HIGH RISK PREGNANCIES AND COMPLICATIONS
treatment for RDS
-if amniocentesis of mother while fetus is in utero shows a low L/S ration, the mother is given corticosteroids to stimulate lung maturity 1-2 days before delivery -surfactant can be administered via ET tube at birth or when symptoms of RDS occur -improvement in the neonates' lung function is generally seen within 72 hours after administration
three actions that can be taken for an ectopic pregnancy
-no action -treatment to inhibit cell division -surgery to remove pregnancy from the tube
preterm labor is between
20-37weeks
if gestational hypertension persists more than __________ after birth, chronic hypertension is diagnosed
6 weeks greater than or equal to 140/90
3. The nursing student learns that spontaneous termination of a pregnancy is considered to be an abortion if a. the pregnancy is less than 20 weeks. b. the fetus weighs less than 1000 g. c. the products of conception are passed intact. d. no evidence exists of intrauterine infection.
A An abortion is the termination of pregnancy before the age of viability (20 weeks). The weight of a fetus is not considered because some fetuses of an older age may have a low birth weight. A spontaneous abortion may be complete or incomplete. A spontaneous abortion may be caused by many problems, one being intrauterine infection
27. The nurse learns that which is the most common cause of spontaneous abortion? a. Chromosomal abnormalities b. Infections c. Endocrine imbalance d. Immunologic factors
A Around 60% of pregnancy losses from spontaneous abortion in the first trimester result from chromosomal abnormalities that are incompatible with life. Maternal infection, endocrine imbalances, and immunologic factors may also be causes of early miscarriage
7. The priority nursing intervention when admitting a pregnant woman who has experienced a bleeding episode in late pregnancy is to a. assess fetal heart rate (FHR) and maternal vital signs. b. perform a venipuncture for hemoglobin and hematocrit levels. c. place clean disposable pads to collect any drainage. d. monitor uterine contractions.
A Assessment of the FHR and maternal vital signs will assist the nurse in determining the degree of the blood loss and its effect on the mother and fetus. The blood levels can be obtained later. It is important to assess future bleeding and provide for comfort, but the top priority is mother/fetal well-being. Monitoring uterine contractions is important but not the top priority.
26. A woman has been admitted to the labor and delivery unit who is HIV positive. She is in active labor. What action by the nurse is most appropriate? a. Prepare to administer IV zidovudine. b. Place the mother on contact precautions. c. Administer oxygen by face mask. d. Notify social services.
A During labor, an IV infusion of zidovudine is administered. The woman does not need contact precautions; standard precautions suffice. The woman does not need oxygen because of her HIV status. There is no reason to notify social services.
17. Rh incompatibility can occur if the woman is Rh negative and her a. fetus is Rh positive. b. husband is Rh positive. c. fetus is Rh negative. d. husband and fetus are both Rh negative.
A For Rh incompatibility to occur, the mother must be Rh negative and her fetus Rh positive. The husband's Rh factor is a concern only as it relates to the possible Rh factor of the fetus. If the fetus is Rh negative, the blood types are compatible and no problems should occur. If the fetus is Rh negative, the blood type with the mother is compatible. The husband's blood type does not enter into the problem.
2. In assessing the knowledge of a pregestational woman with type 1 diabetes concerning changing insulin needs during pregnancy, the nurse recognizes that further teaching is warranted when the patient states a . "I will need to increase my insulin dosage during the first 3 months of pregnancy." b . "Insulin dosage will likely need to be increased during the second and third trimesters." c . "Episodes of hypoglycemia are more likely to occur during the first 3 months." d . "Insulin needs should return to normal within 7 to 10 days after birth if I am bottle feeding."
A Insulin needs are reduced in the first trimester due to increased insulin production by the pancreas and increased peripheral sensitivity to insulin. Also the woman may be experiencing nausea, vomiting, and anorexia that would decrease her insulin needs. The other statements show good understanding of this topic.
20. A woman who delivered her third child yesterday has just learned that her two school-age children have contracted chickenpox. What action by the nurse is best? a . Assess if the woman has had chickenpox or been vaccinated. b . Tell her that the baby has immunity from her and is not susceptible. c . Advise her if she is non-immune, she will get vaccinated at her 2-week postpartum checkup. d . The infant will receive prophylactic acyclovir before discharge.
A The first thing the nurse should do is to determine the woman's susceptibility to this infection. If she is non-immune, she will get her first vaccination prior to discharge. The nurse does not know the baby's immune status without knowing the mother's. Acyclovir is not used to treat chickenpox.
12. A nurse is assessing a woman receiving magnesium sulfate. The nurse assesses her deep tendon reflexes at 0 and 1+. What action by the nurse is best? a. Hold the magnesium sulfate. b. Ask the provider to order a 24-hour UA. c. Assess the woman's temperature. d. Take the woman's blood pressure.
A Absent or hypoactive deep tendon reflexes are indicative of magnesium sulfate toxicity. The nurse should hold the magnesium and notify the provider. There is no need for a 24- hour UA at this point. Temperature changes are not related to magnesium. Blood pressure can be assessed, but that is not the priority.
3. Screening at 24 weeks of gestation reveals that a pregnant woman has gestational diabetes mellitus (GDM). In planning her care, the nurse and the woman mutually agree that an expected outcome is to prevent injury to the fetus as a result of GDM. The nurse identifies that the fetus is at greatest risk for a . macrosomia. b . congenital anomalies of the central nervous system. c . preterm birth. d . low birth weight.
A Poor glycemic control later in pregnancy increases the rate of fetal macrosomia. Poor glycemic control during the preconception time frame and into the early weeks of the pregnancy is associated with congenital anomalies. Preterm labor or birth is more likely to occur with severe diabetes and is the greatest risk in women with pregestational diabetes. Increased weight, or macrosomia, is the greatest risk factor for this woman.
12. With regard to the association of maternal diabetes and other risk situations affecting mother and fetus, nurses should be aware that a . Diabetic ketoacidosis (DKA) can lead to fetal death at any time during pregnancy. b . Hydramnios rarely occurs in diabetic pregnancies. c . Infections occur about as often and are considered about as serious in diabetic and nondiabetic pregnancies. d . Women should not use insulin pumps during pregnancy.
