HESI Practice Quiz OB
When explaining "postpartum blues" to a client who is 1 day postpartum, which symptoms should the nurse include in the teaching plan? (Select all that apply.) a. Mood swings. b. Panic attacks. c. Tearfulness. d. Decreased need for sleep. e. Disinterest in the infant.
a. Mood swings c. Tearfulness Correct choices are (A and C). "Postpartum blues" is a common emotional response related to the rapid decrease in placental hormones after delivery and include mood swings (A), tearfulness (C), feeling low, emotional, and fatigued. (B, D, and E) are more characteristic of postpartum depression that typically occurs 3 to 7 days later than postpartum blues.
The nurse is providing discharge teaching for a client who is 24 hours postpartum. The nurse explains to the client that her vaginal discharge will change from red to pink and then to white. The client asks, "What if I start having red bleeding after it changes?" What should the nurse instruct the client to do? a. Reduce activity level and notify the healthcare provider. b. Go to bed and assume a knee-chest position. c. Massage the uterus and go to the emergency room. d. Do not worry as this is a normal occurrence.
a. Reduce activity level and notify the healthcare provider.
The nurse is teaching care of the newborn to a group of prospective parents and describes the need for administering antibiotic ointment into the eyes of the newborn. Which infectious organism will this treatment prevent from harming the infant? a. Herpes. b. Staphylococcus. c. Gonorrhea. d. Syphilis.
c. Gonorrhea.
A newborn, whose mother is HIV positive, is scheduled for follow-up assessments. The nurse knows that the most likely presenting symptom for a pediatric client with AIDS is a. shortness of breath. b. joint pain. c. a persistent cold. d. organomegaly.
c. a persistent cold.
The nurse is calculating the estimated date of confinement (EDC) using Ngele's rule for a client whose last menstrual period started on December 1. Which date is most accurate? a. August 1. b. August 10. c. September 3. d. September 8.
d. September 8.
A woman who thinks she could be pregnant calls her neighbor, a nurse, to ask when she could use a home pregnancy test to diagnose pregnancy. Which response is appropriate? A. "A home pregnancy test can be used right after your first missed period." B. "These tests are most accurate after you have missed your second period." C. "Home pregnancy tests often give false positives and should not be trusted." D. "The test can provide accurate information when used right after ovulation."
A. "A home pregnancy test can be used right after your first missed period."
A client at 32-weeks gestation is diagnosed with preeclampsia. Which assessment finding is most indicative of an impending convulsion? A. 3+ deep tendon reflexes and hyperclonus. B. Periorbital edema, flashing lights, and aura. C. Epigastric pain in the third trimester. D. Recent decreased urinary output.
A. 3+ deep tendon reflexes and hyperclonus. Three plus deep tendon reflexes and hyperclonus (A) are indicative of an impending convulsion and require immediate attention. Epigastric pain (C) in the third trimester is indicative of HELLP Syndrome leading to impaired hepatic functioning. (B and D) are pathological changes that occur with preeclampsia.
A full term infant is transferred to the nursery from labor and delivery. Which information is most important for the nurse to receive when planning immediate care for the newborn? A. The length of labor and method of delivery B. The infant's condition at birth and treatment received C. The feeding method chosen by the patients D. The history of drugs given to the mother during labor
B. The infant's condition at birth and treatment received
A 4-week-old premature infant has been receiving epoetin alfa (Epogen) for the last three weeks. Which assessment finding indicates to the nurse that the drug is effective? A. Slowly increasing urinary output over the last week. B. Respiratory rate changes from the 40s to the 60s. C. Changes in apical heart rate from the 180s to the 140s. D. Change in indirect bilirubin from 12 mg/dl to 8 mg/dl.
C. Changes in apical heart rate from the 180s to the 140s. Epogen, given to prevent or treat anemia, stimulates erythropoietin production, resulting in an increase in RBCs. Since the body has not had to compensate for anemia with an increased heart rate, changes in heart rate from high to normal (C) is one indicator that Epogen is effective. (A) is not related to Epogen administration. Respiratory rate should decrease rather than increase (B) with Epogen administration. (D) is usually related to resolution of hyperbilirubinemia, treated with phototherapy or increased oral intake in the infant.
The nurse is performing a gestational age assessment on a full-term newborn during the first hour of transition using the Ballard (Dubowitz) scale. Based on this assessment, the nurse determines that the neonate has a maturity rating of 40-weeks. What findings should the nurse identify to determine if the neonate is small for gestational age (SGA)? (Select all that apply.) A. Admission weight of 4 pounds, 15 ounces ( 2244 grams). B. Head to heel length of 17 inches (42.5 cm). C. Frontal occipital circumference of 12.5 inches (31.25 cm). D. Skin smooth with visible veins and abundant vernix. E. Anterior plantar crease and smooth heel surfaces. F. Full flexion of all extremities in resting supine position.
A. Admission weight of 4 pounds, 15 ounces ( 2244 grams). B. Head to heel length of 17 inches (42.5 cm). C. Frontal occipital circumference of 12.5 inches (31.25 cm). Correct choices are (A, B, and C). The normal full-term, appropriate for gestational age (AGA) newborn should fall between the measurement ranges of weight, 6-9 pounds (2700-4000 grams); length, 19-21 inches (48-53 cm); FOC, 13-14 inches (33-35 cm). This neonate's parameters (A, B, and C) plot below the 10% percentile, which indicate that the infant is SGA. (D and E) are criteria for a pre-term neonate. (F) is a criteria for physical maturity score (full-term, 40-weeks) on the Ballard (Dubowitz) scale.
