying position. The client asks why this is important. What is the nurse's response regarding the advantage of this position? "It increases blood flow to the fetus." "It decreases intra-abdominal pressure." "It increases the mean arterial pressure." "It prevents the development of thrombosis."
"It increases blood flow to the fetus." The side-lying position decreases blood pressure and moves the gravid uterus off the great vessels of the lower abdomen, increasing venous return, improving cardiac output, and promoting kidney and placental perfusion. The side-lying position does not influence intra-abdominal pressure. While a pregnant woman is on bed rest the blood pressure decreases. The side-lying position does not prevent thrombosis; bed rest and immobility may increase the risk of thrombosis.
A client who is admitted to the high-risk unit with severe preeclampsia anxiously asks the nurse, "Will my baby be all right?" How should the nurse respond? "There is no way of telling at this time what the outcome will be." "Your baby probably will be all right. It's protected by the amniotic fluid." "If you follow your primary healthcare provider's instructions, everything will progress normally." "We'll be constantly monitoring your baby's condition. I'll let you listen to the baby's heartbeat."
"We'll be constantly monitoring your baby's condition. I'll let you listen to the baby's heartbeat." Telling the client that the baby's condition will constantly be monitored reassures the client of the well-being of the fetus at the moment and indicates that the nurses are aware of and are monitoring the fetus's status. Saying that there is no way to know the outcome does not provide the mother with any reassurance of the status of the fetus or that anything is being done to monitor the fetus. Promising that the baby will be all right provides false reassurance; amniotic fluid will not protect the fetus if the mother has a seizure. Suggesting that everything will progress normally if the client follows the primary healthcare provider's instructions provides false reassurance; following instructions does not guarantee a healthy newborn.
A client in labor at 39 weeks' gestation is told by the primary healthcare provider that she will require a cesarean delivery. The nurse reviews the client's prenatal history. What preexisting condition is the most likely reason for the cesarean birth? Gonorrhea Chlamydia Chronic hepatitis Active genital herpes
Active genital herpes Once the membranes have ruptured, the active herpes infection ascends and can infect the fetus; because herpes does not cross the placenta, a cesarean birth prevents transfer of the virus to the fetus. Gonorrhea, Chlamydia, and chronic hepatitis are not indications for a cesarean birth; treatment is pharmacologic.
A client has delivered her infant via cesarean birth. What is the most important nursing intervention to prevent thromboembolism on the client's first postpartum day? Providing oxygen therapy Administering pain medication Encouraging frequent ambulation Recommending an increase in oral fluids
Encouraging frequent ambulation Ambulation involves muscle contractions that promote an increase in circulation in the legs. During pregnancy, hypercoagulation is associated with an increase in clotting factors and fibrinogen, which increases the risk for thromboembolism. Oxygen therapy will not prevent thromboembolism. Relieving pain does not prevent thromboembolism, but pain medication may be needed to help the client tolerate ambulation. Increasing fluid intake will not prevent thromboembolism.
The nurse is caring for a client who is admitted to the birthing unit with a diagnosis of abruptio placentae. Which complication associated with a placental abruption should the nurse carefully monitor this client for? Cerebral hemorrhage Pulmonary edema Impending seizures Hypovolemic shock
Hypovolemic shock With abruptio placentae, uterine bleeding can result in massive internal hemorrhage, causing hypovolemic shock. A cerebral hemorrhage may occur with a dangerously high blood pressure; there is no information indicating the presence of a dangerously high blood pressure. Pulmonary edema may occur with severe preeclampsia or heart disease, and seizures are associated with severe preeclampsia; there is no information indicating the presence of these conditions.
A client's labor has progressed to the point where she is 6 cm dilated; however, the fetal head is not engaged. An amniotomy is performed. After this procedure, the nurse checks the fetal heart rate. What other nursing action should be performed at this time? <p>A client’s labor has progressed to the point where she is 6 cm dilated; however, the fetal head is not engaged. An amniotomy is performed. After this procedure, the nurse checks the fetal heart rate. What other nursing action should be performed at this time?</p> Inspecting the perineum Preparing for an immediate birth Measuring the maternal blood pressure Increasing the intravenous (IV) fluid rate
Inspecting the perineum After the rupture of membranes, the umbilical cord may prolapse if the fetal head does not engage immediately, and this can lead to fetal compromise. The perineal area should be inspected at this time and frequently thereafter for evidence of cord prolapse. Rupture of the membranes does not lead to precipitous birth; it is done to facilitate labor. Rupture of membranes is not associated with maternal blood pressure changes. Increasing the IV rate is appropriate if the client shows signs of dehydration; the data do not indicate this.