A Prompt treatment of DKA is necessary to save the fetus and the mother. Hydramnios is a potential complication for the diabetic pregnancy. Infections are more common and more serious in pregnant women with diabetes. Women who were treated with an insulin pump before pregnancy can continue this therapy.
15. Prophylaxis of subacute bacterial endocarditis (SBE) is given before and after birth when a pregnant woman has a . valvular disease. b . congestive heart disease. c . dysrhythmias. d . postmyocardial infarction.
A Prophylaxis for intrapartum endocarditis and pulmonary infection may be provided for women who have mitral valve prolapse. It is not indicated for congestive heart failure, dysrhythmias, or myocardial infarctions.
6. Which major neonatal complication is carefully monitored after the birth of the infant of a diabetic mother? a . Hypoglycemia b . Hypercalcemia c . Hypobilirubinemia d . Hypoinsulinemia
A The neonate is at highest risk for hypoglycemia because fetal insulin production is accelerated during pregnancy to metabolize excessive glucose from the mother. At birth, the maternal glucose supply stops and the neonatal insulin exceeds the available glucose, leading to hypoglycemia. Hypocalcemia is associated with preterm birth, birth trauma, and asphyxia, all common problems of the infant of a diabetic mother. Excess erythrocytes are broken down after birth, releasing large amounts of bilirubin into the neonate's circulation, which results in hyperbilirubinemia. Because fetal insulin production is accelerated during pregnancy, the neonate shows hyperinsulinemia.
22. A woman has tested human immunodeficiency virus (HIV)-positive and has now discovered that she is pregnant. Which statement indicates that she understands the risks of this diagnosis? a . "Even though my test is positive, my baby might not be affected." b . "I know I will need to have an abortion as soon as possible." c . "This pregnancy will probably decrease the chance that I will develop AIDS." d . "My baby is certain to have AIDS and die within the first year of life."
A The rate of perinatal transmission of HIV has decreased with the use of antiretroviral medications during pregnancy. There is no need to have an abortion. The mother may or may not go on to develop AIDS.
19. What order should the nurse expect for a patient admitted with a threatened abortion? a. Abstinence from sexual activity b. Pitocin IV c. NPO d. Narcotic analgesia every 3 hours, prn
A The woman may be counseled to avoid sexual activity with a threatened abortion. Activity restrictions were once recommended, but they have not shown effectiveness as treatment. Pitocin would be contraindicated. There is no reason for the woman to be NPO. In fact, hydration is important. Narcotic analgesia is not indicated.
10. A pregnant diabetic woman is in the hospital and her blood glucose reading is 42 mg/dL. What action by the nurse is best? a . Provide her with 15 grams of oral carbohydrate if she can swallow. b . Administer a bolus of rapid-acting insulin. c . Order the woman a meal tray from the cafeteria. d . Notify the provider immediately.
A This woman has hypoglycemia and needs to injest 15 grams of carbohydrate if she is able to swallow. Insulin would make the problem worse. The meal tray is a good idea but not as the first response as it will take too long. The provider should be notified but only after the nurse takes corrective action.
8. Which factor is most likely to result in fetal hypoxia during a dysfunctional labor? a . Incomplete uterine relaxation b . Maternal fatigue and exhaustion c . Maternal sedation with narcotics d . Administration of tocolytic drugs
A A high uterine resting tone, with inadequate relaxation between contractions, reduces maternal blood flow to the placenta and decreases fetal oxygen supply. Maternal fatigue or sedation does not decrease uterine blood flow. Tocolytic drugs decrease contractions. This will increase uterine blood flow.
25. What risk factor for peripartum depression (PPD) is likely to have the greatest effect on the woman's condition? a . Personal history of depression b . Single-mother status c . Low socioeconomic status d . Unplanned or unwanted pregnancy
A A personal history of depression is a known risk factor for peripartum depression. Being single, from a low socioeconomic status, or having an unplanned or unwanted pregnancy may contribute to depression for some women but are not strong predictors.
13. A woman in preterm labor at 30 weeks of gestation receives two 12-mg doses of betamethasone intramuscularly. The purpose of this pharmacologic treatment is to a . stimulate fetal surfactant production. b . reduce maternal and fetal tachycardia associated with ritodrine administration. c . suppress uterine contractions. d . maintain adequate maternal respiratory effort and ventilation during magnesium sulfate therapy.
A Antenatal glucocorticoids given as intramuscular injections to the mother accelerate fetal lung maturity. Inderal would be given to reduce the effects of ritodrine administration. Betamethasone has no effect on uterine contractions. Calcium gluconate would be given to reverse the respiratory depressive effects of magnesium sulfate therapy.
23. A student nurse is preparing to administer a dose of betamethasone. What action by the student warrants intervention by the registered nurse? a . Starts a separate IV line to infuse the medication b . Tells the woman her blood glucose will be monitored more often c . Prepares an IM injection choosing a ´ needle d . Listens to the woman's lungs prior to administering the medication
A Betamethasone is given in two IM injections with the appropriate needle. When the student begins to insert a dedicated line for administering it, the nurse intervenes to stop this incorrect action. Since this drug is a steroid, blood glucose readings can rise, so diabetic patients will have more frequent blood sugars. Pulmonary edema is uncommon, but the astute nurse (or student) will listen to lung sounds prior to administration for a baseline.
4. Birth for the nulliparous woman with a fetus in a breech presentation is usually by a . cesarean delivery. b . vaginal delivery. c . forceps-assisted delivery. d . vacuum extraction.
A Delivery for the nulliparous woman with a fetus in breech presentation is almost always cesarean section. The greatest fetal risk in the vaginal delivery of breech presentation is that the head (largest part of the fetus) is the last to be delivered. The delivery of the rest of the baby must be quick so that the infant can breathe.