A client at 28-weeks gestation calls the antepartal clinic and states that she is experiencing a small amount of vaginal bleeding which she describes as bright red. She further states that she is not experiencing any uterine contractions or abdominal pain. What instruction should the nurse provide? A. Come to the clinic today for an ultrasound. B. Go immediately to the emergency room. C. Lie on your left side for about one hour and see if the bleeding stops. D. Bring a urine specimen to the lab tomorrow to determine if you have a urinary tract infection.
A. Come to the clinic today for an ultrasound. Third trimester painless bleeding is characteristic of a placenta previa. Bright red bleeding may be intermittent, occur in gushes, or be continuous. Rarely is the first incidence life-threatening, nor cause for hypovolemic shock. Diagnosis is confirmed by transabdominal ultrasound (A). Bleeding that has a sudden onset and is accompanied by intense uterine pain indicates abruptio placenta, which IS life-threatening to the mother and fetus--then (B) would be appropriate. (C) does not take the symptoms seriously. The woman is not describing symptoms of a UTI (D).
The nurse is caring for a woman with a previously diagnosed heart disease who is in the second stage of labor. Which assessment findings are of greatest concern? A. Edema, basilar rales, and an irregular pulse. B. Increased urinary output and tachycardia. C. Shortness of breath, bradycardia, and hypertension. D. Regular heart rate and hypertension.
A. Edema, basilar rales, and an irregular pulse. Edema, basilar rales, and an irregular pulse (A) indicate cardiac decompensation and require immediate intervention. Though (B, C, and D) are cardiac symptoms, they require less emergency intervention than (A).
1. The healthcare provider prescribes terbutaline (Brethine) for a client in preterm labor. Before initiating this prescription, it is most important for the nurse to assess the client for which condition? A. Gestational diabetes. B. Elevated blood pressure. C. Urinary tract infection. D. Swelling in lower extremities.
A. Gestational diabetes. The nurse should evaluate the client for gestational diabetes (A) because terbutaline (Brethine) increases blood glucose levels. (B) could be related to the client being in preterm labor, however, terbutaline (Brethine) can cause a decrease in blood pressure. (C) can cause uterine irritability, which can result in preterm labor that should be treated by first resolving the infection rather than by administering a tocolytic agent such as terbutaline (Brethine). (D) is a common pregnancy complaint.
Which action should the nurse implement when preparing to measure the fundal height of a pregnant client? A. Have the client empty her bladder. B. Request the client lie on her left side. C. Perform Leopold's maneuvers first. D. Give the client some cold juice to drink.
A. Have the client empty her bladder. To accurately measure the fundal height, the bladder must be empty (A) to avoid elevation of the uterus. Fundal height is not measured with the client lying on her side (B). Leopold's maneuvers are performed to assess fetal position and the expected location of the point of maximal impulse (PMI) for fetal heart rate (C). Cold juice (D) does not affect the fundal height measurement, but may be given to arouse the fetus if the fetus appears to be sleeping during a non-stress test.
A new mother asks the nurse, "How do I know that my daughter is getting enough breast milk?" Which explanation will the nurse provide? A, "Weigh the baby daily, and if she is gaining weight, she is eating enough." B. "Your milk is sufficient if the baby is voiding pale straw-colored urine 6 to 10 times a day." C, "Offer the baby extra bottle milk after her feeding, and see if she is still hungry." D. "If you're concerned, you might consider bottle feeding so that you can monitor her intake."'
B. "Your milk is sufficient if the baby is voiding pale straw-colored urine 6 to 10 times a day." The urine will be dilute (straw-colored) and frequent (>6 to 10 times/day) (B), if the infant is adequately hydrated. Although a weight gain (A) of 30 grams/day is indicative of adequate nutrition, most home scales do not measure this accurately and this suggestion is likely to make the mother very anxious! (C) causes nipple confusion and diminishes the mother's milk production. (D) does not answer the client's question.
A client who is attending antepartum classes asks the nurse why her healthcare provider has prescribed iron tablets. The nurse's response is based on what knowledge? A. Supplementary iron is more efficiently utilized during pregnancy. B. It is difficult to consume 18 mg of additional iron by diet alone. C. Iron absorption is decreased in the GI tract during pregnancy. D. Iron is needed to prevent megaloblastic anemia in the last trimester.
B. It is difficult to consume 18 mg of additional iron by diet alone. Consuming enough iron-containing foods to facilitate adequate fetal storage of iron and to meet the demands of pregnancy is difficult (B) so iron supplements are often recommended. Dietary iron (A) is just as "good" as iron in tablet form. Iron absorption occurs readily during pregnancy, and is not decreased within the GI tract (C). Megaloblastic anemia (D) is caused by folic acid deficiency.
A 30-year-old gravida 2, para 1 client is admitted to the hospital at 26-weeks gestation in preterm labor. She is started on an IV solution of terbutaline (Brethine). Which assessment is the highest priority for the nurse to monitor during the administration of this drug? A. Maternal blood pressure and respirations. B. Maternal and fetal heart rates. C. Hourly urinary output. D.Deep tendon reflexes.
B. Maternal and fetal heart rates. Monitoring maternal and fetal heart rates (B) is most important when terbutaline is being administered. Terbutaline acts as a sympathomimetic agent that stimulates both beta 1 receptors (causing tachycardia, a side effect of the drug) and stimulation of beta 2 receptors (causing uterine relaxation, a desired effect of the drug). While monitoring (A, C, and D) is helpful, these do not have the priority of monitoring (B) when a beta-adrenergic agonists is administered.