The nurse is caring for a client in her third trimester who is scheduled for an amniocentesis. What should the nurse do to prepare the client for this test? Instruct her to void immediately before the test. Tell her to assume the high Fowler position before the test. Encourage her to drink three glasses of water before the test. Advise her to take nothing by mouth for several hours before the test.
Instruct her to void immediately before the test. The client is instructed to void immediately before the test to help prevent injury to the bladder as the needle is introduced into the amniotic sac. The supine position with a hip roll under the right hip is the preferred position for this procedure. Telling the client to assume the high Fowler position before the test will cause the bladder to fill, making it vulnerable to injury as the needle is inserted into the amniotic sac. Encouraging the client to drink three glasses of water before the test is advised if the amniocentesis is being performed early during pregnancy. There is no reason to withhold food or fluid, because the test does not involve the gastrointestinal tract.
A 26-year-old G1 P0 client is seen in the clinic for her routine prenatal visit at 29 weeks' gestation. On examination the nurse notes that she has gained 8 lb (3.6 kg) since her last visit, 2 weeks ago; that her blood pressure is 150/90 mm Hg; and that she has 1+ proteinuria on urine dipstick. What is the most likely diagnosis for this client? Mild preeclampsia Severe preeclampsia Chronic hypertension Gestational hypertension
Mild preeclampsia Preeclampsia is hypertension that develops after 20 weeks' gestation in a previously normotensive woman. With mild preeclampsia the systolic blood pressure is below 160 mm Hg and diastolic BP is below 110 mm Hg. Proteinuria is present, but there is no evidence of organ dysfunction. Severe preeclampsia is a systolic blood pressure of greater than 160 mm Hg or diastolic blood pressure of at least 110 mm Hg and proteinuria of 5 g or more per 24-hour specimen. Chronic hypertension is hypertension that is present before the pregnancy or diagnosed before 20 weeks' gestation. Gestational hypertension is the onset of hypertension during pregnancy without other signs or symptoms of preeclampsia and without preexisting hypertension.
The nurse is providing care for parents who have experienced a stillbirth. What is the most appropriate intervention at this time? Giving a detailed explanation of what may have caused the stillbirth Providing the parents the opportunity to say goodbye to their newborn Explaining that autopsy is not recommended in the setting of a stillbirth Waiting to provide any information about follow-up care until the parents have had an opportunity to adjust to the grief
Providing the parents the opportunity to say goodbye to their newborn Parents should be given the opportunity to say goodbye to a stillborn baby. Because the parents may not think to ask to see the baby, the nurse should provide this opportunity. Giving a detailed explanation of possible causes of the stillbirth is nontherapeutic. An autopsy may be performed when there is a stillbirth. The decision is left to the parents. The procedure can be very important in answering the question "Why?" if there is a chance that the cause of death can be determined. Before the parents leave the hospital, arrangements for follow-up care should be made. This information should be provided immediately, because it can help the parents begin the grieving process. Many hospitals have a team consisting of a social worker, chaplain, and nurse that is called when a stillbirth occurs.
A 16-year-old primigravida at 32 weeks' gestation is admitted to the high-risk unit. Her blood pressure is 170/110 mm Hg and she has 4+ proteinuria. She has gained 50 lb (22.7 kg) during the pregnancy, and her face and extremities are edematous. Which complication is this client experiencing? Eclampsia Severe preeclampsia Chronic hypertension Gestational hypertension
Severe preeclampsia With severe preeclampsia, arteriolar spasms result in hypertension and decreased arterial perfusion of the kidneys. This in turn causes an alteration in the glomeruli, resulting in oliguria and proteinuria, retention of sodium and water, and edema. Eclampsia is characterized by seizures; there is no data to indicate that the client is having or has had seizures. Chronic hypertension is hypertension diagnosed before pregnancy or before 20 weeks' gestation. Hypertension that is first diagnosed during pregnancy that persists beyond the postpartum period is also considered chronic hypertension. Gestational hypertension is hypertension that first occurs during midpregnancy without proteinuria; it is definitively diagnosed when the hypertension resolves 12 weeks after delivery.
A client who has had a postpartum hemorrhage is to receive 1 unit of packed red blood cells (RBCs). The nurse manager observes a staff nurse administering the packed RBCs without wearing gloves. What does the nurse manager conclude? The client does not have an infection. The donor blood is free of bloodborne pathogens. The nurse should have worn gloves for self-protection. The nurse was skilled enough to prevent exposure to the blood.
The nurse should have worn gloves for self-protection. The Centers for Disease Control and Prevention (CDC) recommends that gloves be worn when there is the potential for contact with blood or other body fluids. Even if the client does not have an infection, gloves are always worn when exposure to blood or other body fluids is a possibility. All blood is considered potentially infectious. Nurses are required to take precautions that limit exposure; gloves must be worn.