20. Which measure may prevent mastitis in the breastfeeding mother? a . Initiating early and frequent feedings b . Nursing the infant for 5 minutes on each breast c . Wearing a tight-fitting bra d . Applying ice packs before feeding
A Early and frequent feedings prevent stasis of milk, which contributes to engorgement and mastitis. Five minutes does not adequately empty the breast. This will produce stasis of the milk. A firm-fitting bra will support the breast but not prevent mastitis. The breast should not be bound. Warm packs before feeding will increase the flow of milk.
3. An infant with severe meconium aspiration syndrome (MAS) is not responding to conventional treatment. Which treatment may be necessary for this infant? a . Extracorporeal membrane oxygenation b . Respiratory support with ventilator c . Insertion of laryngoscope and suctioning of the trachea d . Insertion of an endotracheal tube
A Extracorporeal membrane oxygenation is a highly technical method that oxygenates the blood while bypassing the lungs, allowing the infant's lungs to rest and recover. The infant is most likely intubated and on a ventilator already. Laryngoscope insertion and tracheal suctioning are performed after birth before the infant takes the first breath.
10. The nurse is teaching the parents of a newborn who is going to receive phototherapy. What other measure does the nurse teach to help reduce the bilirubin? a . Increase the frequency of feedings. b . Increase oral intake of water between feedings. c . How to prepare the newborn for an exchange transfusion d . Wrap the infant in triple blankets to prevent cold stress during phototherapy.
A Frequent feedings prevent hypoglycemia, provide protein to maintain albumin levels in the blood and promote gastrointestinal motility and removal of bilirubin in the stools. More frequent breastfeeding should be encouraged. Avoid offering water between feedings, because the infant may decrease his or her milk intake. Breast milk or formula is more effective at removing bilirubin from the intestines. Exchange transfusions are seldom necessary but may be performed when phototherapy cannot reduce high bilirubin levels quickly enough. Wrapping the infant in blankets will prevent the phototherapy from getting to the skin and being effective. The infant should be uncovered and unclothed.
18. With regard to anemia, nurses should be aware that a . it is the most common medical disorder of pregnancy. b . it can trigger reflex brachycardia. c . the most common form of anemia is caused by folate deficiency. d . thalassemia is a European version of sickle cell anemia.
A Iron deficiency anemia causes 75% of anemias in pregnancy. It is difficult to meet the pregnancy needs for iron through diet alone. It does not cause bradycardia. Thalassemia is a distinct disease from sickle cell anemia.
18. Which data should alert the nurse that the neonate is postmature? a . Cracked, peeling skin b . Short, chubby arms and legs c . Presence of vernix caseosa d . Presence of lanugo
A Loss of vernix caseosa, which protects the fetal skin in utero, may leave the skin macerated and appearing cracked and peeling. Postmature infants usually have long, thin arms and legs. Vernix caseosa decreases in the postmature infant. Absence of lanugo is common in postmature infants.
3. Which technique is least effective for the woman with persistent occiput posterior position? a . Lie supine and relax. b . Sit or kneel, leaning forward with support. c . Rock the pelvis back and forth while on hands and knees. d . Squat.
A Lying supine increases the discomfort of "back labor." A sitting or kneeling position may help the fetal head to rotate to occiput anterior. Rocking the pelvis encourages rotation from occiput posterior to occiput anterior. Squatting aids both rotation and fetal descent.
12. The nurse should expect medical intervention for subinvolution to include a . oral methylergonovine maleate (Methergine) for 48 hours. b . oxytocin intravenous infusion for 8 hours. c . oral fluids to 3000 mL/day. d . intravenous fluid and blood replacement.
A Methergine provides long-sustained contraction of the uterus and is the usual treatment. Oxytocin and oral fluids are not used for this condition. There is no indication that blood loss has occurred in this situation; if it does blood replacement may be necessary.
12. Nursing care of the infant with neonatal abstinence syndrome should include a . Positioning the infant's crib in a quiet corner of the nursery b . Feeding the infant on a 2-hour schedule c . Placing stuffed animals and mobiles in the crib to provide visual stimulation d . Spending extra time holding and rocking the infant
A Placing the crib in a quiet corner helps avoid excessive stimulation of the infant. These infants have an increase calorie needs but poor suck and swallow coordination. Feeding should occur to meet these needs. Stimulation should be kept to a minimum.
16. The nurse is caring for a neonate undergoing phototherapy. What action does the nurse include on the infant's care plan? a . Keep the infant's eyes covered under the light. b . Keep the infant supine at all times. c . Restrict parenteral and oral fluids. d . Dress the infant in only a T-shirt and diaper.
A Retinal damage from phototherapy should be prevented by using eye shields on the infant under the light. To ensure total skin exposure, the infant's position is changed frequently. Special attention to increasing fluid intake ensures that the infant is well hydrated. To ensure total skin exposure, the infant is not dressed.
17. The perinatal nurse caring for the postpartum woman understands that late postpartum hemorrhage is most likely caused by a . subinvolution of the uterus. b . defective vascularity of the decidua. c . cervical lacerations. d . coagulation disorders.
A The most common causes of late postpartum hemorrhage are subinvolution and retained placental fragments.
5. Early postpartum hemorrhage is defined as signs and symptoms of hypovolemia with which of the following descriptions of blood loss? a . Cumulative blood loss >1000 mL in the first 24 hours after the birth process. b . 750 mL in the first 24 hours after vaginal delivery c . Cumulative blood loss >1000 mL in the first 48 hours after the birth process d . 1500 mL in the first 48 hours after cesarean delivery
A The newest definition of early postpoartum hemorrhage is cumulative blood loss >1000 mL with signs of hypovolemia within the first 24 hours after the birth process. Hemorrhage after 24 hours is considered late postpartum hemorrhage.
23. A nurse has taught a pregnant woman about toxoplasmosis. What statement by the patients indicates a need for further instruction? a . "I will be certain to empty the litter boxes regularly." b . "I won't eat raw eggs." c . "I had better wash all of my fruits and vegetables." d . "I need to be cautious when cooking meat."
A The patient should avoid contact with materials that are possibly contaminated with cat feces while pregnant. This includes cat litter boxes, sand boxes, and garden soil. She should wash her hands thoroughly after working with soil or handling animals. The other statements show good understanding.