A 30-year-old gravida 2, para 1 client is admitted to the hospital at 26-weeks gestation in preterm labor. She is started on an IV solution of terbutaline (Brethine). Which assessment is the highest priority for the nurse to monitor during the administration of this drug? A. Maternal blood pressure and respirations. B. Maternal and fetal heart rates. C. Hourly urinary output. D. Deep tendon reflexes.
B. Maternal and fetal heart rates. Monitoring maternal and fetal heart rates (B) is most important when terbutaline is being administered. Terbutaline acts as a sympathomimetic agent that stimulates both beta 1 receptors (causing tachycardia, a side effect of the drug) and stimulation of beta 2 receptors (causing uterine relaxation, a desired effect of the drug). While monitoring (A, C, and D) is helpful, these do not have the priority of monitoring (B) when a beta-adrenergic agonists is administered.
The nurse identifies crepitus when examining the chest of a newborn who was delivered vaginally. Which further assessment should the nurse perform? A. Elicit a positive scarf sign on the affected side. B. Observe for an asymmetrical Moro (startle) reflex. C. Watch for swelling of fingers on the affected side. D.Note paralysis of affected extremity and muscles
B. Observe for an asymmetrical Moro (startle) reflex. Attachment/bonding theory indicates that most mothers will demonstrate behaviors described in (B) during the first visit with the newborn, which may be at delivery or later. After the first visit, the mother may exhibit greater affection such as eagerly reaching, hugging, etc. (A, C, and D).
The nurse should explain to a 30-year-old gravid client that alpha fetoprotein testing is recommended for which purpose? A. Detect cardiovascular disorders. B. Screen for neural tube defects. C. Monitor the placental functioning. D. Assess for maternal pre-eclampsia.
B. Screen for neural tube defects. Alpha-fetoprotein (AFP) is a screening test used in pregnancy. Elevated AFP may indicate an increased rish of neural tube defects (B) such as anencephaly and spinal bifida. AFP does not apply in (A, C, or D).
A newborn infant is brought to the nursery from the birthing suite. The nurse notices that the infant is breathing satisfactorily but appears dusky. What action should the nurse take first? A. Notify the pediatrician immediately. B. Suction the infant's nares, then the oral cavity. C. Check the infant's oxygen saturation rate. D. Position the infant on the right side.
C. Check the infant's oxygen saturation rate. When possible, the nurse should first obtain measurable objective data; an oxygen saturation rate provides such information (C). The pediatrician should be notified if the oxygen saturation rate is below 90% (A). The infant is not demonstrating signs of an obstructed airway, but if suctioning was required, the oral cavity should be suctioned first to prevent the infant from aspirating pharyngeal secretions (B). (D) facilitates drainage from the mouth and promotes emptying into the small intestine, but at this time, this intervention is not as high a priority as (C).
A client with no prenatal care arrives at the labor unit screaming, "The baby is coming!" The nurse performs a vaginal examination that reveals the cervix is 3 centimeters dilated and 75% effaced. What additional information is most important for the nurse to obtain? A. Gravidity and parity. B. Time and amount of last oral intake. C. Date of last normal menstrual period. D.Frequency and intensity of contractions
C. Date of last normal menstrual period. Evaluating the gestation of the pregnancy (C) takes priority. If the fetus is preterm and the fetal heart pattern is reassuring, the healthcare provider may attempt to prolong the pregnancy and administer corticosteroids to mature the lungs of the fetus. (A, B, and D) are all important to evaluate and incorporate into the plan of care, but establishing gestation takes priority.
The nurse is teaching breastfeeding to prospective parents in a childbirth education class. Which instruction should the nurse include as content in the class? a. Begin as soon as your baby is born to establish a four-hour feeding schedule. b. Resting helps with milk production. Ask that your baby be fed at night in the nursery. c. Feed your baby every 2 to 3 hours or on demand, whichever comes first d. Do not allow your baby to nurse any longer than the prescribed number of minutes
C. Feed your baby every 2 to 3 hours or on demand, whichever comes first Breastfeeding infants should be kept in the room with the mother and fed every 2 to 3 hours or on demand--whichever comes first (C). Rigid scheduling (A) can be detrimental to breastfeeding and impede milk production. While (B) does promote milk production, not feeding at night will decrease the amount of milk produced. The infant should be allowed to decide when to stop breastfeeding rather than breaking suction and pulling the infant off the breast (D) after a set number of minutes since the infant tells the breast how much milk to produce by sucking at the breast.
The nurse assesses a client admitted to the labor and delivery unit and obtains the following data: dark red vaginal bleeding, uterus slightly tense between contractions, BP 110/68, FHR 110 beats/minute, cervix 1 cm dilated and uneffaced. Based on these assessment findings, what intervention should the nurse implement? A, Insert an internal fetal monitor. B, Assess for cervical changes q1h. C. Monitor bleeding from IV sites. D. Perform Leopold's maneuvers.
C. Monitor bleeding from IV sites. Monitoring bleeding from peripheral sites (C) is the priority intervention. This client is presenting with signs of placental abruption. Disseminated intravascular coagulation (DIC) is a complication of placental abruptio, characterized by abnormal bleeding. Invasive vaginal procedures (A and B) or (D) can increase the abruption and bleeding, so these interventions are contraindicated.
A client is admitted with the diagnosis of total placenta previa. Which finding is most important for the nurse to report to the healthcare provider immediately? A. Heart rate of 100 beats/minute. B. Variable fetal heart rate. C. Onset of uterine contractions. D. Burning on urination.