8. A newborn has meconium aspiration at birth. The nurse notes increasing respiratory distress. What action takes priority? a . Obtain an oxygen saturation. b . Notify the provider at once. c . Stimulate the baby to increase respirations. d . Prepare to initiate ECMO.
A This baby has a risk for, and signs of, persistent pulmonary hypertension. The nurse first checks an oxygen saturation then notifies the provider, or alternatively, gets the reading (and other assessments) while another nurse does the notification. This baby most likely has tachypnea so stimulation to increase respirations is not needed. ECMO may or may not be needed depending on whether or not other treatments work.
21. A nurse is caring for a preterm baby who weighs 4.8 pounds. What assessment finding indicates the baby is dehydrated? a . Urine output of 3.3 mL/hour b . Urine specific gravity of 1.001 c . Low serum sodium d . Weight gain of 43 g in one day
A This baby weighs 2.18 kg. Dehydration is noted with a urine output of <2 mL/kg/hour. A urine output of 3.3 mL is 1.5 mL/kg/hour and so indicates dehydration. The dilute urine specific gravity indicates overhydration as does the low serum sodium. The weight gain is normal (15 to 20 g/kg/day).
2. The perinatal nurse is caring for a woman in the immediate postbirth period. Assessment reveals that the woman is experiencing profuse bleeding. The most likely etiology for the bleeding is a . uterine atony. b . uterine inversion. c . vaginal hematoma. d . vaginal laceration.
A Uterine atony is marked hypotonia of the uterus. It is the leading cause of postpartum hemorrhage. The other situations can cause bleeding but are not the most common cause.
20. What action by the nurse is the most important action in preventing neonatal infection? a . Good hand hygiene b . Isolation of infected infants c . Separate gown technique d . Standard Precautions
A Virtually all controlled clinical trials have demonstrated that effective handwashing is responsible for the prevention of nosocomial infection in nursery units. The other actions do reduce risk but not nearly to the degree that good hand hygiene does.
5. A nurse is caring for a late preterm infant. What action by the nurse is inconsistent with best practice to prevent cold stress? a . Wean the infant directly to an open crib. b . Check temperature every 3 to 4 hours. c . Encourage kangaroo care. d . Place infant on a radiant warmer.
A Weaning to an open crib takes many steps and is not done directly because of the risk of cold stress. The other actions help prevent cold stress.
17. While caring for the postterm infant, the nurse recognizes that the fetus may have passed meconium prior to birth as a result of a . hypoxia in utero. b . NEC. c . placental insufficiency. d . rapid use of glycogen stores.
A When labor begins, poor oxygen reserves may cause fetal compromise. The fetus may pass meconium as a result of hypoxia before or during labor, increasing the risk of meconium aspiration. Meconium is not passed as a result of NEC, placental insufficiency, or rapid use of glycogen stores.
26. A woman who has had no prenatal care enters the labor and delivery unit in advanced labor. She has chickenpox. What action by the nurse is best? a . Place the woman in isolation. b . Give the woman immune globulin before delivery. c . Treat the woman with acyclovir. d . Administer antibiotics to the infant after birth.
A Women with varicella infections (chickenpox or shingles) need to be in isolation (airborne and contact per the CDC). There might not be enough time to administer immune globulin to the mother before delivery, but it could be given to the baby. Acyclovir is the drug of choice for treatment, but the staff needs to be protected from this infection through isolation precautions. Antibiotics are not used for this disease.
what is a DIC and diagnostic tests
A life-threatening complication of missed abortion, abruptio placentae, and preeclampsia PTT, PT, platelets, Hemoglobin, creatinine • Pro-coagulation and anti-coagulation factors are simultaneously active
what is subinvolution
A slower than expected return of the uterus to its nonpregnant size and consistency that may be due to retention of placental fragments, pelvic infection, may not be evident until well after discharge
5. A home health care nurse is checking on a new mother with signs of obsessive-compulsive disorder. What assessment findings correlate with this condition? (Select all that apply.) a . Frequently checking on the baby b . Fear of being alone with the baby c . Woman states she feels worthless d . Woman has bought $5,000 worth of toys e . Mother states birth was very traumatic
A, B Postpartum OCD often manifests with women performing obsessive behaviors and voicing fear of being left alone with their baby. Feeling worthless is a sign of depression. A spending spree might be a sign of the manic phase of bipolar disease. Viewing the birth as traumatic may lead to PTSD.
2. Congenital anomalies can occur with the use of antiepileptic drugs, including (Select all that apply.) a. Craniofacial abnormalities b. Congenital heart disease c. Neural tube defects d. Gastroschisis e. Diaphragmatic hernia
A, B, C Congenital anomalies that can occur with antiepileptic drugs include craniofacial abnormalities, congenital heart disease, and neural tube defects. They are not known to cause gastroschisis or diaphragmatic hernias.
2. What actions can the labor and delivery nurse take to decrease a woman's chance of contracting a puerperal infection? (Select all that apply.) a . Avoid straight catheterizing the woman unless she cannot void. b . Keep vaginal examinations to a minimum. c . Change wet peripads and linens frequently. d . Maintain the woman on bedrest while laboring. e . Use good hand hygiene before and after contact with the woman.
A, B, C, E Risk for infection increases with catheterization, vaginal examinations, exposure to wet linens and pads, and poor hand hygiene. Remaining on bedrest does not reduce the chance for infection.
1. The student nurse learns that maternal complications of diabetes include which of the following? (Select all that apply.) a. Atherosclerosis b. Retinopathy c. IUFD d. Nephropathy e. Caudal regression syndrome
A, B, D Maternal complications of diabetes include heart disease, retinopathy, nephropathy, and neuropathy. Stillbirth and caudal regression syndrome are fetal complications
1. Medications used to manage postpartum hemorrhage include which of the following? (Select all that apply.) a . Oxytocin b . Methergine c . Terbutaline d . Hemabate e . Magnesium sulfate
A, B, D Pitocin, Methergine, and Hemabate are all used to manage PPH. Terbutaline and magnesium sulfate are tocolytics; relaxation of the uterus causes or worsens PPH.
1. The nurse who suspects that a patient has early signs of ectopic pregnancy should be observing her for which symptoms? (Select all that apply.) a. Pelvic pain b. Abdominal pain c. Unanticipated heavy bleeding d. Vaginal spotting or light bleeding e. Missed period
A, B, D, E Early signs of ectopic pregnancy include pelvic pain, abdominal pain, spotting or light bleeding, and a woman's report of a "missed period." Heavy bleeding is a later sign and occurs after the tube has ruptured.
3. The nurse explain to the student that which of the following factors increase a woman's risk for thrombosis? (Select all that apply.) a . Use of stirrups for a prolonged period of time b . Prolonged bedrest during or after labor and delivery c . Adherence to a strict vegetarian diet d . Excessive sweating during labor e . Maternal age greater than 30 years of age
A, B, D, E Use of stirrups for a prolonged period of time, bedrest, excessive sweating (leading to dehydration) all increase the risk of thrombosis. Vegetarian diets are not related. Maternal age >35 increases the risk.
2. What are the priority nursing assessments for a woman receiving tocolytic therapy with terbutaline? (Select all that apply.) a . Fetal heart rate b . Maternal heart rate c . Intake and output d . Maternal blood glucose e . Maternal blood pressure f . Odor of amniotic fluid
A, B, E All assessments are important, but those most relevant to the medication include the fetal heart rate and maternal pulse, which tend to increase, and the maternal blood pressure, which tends to exhibit a wide pulse pressure. The other assessments are important but not related to this medication.
1. The nurse tells the nursing student that late preterm infants are at increased risk for which of the following problems? (Select all that apply.) a . Problems with thermoregulation b . Cardiac distress c . Hyperbilirubinemia d . Sepsis e . Hyperglycemia
A, C, D Problems with thermoregulation, hyperbilirubinemia, and sepsis are common with late preterm infants. They typically have respiratory distress and hypoglycemia.
3. The student nurse learns that maternal risks of systemic lupus erythematosus include (Select all that apply.) a. Premature rupture of membranes (PROM) b. Fetal death resulting in stillbirth c. Hypertension d. Preeclampsia e. Renal complications
A, C, D, E PROM, hypertension, preeclampsia, and renal complications are all maternal risks associated with SLE. Stillbirth and prematurity are fetal risks of SLE
3. A woman reports a sudden gush of fluid from her vagina and is worried about premature rupture of her membranes. What other causes of this does the nurse assess for? (Select all that apply.) a . Urinary incontinence b . Leaking of amniotic fluid c . Loss of mucous plug d . An increase in vaginal discharge e . Bloody show
A, C, D, E Urinary incontinence, loss of the mucous plug (leading to bloody show), and increased vaginal discharge can all be mistaken for PROM. Leaking amniotic fluid is an indication of PROM.
4. The nursing faculty explains to students on the labor and delivery unit that late preterm and term births are very different. What distinguishes the late preterm birth from a term birth? (Select all that apply.) a . Late preterm births are between 34 and 36 completed weeks of pregnancy. b . There is no real difference in mortality between the two types of births. c . Late preterm infants may appear to be full term at delivery. d . A late preterm infant who appears full term is classified full term. e . Late preterm infants need careful assessments of gestational age.
A, C, E Late preterm and term deliveries are very different, with late preterm occurring between 34 and 36 completed weeks of gestation. Mortality for late preterm babies is three times higher than for term babies. Because infant appearance can be deceiving, very careful assessment are needed; the late preterm baby can appear as if he or she is full term.
31. A woman is in the emergency department with severe abdominal pain. When her pregnancy test comes back positive, she yells "I can't be pregnant! I had a tubal ligation two months ago!" What action by the nurse is the priority? a. Provide emotional support to the woman. b. Facilitate an ultrasound examination. c. Call the lab to have them repeat the test. d. Administer an opioid pain medication.
B A failed tubal ligation is a risk factor for ectopic pregnancy. After a blood pregnancy test, a transvaginal ultrasound is needed to look for a gestational sac within the uterus. Of course the nurse provides emotional support, but that is not the priority. There is no need to repeat the test. Pain medications may be contraindicated if surgery is needed and consents have not yet been signed.
21. A woman has a history of drug use and is screened for hepatitis B during the first trimester. What is an appropriate action? a . Provide a low-protein diet. b . Offer the vaccine. c . Discuss the recommendation to bottle-feed her baby. d . Practice respiratory isolation.
B A person who has a history of high-risk behaviors should be offered the hepatitis B vaccine. A low-protein diet will not prevent the infection. The first trimester is too early to discuss feeding methods. Respiratory isolation is not needed for this blood- and body fluid-borne disease.
9. A woman with severe preeclampsia is being treated with bed rest and intravenous magnesium sulfate. The drug classification of this medication is a. tocolytic. b. anticonvulsant. c. antihypertensive. d. diuretic.
B Anticonvulsant drugs act by blocking neuromuscular transmission and depress the central nervous system to control seizure activity. A tocolytic drug does slow the frequency and intensity of uterine contractions, but it is not used for that purpose in this scenario. Decreased peripheral blood pressure is a therapeutic response (side effect) of the anticonvulsant magnesium sulfate. Diuresis is a therapeutic response to magnesium sulfate.
24. Which laboratory marker is indicative of disseminated intravascular coagulation (DIC)? a. Positive KB test b. Presence of fibrin split products c. Thrombocytopenia d. Positive drug screen
B Degradation of fibrin leads to the accumulation of multiple fibrin clots throughout the body's vasculature. The other lab tests are not indicative of DIC.
16. A patient with pregnancy-induced hypertension is admitted complaining of pounding headache, visual changes, and epigastric pain. Nursing care is based on the knowledge that these signs indicate a. Anxiety due to hospitalization b. Worsening disease and impending seizure c. Effects of magnesium sulfate d. Gastrointestinal upset
B Headache and visual disturbances are due to increased cerebral edema. Epigastric pain indicates distention of the hepatic capsules and often warns that a seizure is imminent. These sign are not due to anxiety or magnesium sulfate or related to gastrointestinal upset
20. What data on a patient's health history places her at risk for an ectopic pregnancy? a. Use of oral contraceptives for 5 years b. Recurrent pelvic infections c. Ovarian cyst 2 years ago d. Heavy menstrual flow of 4 days' duration
B Infection and subsequent scarring of the fallopian tubes prevents normal movement of the fertilized ovum into the uterus for implantation. Oral contraceptives, ovarian cysts, and heavy menstrual flows do not increase risk.