C. Onset of uterine contractions. Total (complete) placenta previa involves the placenta covering the entire cervical os (opening). The onset of uterine contractions places the client at risk for dilation and placental separation, which causes painless hemorrhaging. Although (A, B, and C) should be reported, the risk of hemorrhage is the priority.
A couple, concerned because the woman has not been able to conceive, is referred to a healthcare provider for a fertility workup and a hysterosalpingography is scheduled. Which complaint would indicate to the nurse that the woman's fallopian tubes are patent? A. Back pain. B. Abdominal pain. C. Shoulder pain. D. Leg cramps.
C. Shoulder pain. If the tubes are patent (open), pain is referred to the shoulder from a subdiaphragmatic collection of peritoneal dye/gas (C). (B) could be caused from uterine cramping, but might also be indicative of gas/dye collecting in the uterus due to occluded tubes. It should be further evaluated; it would not be normal after hysterosalpingography. (A and D) are not related to the procedure.
The nurse is preparing a client with a term pregnancy who is in active labor for an amniotomy. What equipment should the nurse have available at the client's bedside? (SATA) A. Litmus paper B. Fetal scalp electrode C. A sterile glove D. An amnihook E. Sterile vaginal speculum F. Lubricant
C. Sterile glove D. Amnihook F. Lubricant
The nurse should encourage the laboring client to begin pushing when... A. there is only anterior or posterior lip of cervix left B. the client describes the need to have a bowel movement C. the cervix is completely dilated D. the cervix is completely effaced
C. the cervix is completely dilated
A client at 32-weeks' gestation is hospitalized with severe pregnancy-induced hypertension (PIH), and magnesium sulfate is prescribed to control the symptoms. Which assessment finding would indicate that therapeutic drug level has been achieved? A.4+ reflexes. B.Urinary output of 50 ml per hour. C.A decrease in respiratory rate from 24 to 16. D.A decreased body temperature.
C.A decrease in respiratory rate from 24 to 16. Magnesium sulfate, a CNS depressant, helps prevent seizures. A decreased respiratory rate (C) indicates that the drug is effective. (Respiratory rate below 12 indicates toxic effects.) (A) indicates high CNS irritability. Urinary output must be monitored when administering magnesium sulfate and should be at least 30 ml per hour. (B) indicates that the magnesium sulfate is not at a toxic level but does not indicate that a therapeutic level has been achieved. (D) is not specifically related to magnesium sulfate. (The therapeutic level of magnesium sulfate for a PIH client is 4.8 to 9.6 mg/dl.)
A 24-hour-old newborn has a pink papular rash with vesicles superimposed on the thorax, back, and abdomen. What action should the nurse implement? A.Notify the healthcare provider. B.Move the newborn to an isolation nursery. C.Document the finding in the infant's record. D.Obtain a culture of the vesicles.
C.Document the finding in the infant's record. Erythema toxicum (or erythema neonatorum) is a newborn rash that is commonly referred to as "flea bites," but is a normal finding that is documented in the infant's record (C), and requires no further action (A, B, and D).
A 30-year-old multiparous woman who has a 3-year-old boy and an newborn girl tells the nurse, "My son is so jealous of my daughter, I don't know how I'll ever manage both children when I get home." How should the nurse respond? A. "Tell the older child that he is a big boy now and should love his new sister." B. "Ask friends and relatives not to bring gifts to the older sibling because you do not want to spoil him." C. "Let the older child stay with his grandparents for the first six weeks to allow him to adjust to the newborn." D. "Regression in behaviors in the older child is a typical reaction so he needs attention at this time."
D. "Regression in behaviors in the older child is a typical reaction so he needs attention at this time."
A new mother is afraid to touch her baby's head for fear of hurting the "large soft spot." Which explanation should the nurse give to this anxious client? A. "Some care is required when touching the large soft area on top of your baby's head until the bones fuse together." B. "That's just an 'old wives' tale' so don't worry, you can't harm your baby's head by touching the soft spot." C. "The soft spot will disappear within 6 weeks and is very unlikely to cause any problems for your baby." D. "There's a strong, tough membrane there to protect the baby so you need not be afraid to wash or comb his/her hair."
D. "There's a strong, tough membrane there to protect the baby so you need not be afraid to wash or comb his/her hair." (D) provides correct information and attempts to alleviate anxiety related to knowledge deficit. The anterior fontanel or "large soft spot" has a strong epidermal membrane present, which can be touched (A). (B) dismisses the client's concerns. The anterior fontanel normally closes at 12 to 18 months of age, not 6 weeks (C). The posterior fontanel closes at 8 to 12 weeks of age.
The nurse is preparing to give an enema to a laboring client. Which client requires the most caution when carrying out this procedure? A. A gravida 6, para 5 who is 38 years of age and in early labor. B. A 37- week primigravida who presents at 100% effacement, 3 cm cervical dilation, and a -1 station. C. A gravida 2, para 1 who is at 1cm cervical dilution and a 0 station admitted for induction of labor due to post dates. D. A 40 week primigravida who is 6cm cervical dilation and the presenting part is not engaged.
D. A 40 week primigravida who is 6cm cervical dilation and the presenting part is not engaged. When the presenting part is ballottable (D), it is floating out of the pelvis. In such a situation, the cord can descend before the fetus causing a prolapsed cord, which is an emergency situation.
A primigravida client who is 5 cm dilated, 90% effaced, and at 0 station is requesting an epidural for pain relief. Which assessment finding is most important for the nurse to report to the healthcare provider? A. Cervical dilation of 5 cm with 90% effacement. B. White blood cell count of 12,000/mm3. C. Hemoglobin of 12 mg/dl and hematocrit of 38%. D. A platelet count of 67,000/mm3.
D. A platelet count of 67,000/mm3. Thrombocytopenia (low platelet count) (D) should be reported to the healthcare provider because it places the client at risk for bleeding when an epidural is administered. (A, B, and C) are within the normal parameters for a client in active labor and is not contraindicated for the placement of an epidural.
1. An off-duty nurse finds a woman in a supermarket parking lot delivering an infant while her husband is screaming for someone to help his wife. Which intervention has the highest priority? A. Use a thread to tie off the umbilical cord. B. Provide as much privacy as possible for the woman. C. Reassure the husband and try to keep him calm. D. Put the newborn to breast.
D. Put the newborn to breast. Putting the newborn to breast (D) will help contract the uterus and prevent a postpartum hemorrhage--this intervention has the highest priority. It is not necessary to tie off the umbilical cord (A), the infant can be transported attached to the placenta. Providing privacy (B) is an important psychosocial need, but does not have the priority of (D). Although the husband is an important part of family-centered care, he is not the most important concern at this time (C).
A woman who had a miscarriage 6 months ago becomes pregnant. Which instruction is most important for the nurse to provide this client? A. Elevate lower legs while resting. B. Increase caloric intake by 200 to 300 calories per day. C. Increase water intake to 8 full glasses per day. D. Take prescribed multivitamin and mineral supplements.
D. Take prescribed multivitamin and mineral supplements. A client who has had a spontaneous abortion or still birth in the last 1 years should take multivitamin and mineral supplements (D) and maintain a balanced diet because the previous pregnancy may have left her nutritionally depleted. (A, B, and C) are sound instructions to provide any pregnant client, but do not have the priority of (D) for this particular client who had a miscarriage 6 months ago.
While breastfeeding, a new mother strokes the top of her baby's head and asks the nurse about the baby's swollen scalp. The nurse responds that the swelling is caput succedaneum. Which additional information should the nurse provide this new mother? A. The infant should be positioned to reduce the swelling. B. The swelling is a subperiosteal collection of blood. C. The pediatrician will aspirate the blood if it gets larger. D. The scalp edema will subside in a few days after birth.
D. The scalp edema will subside in a few days after birth. Caput succedaneum is edema of the fetal scalp that crosses over the suture lines and is caused by pressure on the fetal head against the cervix during labor; it subside in a few days after birth without treatment (D). (B) describes a cephalohematoma, a subperiosteal collection of blood that does not cross the suture lines and is a common benign birth injury. (A and C) are not necessary for caput or cephalohematoma.
A couple has been trying to conceive for nine months without success. Which information obtained from the clients is most likely to have an impact on the couple's ability to conceive a child? A. Exercise regimen of both partners includes running four miles each morning. B. History of having sexual intercourse 2 to 3 times per week. C. The woman's menstrual period occurs every 35 days. D. They use lubricants with each sexual encounter to decrease friction.
D. They use lubricants with each sexual encounter to decrease friction. The use of lubricants (D) has the potential to affect fertility because some lubricants interfere with sperm motility. While excessive heat can affect sperm production, bicycling, rather than running (A) is more likely to concentrate heat in the groin area. While having intercourse too frequently has been implicated as a cause for decreased numbers of sperm, 2 to 3 times per week (B) is not considered excessive. (C) should not affect fertility.
A client who gave birth to a healthy 8 pound infant 3 hours ago is admitted to the postpartum unit. Which nursing plan is best in assisting this mother to bond with her newborn infant? A. Encourage the mother to provide total care for her infant. B ,Provide privacy so the mother can develop a relationship with the infant. C. Encourage the father to provide most of the infant's care during hospitalization. D.Meet the mother's physical needs and demonstrate warmth toward the infant.
D.Meet the mother's physical needs and demonstrate warmth toward the infant. It is most important It is most important to meet the mother's requirement for attention to her needs so that she can begin infant care-taking (D). Nurse theorist Reva Rubin describes the initial postpartal period as the "taking-in phase," which is characterized by maternal reliance on others to satisfy the needs for comfort, rest, nourishment, and closeness to families and the newborn. (A) could impede development of maternal bonding. (B) is important but not the priority. (C) might encourage paternal bonding, but does not specifically encourage maternal bonding.
Just after delivery, a new mother tells the nurse, "I was unsuccessful breastfeeding my first child, but I would like to try with this baby." Which intervention is best for the nurse to implement first? A. Assess the husband's feelings about his wife's decision to breastfeed their baby. B. Ask the client to describe why she was unsuccessful with breastfeeding her last child. C. Encourage the client to develop a positive attitude about breastfeeding to help ensure success. D. Provide assistance to the mother to begin breastfeeding as soon as possible after delivery.
D.Provide assistance to the mother to begin breastfeeding as soon as possible after delivery. Infants respond to breastfeeding best when feeding is initiated in the active phase soon after delivery (D). (A and B) might provide interesting data, but gathering this information is not as important as providing support and instructions to the new mother. While (C) is also true, this response by the nurse might seem judgmental to a new mother.
A client with gestational hypertension is in active labor and receiving an infusion of magnesium sulfate. Which drug should the nurse have available for signs of potential toxicity? a. Oxytocin (PItocin). b. Calcium gluconate. c. Terbutaline (Brethine). d. Naloxone (Narcan).
b. Calcium gluconate.