4. An abortion in which the fetus dies but is retained in the uterus is called ________ abortion. a. inevitable b. missed c. incomplete d. threatened
B Missed abortion refers to a dead fetus being retained in the uterus. An inevitable abortion means that the cervix is dilating with the contractions. An incomplete abortion means that not all of the products of conception were expelled. With a threatened abortion the woman has cramping and bleeding but not cervical dilation.
1. Preconception counseling is critical to the outcome of diabetic pregnancies because poor glycemic control before and during early pregnancy is associated with a . frequent episodes of maternal hypoglycemia. b . congenital anomalies in the fetus. c . polyhydramnios. d . hyperemesis gravidarum.
B Preconception counseling is particularly important because strict metabolic control before conception and in the early weeks of gestation is instrumental in decreasing the risks of congenital anomalies. Frequent episodes of maternal hypoglycemia may occur during the first trimester (not before conception) as a result of hormone changes and the effects on insulin production and usage. Hydramnios occurs about 10 times more often in diabetic pregnancies than in nondiabetic pregnancies. Typically, it is seen in the third trimester of pregnancy. Hyperemesis gravidarum may exacerbate hypoglycemic events as the decreased food intake by the mother and glucose transfer to the fetus contribute to hypoglycemia.
4. In terms of the incidence and classification of diabetes, maternity nurses should know that a . type 1 diabetes is most common. b . type 2 diabetes often goes undiagnosed. c . there is only one type of gestational diabetes. d . type 1 diabetes may become type 2 during pregnancy.
B Type 2 often goes undiagnosed, because hyperglycemia develops gradually and often is not severe. Type 2, previously called adult onset diabetes, is the most common. There are 2 subgroups of gestational diabetes. Type GDM A1 is diet-controlled whereas type GDM A2 is controlled by insulin and diet. People do not go back and forth between type 1 and type 2 diabetes.
32. A woman who is 8 months pregnant is brought to the emergency department after a serious motor vehicle crash. Although she has no apparent injuries, she is admitted to the hospital. Her partner is upset and wants to know why she just can't come home. What response by the nurse is best? a. "This is standard procedure for all pregnant crash victims." b. "She needs to be monitored for some potential complications." c. "We may have to deliver the baby at any time now." d. "We are giving her medicine to keep her from laboring."
B After serious trauma, a woman may be admitted and observed because an abruptio placentae may take up to 24 hours to become apparent. Not all motor vehicle crash patients will need to be admitted. The baby may or may not need to be delivered at any time, but this statement will frighten the partner. There is no indication the patient is in labor.
1. The perinatal nurse is giving discharge instructions to a woman, status post suction and curettage secondary to a hydatidiform mole. The woman asks why she must take oral contraceptives for the next 12 months. The best response from the nurse is a. "If you get pregnant within 1 year, the chance of a successful pregnancy is very small. Therefore, if you desire a future pregnancy, it would be better for you to use the most reliable method of contraception available." b. "The major risk to you after a molar pregnancy is a type of cancer that can be diagnosed only by measuring the same hormone that your body produces during pregnancy. If you were to get pregnant, it would make the diagnosis of this cancer more difficult." c. "If you can avoid a pregnancy for the next year, the chance of developing a second molar pregnancy is rare. Therefore, to improve your chance of a successful pregnancy, it is better not to get pregnant at this time." d. "Oral contraceptives are the only form of birth control that will prevent a recurrence of a molar pregnancy."
B Beta-hCG levels will be drawn for 1 year to ensure that the mole is completely gone. There is an increased chance of developing choriocarcinoma after the development of a hydatidiform mole. The goal is to achieve a "zero" hCG level. If the woman were to become pregnant, it may obscure the presence of the potentially carcinogenic cells. Any contraceptive method except an IUD is acceptable.
2. Which maternal condition always necessitates delivery by cesarean section? a. Partial abruptio placentae b. Total placenta previa c. Ectopic pregnancy d. Eclampsia
B In total placenta previa, the placenta completely covers the cervical os. The fetus would die if a vaginal delivery occurred. In a partial abruptio placentae, if the mother has stable vital signs and the fetus is alive, a vaginal delivery can be attempted. If the fetus has died, a vaginal delivery is preferred. The most common ectopic pregnancy is a tubal pregnancy, which is usually detected and treated in the first trimester. Labor can be safely induced if the eclampsia is under control
29. The nurse caring for a woman hospitalized for hyperemesis gravidarum should expect that initial treatment involves a. corticosteroids to reduce inflammation. b. IV therapy to correct fluid and electrolyte imbalances. c. an antiemetic, such as pyridoxine, to control nausea and vomiting. d. enteral nutrition to correct nutritional deficits.
B Initially, the woman who is unable to down clear liquids by mouth requires IV therapy for correction of fluid and electrolyte imbalances. Corticosteroids are not the expected treatment for this disorder. Pyridoxine is vitamin B6, not an antiemetic. Promethazine, a common antiemetic, may be prescribed. In severe cases of hyperemesis gravidarum, enteral nutrition via a feeding tube may be necessary to correct maternal nutritional deprivation. This is not an initial treatment for this patient.
19. For which of the infectious diseases can a woman be immunized? a . Toxoplasmosis b . Rubella c Cytomegalovirus . d . Herpesvirus type 2
B Rubella is the only infectious disease listed for which a vaccine is available.
8. A postpartum patient is at increased risk for postpartum hemorrhage if she delivers a(n) a . 5-lb, 2-oz infant with outlet forceps. b . 6.5-lb infant after a 2-hour labor. c . 7-lb infant after an 8-hour labor. d . 8-lb infant after a 12-hour labor.