The total bilirubin level of a 36-hour, breastfeeding newborn is 14 mg/dl. Based on this finding, which intervention should the nurse implement? a. Provide phototherapy for 30 minutes q8h. b. Feed the newborn sterile water hourly. c. Encourage the mother to breastfeed frequently. d. Assess the newborn's blood glucose level.
c. Encourage the mother to breastfeed frequently. The normal total bilirubin level is 6 to 12 mg/dl after Day 1 of life. This infant's bilirubin is beginning to climb and the infant should be monitored to prevent further complications. Breast milk provides calories and enhances GI motility, which will assist the bowel in eliminating bilirubin (C). (A) is not indicated at this level. (B) would limit caloric intake, which is essential in preventing jaundice. (D) is not related to bilirubin levels.
A client at 30-weeks gestation, complaining of pressure over the pubic area, is admitted for observation. She is contracting irregularly and demonstrates underlying uterine irritability. Vaginal examination reveals that her cervix is closed, thick, and high. Based on these data, which intervention should the nurse implement first? a. Provide oral hydration. b. Have a complete blood count (CBC) drawn. c. Obtain a specimen for urine analysis. d. Place the client on strict bedrest.
c. Obtain a specimen for urine analysis. Obtaining a urine analysis (C) should be done first because preterm clients with uterine irritability and contractions are often suffering from a urinary tract infection, and this should be ruled out first. (A) is important, but gathering objective data through a urine analysis has a higher priority. (B) would be indicated if the client's temperature was elevated. (D) is indicated only if the client is in preterm labor which would be determined by vaginal examination
Twenty minutes after a continuous epidural anesthetic is administered, a laboring client's blood pressure drops from 120/80 to 90/60. What action will the nurse take? a. Notify the healthcare provider or anesthesiologist immediately. b. Continue to assess the blood pressure q5 minutes. c. Place the woman in a lateral position. d. Turn off the continuous epidural.
c. Place the woman in a lateral position. The nurse should immediately turn the woman to a lateral position (C), place a pillow or wedge under the right hip to deflect the uterus, increase the rate of the main line IV infusion, and administer oxygen by face mask at 10-12 L/min. If the blood pressure remains low, especially if it further decreases, the anesthesiologist/healthcare provider should be notified immediately (A). Continued assessment of (B), without taking any further action would constitute malpractice. (D) may also be warranted, but such action is based on hospital protocol.
When assessing a client who is at 12-weeks gestation, the nurse recommends that she and her husband consider attending childbirth preparation classes. When is the best time for the couple to attend these classes? a.At 16-weeks gestation. b.At 20-weeks gestation. c.At 24-weeks gestation. d.At 30-weeks gestation.
d.At 30-weeks gestation. D) is closest to the time parents would be ready for such classes. Learning is facilitated by an interested pupil! The couple is most interested in childbirth toward the end of the pregnancy when they are psychologically ready for the termination of the pregnancy, and the birth of their child is an immediate concern. (A, B, and C) are not the best times during a pregnancy for the couple to attend childbirth education classes--they will have other teaching needs.
Which nursing intervention would be most helpful in relieving postpartum uterine contractions or "afterpains"? A. Lying prone with a pillow on the abdomen B. Using a breast pump C. Massaging the abdomen D. Giving oxytocin medication
A. Lying prone with a pillow on the abdomen Lying prone keeps the funds contracted and is especially useful with multiparae, who commonly experience afterpains due to lack of uterine tone. B and D stimulate uterine contractions. C may contract the uterus temporarily then encourage more afterpains later
The nurse is providing discharge teaching for a client who is 24 hours postpartum. The nurse explains to the client that her vaginal discharge will change from red to pink and then to white. The client asks, "What if I start having red bleeding after it changes?" What should the nurse instruct the client to do? A. Reduce activity level and notify the healthcare provider. B. Go to bed and assume a knee-chest position. C. Massage the uterus and go to the emergency room. D. Do not worry as this is a normal occurrence.
A. Reduce activity level and notify the healthcare provider. 1. Lochia should progress in stages from rubra (red) to serosa (pinkish) to alba (whitish), and not return to red. The return to rubra usually indicates subinvolution or infection. If such a sign occurs, the mother should notify the clinic/healthcare provider and reduce her activity to conserve energy (A). Going to bed, or resting might be helpful, but (B) is not indicated. (C) would be an over-reaction and the uterus might not be palpable at that time. This is not a normal occurrence (D).
A multigravida client at 41-weeks gestation presents in the labor and delivery unit after a non-stress test indicated that the fetus is experiencing some difficulties in utero. Which diagnostic test should the nurse prepare the client for additional information about fetal status? A. Biophysical profile (BPP). B. Ultrasound for fetal anomalies. C.Maternal serum alpha-fetoprotein (AF) screening. D. Percutaneous umbilical blood sampling (PUBS).
A. Biophysical profile (BPP). BPP (A) provides data regarding fetal risk surveillance by examining 5 areas: fetal breathing movements, fetal movements, amniotic fluid volume, and fetal tone and heart rate. The client's gestation has progressed past the estimated date of confinement, so the major concern is fetal well-being related to an aging placenta, not screening for fetal anomalies (B). Maternal serum AF screening is generally checked between 15 and 22 weeks to detect neural tube defects (C). Although PUBS is performed to determine a number of at-risk fetal conditions, the BPP determines current fetal risk (D).
A 42-week gestational client is receiving an intravenous infusion of oxytocin (Pitocin) to augment early labor. The nurse should discontinue the oxytocin infusion for which pattern of contractions? A. Transition labor with contractions every 2 minutes, eating 90 seconds each. B. Early labor with contractions every 5 minutes, lasting 40 seconds each. C. Active labor with contractions every 31 minutes, lasting 60 seconds each. D. Active labor with contractions every 2 to 3 minutes, lasting 70 to 80 seconds each.
A. Transition labor with contractions every 2 minutes, eating 90 seconds each. When oxytocin causes uterine hyper stimulation as evidence by inadequate resting time between contractions, the oxytocin infusion should be discontinued because placental perfusion is impeded.
Twenty-four hours after admission to the newborn nursery, a full-term male infant develops localized edema on the right side of his head. The nurse knows that, in the newborn, an accumulation of blood between the periosteum and skull which does not cross the suture line is a newborn variation known as A. a cephalhematoma, caused by forceps trauma and may last up to 8 weeks. B. a subarachnoid hematoma, which requires immediate drainage to prevent further complications. C. molding, caused by pressure during labor and will disappear within 2 to 3 days. D. a subdural hematoma which can result in lifelong damage.
A. a cephalhematoma, caused by forceps trauma and may last up to 8 weeks. Cephalhematoma (A), a slight abnormal variation of the newborn, usually arises within the first 24 hours after delivery. Trauma from delivery causes capillary bleeding between the periosteum and the skull. (C) is a cranial distortion lasting 5 to 7 days and is caused by pressure on the cranium during vaginal delivery--it is a normal finding, or a common variation of the newborn. (B and D) both involve intracranial bleeding, and could not be detected by physical assessment alone.
A woman who gave birth 48 hours ago is bottle-feeding her infant. During assessment, the nurse determines that both breasts are swollen, warm, and tender upon palpation. What action should the nurse take? A.Apply cold compresses to both breasts for comfort. B. Instruct the client run warm water on her breasts. C. Wear a loose-fitting bra to prevent nipple irritation. D,Express small amounts of milk to relieve pressure.
A.Apply cold compresses to both breasts for comfort. The client is experiencing engorgement even though she is bottle-feeding her infant, and cold compresses (A) may help reduce discomfort. Lactation begins about the third day after delivery, so the mother should avoid any breast stimulation, such as (B or D), which further stimulates milk production. To aid in suppressing lactation, a well-fitting bra, not (C),
A client who has an autosomal dominant inherited disorder is exploring family planning options and the risk of transmission of the disorder to an infant. There nurse's response should be based on what information? A. Males inherit the disorder with a great frequency than females. B. Each pregnancy carries a 50% change of inheriting the disorder. C. The disorder occurs in 25% of pregnancies. D. All children will be carriers of the disorder.
B. Each pregnancy carries a 50% change of inheriting the disorder.
A 35-year-old primigravida client with severe preeclampsia is receiving magnesium sulfate via continuous IV infusion. Which assessment data would indicate to the nurse that the client is experiencing magnesium sulfate toxicity? A. Deep tendon reflexes 2+. B. Blood pressure 140/90. C. Respiratory rate 18/minute. D. Urine output 90 ml/4 hours.
B. Blood pressure 140/90. Urine outputs of less than 100 ml/4 hours (D), absent DTRs, and a respiratory rate of less than 12 breaths/minute are cardinal signs of magnesium sulfate toxicity. (A, B, and C) do not indicate a magnesium sulfate toxicity.
Which maternal behavior is the nurse most likely to see when a new mother receives her infant for the first time? A. She eagerly reaches for the infant, undresses the infant, and examines the infant completely. B. Her arms and hands receive the infant and she then traces the infant's profile with her fingertips. C. Her arms and hands receive the infant and she then cuddles the infant to her own body. D. She eagerly reaches for the infant and then holds the infant close to her own body.
B. Her arms and hands receive the infant and she then traces the infant's profile with her fingertips. Attachment/bonding theory indicates that most mothers will demonstrate behaviors described in (B) during the first visit with the newborn, which may be at delivery or later. After the first visit, the mother may exhibit greater affection such as eagerly reaching, hugging, etc. (A, C, and D).
A primigravida at 40-weeks gestation is receiving oxytocin (Pitocin) to augment labor. Which adverse effect should the nurse monitor for during the infusion of Pitocin? A. Dehydration. B. Hyperstimulation. C. Galactorrhea. D. Fetal tachycardia.
B. Hyperstimulation. 1. Pitocin causes the uterine myofibril to contract, so unless the infusion is closely monitored, the client is at risk for hyperstimulation (B) which can lead to tetanic contractions, uterine rupture, and fetal distress or demise. Dehydration (A) and galactorrhea (C) are not adverse effects associated with the administration of Pitocin. Fetal tachycardia (D) is an initial response to any stressor, including an increase in maternal temperature or intrauterine infection, but fetal decelerations indicate distress following tetanic contractions.
A mother who is breastfeeding her baby receives instructions from the nurse. Which instruction is most effective to prevent nipple soreness? A. Wear a cotton bra. B. Increase nursing time gradually. C. Correctly place the infant on the breast. D. Manually express a small amount of milk before nursing.
C. Correctly place the infant on the breast.
1. A client at 32-weeks gestation is diagnosed with preeclampsia. Which assessment finding is most indicative of an impending convulsion? A. 3+ deep tendon reflexes. B. Periorbital edema. C. Epigastric pain. D. Decreased urine output.
C. Epigastric pain. Epigastric pain (C) is indicative of an edematous liver or pancreas which is an early warning sign of an impending convulsion (eclampsia) and requires immediate attention. (A, B and D) are pathological changes that occur with preeclampsia, but (C) is often an early indicator of an impending seizure.
The nurse is counseling a woman who wants to become pregnant. The woman tells the nurse that she has a 36-day menstrual cycle and the first day of her last menstrual period was January 8. The nurse correctly calculates that the woman's next fertile period will be A. January 14-15. B. January 22-23. C. January 30-31. D. February 6-7.