B A rapid (precipitous) labor and delivery may cause exhaustion of the uterine muscle and prevent contraction. The use of forceps may cause lacerations that could lead to bleeding, but that is not as common as hemorrhage after a precipitous labor when they are used only in the outlet. Eight-hour and 12-hour labors are normal in length.
16. The nurse understands that postpartum care of the woman with cardiac disease a . is the same as that for any pregnant woman. b . includes rest and monitoring of the effect of activity. c . includes ambulating frequently, alternating with active range of motion. d . includes limiting visits with the infant to once per day.
B After delivery, the woman with cardiac disease should rest, and the nurse monitors her for the effect activity has on her cardiovascular status. Care of the woman with cardiac disease in the postpartum period is tailored to the woman's functional capacity. Although the woman may need help caring for the infant, breastfeeding and infant visits are not contraindicated.
4. A multiparous woman is admitted to the postpartum unit after a rapid labor and birth of a 4000-g infant. Her fundus is boggy, lochia is heavy, and vital signs are unchanged. The nurse has the woman void and massages her fundus, but her fundus remains difficult to find, and the rubra lochia remains heavy. What action should the nurse take next? a . Continue to massage the fundus. b . Notify the provider. c . Recheck vital signs. d . Insert an indwelling urinary catheter.
B After taking these corrective actions, the nurse should contact the provider and anticipate collaborative care measures. Another nurse can assess vital signs. Since the woman just voided, an indwelling catheter is not needed.
20. To maintain optimal thermoregulation for the premature infant, what action by the nurse is most appropriate? a . Bathe the infant once a day. b . Put an undershirt on the infant in the incubator. c . Assess the infant's hydration status. d . Lightly clothe the infant under the radiant warmer.
B Air currents around an unclothed infant will result in heat loss. Bathing causes evaporative heat loss. Assessing hydration will not maintain thermoregulation. Clothing is not worn when the infant is under a radiant warmer.
22. If the nurse suspects a uterine infection in the postpartum patient, she should assess the a . pulse and blood pressure. b . odor of the lochia. c . episiotomy site. d . abdomen for distention.
B An abnormal odor of the lochia indicates infection in the uterus. The pulse may be altered with an infection, but the odor of the lochia will be an earlier sign and more specific. The infection may move to the episiotomy site if proper hygiene is not followed, but this does not demonstrate a uterine infection. The abdomen becomes distended usually because of a decrease of peristalsis, such as after cesarean section.
9. What instructions should be included in the discharge teaching plan to assist the patient in recognizing early signs of complications? a . Palpate the fundus daily to ensure that it is soft. b . Notify the physician of a return to bright red bleeding. c . Report any decrease in the amount of brownish red lochia. d . The passage of clots as large as an orange can be expected.
B An increase in lochia or a return to bright red bleeding after the lochia has become pink indicates a complication. The fundus should stay firm. Large clots after discharge are a sign of complications and should be reported.
6. Which preterm infant should receive gavage feedings instead of a bottle? a . Sometimes gags when a feeding tube is inserted b . Is unable to coordinate sucking and swallowing c . Sucks on a pacifier during gavage feedings d . Has an axillary temperature of 98.4° F, an apical pulse of 149 beats/min, and respirations of 54 breaths/min
B An infant who cannot coordinate sucking, swallowing, and breathing should receive gavage feedings. The other infants are ready for bottle feedings.
14. The goal of treatment of the infant with phenylketonuria (PKU) is to a . cure cognitive delays. b . prevent central nervous system (CNS) damage. c . prevent gastrointestinal symptoms. d . prevent the renal system damage.
B CNS damage can occur as a result of toxic levels of phenylalanine. No cure exists for cognitive delays should they occur. Digestive problems are a clinical manifestation of PKU, but it is more important to prevent the CNS damage. PKU does not involve renal dysfunction.
11. Why is adequate hydration important when uterine activity occurs before pregnancy is at term? a . Fluid and electrolyte imbalance can interfere with the activity of the uterine pacemakers. b . Dehydration may contribute to uterine irritability for some women. c . Dehydration decreases circulating blood volume, which leads to uterine ischemia. d . Fluid needs are increased because of increased metabolic activity occurring during contractions.
B Dehydration can contribute to uterine irritability for some women, especially if the woman has an infection. Fluid and electrolyte imbalances are not associated with preterm labor. The woman has an increased blood volume during pregnancy. Fluid needs do not increase due to contractions.
24. An hour after her membranes ruptured, a laboring woman has a temperature of 38.2° C (100.7° F). What action does the nurse perform first? a . Provide cool, wet washcloths for the woman's forehead. b . Assess and document the fetal heart rate. c . Administer acetaminophen orally. d . Encourage the woman to drink clear fluids.
B Fetal tachycardia is associated with maternal fever. While all options are reasonable, the nurse needs to assess fetal well-being first.
6. A woman delivered a 9-lb, 10-oz baby 1 hour ago. When you arrive to perform her 15- minute assessment, she tells you that she "feels all wet underneath." You discover that both pads are completely saturated and that she is lying in a 6-inch-diameter puddle of blood. What is your first action? a . Call for help. b . Assess the fundus for firmness. c . Take her blood pressure. d . Check the perineum for lacerations.
B Firmness of the uterus is necessary to control bleeding from the placental site. The nurse should first assess for firmness and massage the fundus as indicated. Calling for help is not needed unless corrective action does not improve the situation. Another nurse can take the blood pressure or the original nurse can do so after assessing the fundus and massaging it if needed. Checking the perineum for lacerations would be appropriate if the fundus was firm.
2. The nurse learns that the most common cause of pathologic hyperbilirubinemia is which of the following? a . Hepatic disease b . Hemolytic disorders in the newborn c . Postmaturity d . Congenital heart defect
B Hemolytic disorders in the newborn are the most common cause of pathologic jaundice. Hepatic damage and prematurity may be causes of pathologic hyperbilirubinemia, but they are not the most common cause. Congenital heart defect is not a common cause of pathologic hyperbilirubinemia in neonates.
17. An infant with hypocalcemia is receiving an intravenous bolus of calcium. The infant's heart rate changes from 144 beats/minute to 62 beats/minute. What action by the nurse is best? a . Call for a stat EGG. b . Stop the infusion. c . Stimulate the infant. d . Administer magnesium.