C. January 30-31. This woman can expect her next period to begin 36 days from the first day of her last menstrual period--the cycle begins at the first day of the cycle and continues to the first day of the next cycle. Her next period would, therefore, begin on February 13. Ovulation occurs 14 days before the first day of the menstrual period. Therefore, ovulation for this woman would occur January 31 (C).
A client who is in the second trimester of pregnancy tells the nurse that she wants to use herbal therapy. Which response is best for the nurse to provide? A. "Herbs are a cornerstone of good health to include in your treatment." B. "Touch is also therapeutic in reliving discomfort and anxiety." C. "Your healthcare provider should direct treatment options for herbal therapy." D. " It is important that you want to take part in your care."
D. " It is important that you want to take part in your care."
A client at 32-weeks gestation comes to the prenatal clinic with complaints of pedal edema, dyspnea, fatigue, and a moist cough. Which question is most important for the nurse to ask this client? A. "Which symptom did you experience first?" B. "Are you eating large amounts of salty foods?" C. "Have you visited a foreign country recently?" D. "Do you have a history of rheumatic fever?"
D. "Do you have a history of rheumatic fever?" Clients with a history of rheumatic fever (D) may develop mitral valve prolapse, which increases the risk for cardiac decompensation due to the increased blood volume that occurs during pregnancy, so obtaining information about this client's health history is a priority. (A) is not important. Salty foods (B) sometimes cause edema, but this client is experiencing additional cardiac symptoms. (C) assesses for possible exposure to microorganisms, but these symptoms are more indicative of a cardiovascular etiology.
One hour after giving birth to an 8-pound infant, a client's lochia rubra has increased from small to large and her fundus is boggy despite massage. The client's pulse is 84 beats/minute and blood pressure is 156/96. The healthcare provider prescribes Methergine 0.2 mg IM X 1. What action should the nurse take immediately? A. Give the medication as prescribed and monitor for efficacy. B. Encourage the client to breastfeed rather than bottle feed. C. Have the client empty her bladder and massage the fundus. D. Call the healthcare provider to question the prescription.
D. Call the healthcare provider to question the prescription. Methergine is contraindicated for clients with elevated blood pressure, so the nurse should contact the healthcare provider and question the prescription (D). (A) compromises patient safety. While (B) releases endogenous oxytocin, and (C) promotes uterine contraction, questioning the administration of Methergine is a higher priority because it concerns medication safety.
A multigravida client arrives at the labor and delivery unit and tell the nurse that her "bag of water" has broken. The nurse identifies the presence of meconium fluid on the perineum and determines the fetal heart rate is between 140 to 150 beats/minute. What action should the nurse implement next? a. Complete a sterile vaginal exam. b. Take maternal temperature every 2 hours. c. Prepare for an immediate cesarean birth. Obtain sterile suction equipment
a. Complete a sterile vaginal exam. A vaginal exam (A) should be performed after the rupture of membranes to determine the presence of a prolapsed cord. (B and D) can be implemented after the completion of (A). (C) is not indicated at this time since the fetal heart rate is within normal limits.
A healthcare provider informs the charge nurse of a labor and delivery unit that a client is coming to the unit with suspected abruptio placentae. What findings should the charge nurse expect the client to demonstrate? (Select all that apply.) a. Dark, red vaginal bleeding. b. Lower back pain. c. Premature rupture of membranes. d. Increased uterine irritability. e. Bilateral pitting edema. f. A rigid abdomen.
a. Dark, red vaginal bleeding. d. Increased uterine irritability. f. A rigid abdomen.
A woman with Type 2 diabetes mellitus becomes pregnant, and her oral hypoglycemic agents are discontinued. Which intervention is most important for the nurse to implement? a. Describe diet changes that can improve the management of her diabetes. b. Inform the client that oral hypoglycemic agents are teratogenic during pregnancy. c. Demonstrate self-administration of insulin. d. Evaluate the client's ability to do glucose monitoring.
a. Describe diet changes that can improve the management of her diabetes. Diet modifications (A) are effective in managing Type 2 diabetes during pregnancy, and describing the necessary diet changes is the most important intervention for the nurse to implement with this client. (B, C, and D) are interventions that should also be implemented, but do not have the priority of (A).
A client receiving epidural anesthesia begins to experience nausea and becomes pale and clammy. What intervention should the nurse implement first? a. Raise the foot of the bed. b. Assess for vaginal bleeding. c. Evaluate the fetal heart rate. Take the client's blood pressure
a. Raise the foot of the bed. These symptoms are suggestive of hypotension which is a side effect of epidural anesthesia. Raising the foot of the bed (A) will increase venous return and provide blood to the vital areas. Increasing the IV fluid rate using a balanced non-dextrose solution and ensuring that the client is in a lateral position are also appropriate interventions. (B and C) will not raise the maternal blood pressure. Since the symptoms are common side effects of epidural anesthesia and suggest hypotension, (D) can wait until (A) is implemented.
The nurse instructs a laboring client to use accelerated-blow breathing. The client begins to complain of tingling fingers and dizziness. What action should the nurse take? a. Administer oxygen by face mask. b. Notify the healthcare provider of the client's symptoms. c. Have the client breathe into her cupped hands. d. Check the client's blood pressure and fetal heart rate.
c. Have the client breathe into her cupped hands. Tingling fingers and dizziness are signs of hyperventilation (blowing off too much carbon dioxide). Hyperventilation is treated by retaining carbon dioxide. This can be facilitated by breathing into a paper bag or cupped hands (C). (A) is inappropriate since the C02 level is low, not 02. (B and D) are not specific for this situation.