B IV calcium can lead to bradycardia. When this infant's heart rate drops to 60 beats/minute, the nurse stops the infusion. A stat ECG is not necessary unless policy requires it or the bradycardia does not resolve. Stimulating the infant will not increase the heart rate. Magnesium infusion will also not increase the heart rate.
3. The nurse knows that a measure for preventing late postpartum hemorrhage is to a administer broad-spectrum antibiotics. . b . inspect the placenta after delivery. c . manually remove the placenta. d . pull on the umbilical cord to hasten the delivery of the placenta.
B If a portion of the placenta is missing, the clinician can explore the uterus, locate the missing fragments, and remove the potential cause of late postpartum hemorrhage. Broad-spectrum antibiotics will be given if postpartum infection is suspected. Manual removal of the placenta increases the risk of postpartum hemorrhage. The placenta is usually delivered 5 to 30 minutes after birth of the baby without pulling on the cord. That can cause uterine inversion.
18. The patient who is being treated for endometritis is placed in Fowler's position because it a . promotes comfort and rest. b . facilitates drainage of lochia. c . prevents spread of infection to the urinary tract. d . decreases tension on the reproductive organs.
B Lochia and infectious material are eliminated by gravity drainage when the woman is placed in the Fowler's position.
10. Which woman is at greatest risk for early postpartum hemorrhage? a A primiparous woman being prepared for an emergency cesarean birth for fetal . distress b . A woman with severe preeclampsia on magnesium sulfate whose labor is being induced c . A multiparous woman with an 8-hour labor d . A primigravida in spontaneous labor with preterm twins
B Magnesium sulfate administration during labor poses a risk for PPH. Magnesium acts as a smooth muscle relaxant, thereby contributing to uterine relaxation and atony. The other situations do not post risk factors or causes of early PPH.
29. A provider left an order for a woman to have Methylergonovine 0.2 mg IM. The nurse assesses the woman and finds her vital signs to be: temperature 37.9° C (100.2° F), pulse 90 beats/minute, respirations 18 breaths/minute, and blood pressure 152/90 mm Hg. What action by the nurse is most appropriate? a . Administer acetaminophen first. b . Check policy for administration. c Give the medication as prescribed. . d . Consult with the provider.
B Methylergonovine is contraindicated in women with hypertension. The nurse should check the agency's policy to see at what blood pressure reading this medication should be held. After checking the policy, the nurse can consult the provider if it can't be given. Acetaminophen is not related to this situation.
13. The difference between physiologic and nonphysiologic jaundice is that nonphysiologic jaundice a . usually results in kernicterus. b . appears during the first 24 hours of life. c . results from breakdown of excessive erythrocytes not needed after birth. d . begins on the head and progresses down the body.
B Nonphysiologic jaundice appears during the first 24 hours of life, whereas physiologic jaundice appears after the first 24 hours of life. Pathologic jaundice may lead to kernicterus, but it needs to be stopped before that occurs. Both jaundices are the result of the breakdown of erythrocytes. Pathologic jaundice is due to a pathologic condition, such as Rh incompatibility.
15. Parents of a newborn with phenylketonuria are anxious to learn about the appropriate treatment for their infant. What topic does the nurse include in the teaching plan? a . Fluid and sodium restrictions b . A phenylalanine-free diet c . Progressive mobility and splinting d . A protein-rich diet
B Phenylketonuria is treated with a special diet that restricts phenylalanine intake. Fluid and sodium restrictions are not included in this plan. Mobility and splinting are not included in the plan. A protein-rich diet is not in the plan.
1. What is most helpful in preventing premature birth? a . High socioeconomic status b . Adequate prenatal care c . Transitional Assistance to Needy Families d . Women, Infants, and Children nutritional program
B Prenatal care is vital in identifying possible problems. Women from higher economic status are more likely to seek adequate prenatal care, but it is the care that is most helpful. Government programs help with specific needs of the pregnant woman, but adequate care is more important.
9. In caring for the preterm infant, what complication is thought to be a result of high arterial blood oxygen level? a . Necrotizing enterocolitis (NEC) b . Retinopathy of prematurity (ROP) c . Bronchopulmonary dysplasia (BPD) d . Intraventricular hemorrhage (IVH)
B ROP is thought to occur as a result of high levels of oxygen in the blood. NEC is due to the interference of blood supply to the intestinal mucosa. Necrotic lesions occur at that site. BPD is caused by the use of positive pressure ventilation against the immature lung tissue. IVH is due to rupture of the fragile blood vessels in the ventricles of the brain. It is most often associated with hypoxic injury, increased blood pressure, and fluctuating cerebral blood flow.
20. An important independent nursing action to promote normal progress in labor is a . assessing the fetus. b . encouraging urination about every 1 to 2 hours. c . allowing the woman to stay in her preferred position. d . regulating intravenous fluids.
B The bladder can reduce room in the woman's pelvis that is needed for fetal descent and can increase her discomfort. Assessment of the fetus is an important task, but will not promote normal progression of labor. Position changes help labor progress and should be encouraged. Maintaining hydration is an important task, but it will not promote normal progression of labor.
2. A woman in labor at 34 weeks of gestation is hospitalized and treated with intravenous magnesium sulfate for 18 to 20 hours. When the magnesium sulfate is discontinued, which oral drug will probably be prescribed for continuation of the tocolytic effect? a . Ritodrine b . Terbutaline c . Calcium gluconate d . Pitocin
B The woman receiving decreasing doses of magnesium sulfate is often switched to oral terbutaline to maintain tocolysis for 48 hours. The terbutaline will probably be discontinued prior to discharge. Ritodrine is the only drug approved by the FDA for tocolysis; however, it is rarely used because of significant side effects. Calcium gluconate reverses magnesium sulfate toxicity. The drug should be available for complications of magnesium sulfate therapy. Pitocin is used to augment labor, not stop it.
23. A nurse is caring for a preterm infant who has a weak cry and is irritable. What action by the nurse is best? a . Assess the infant for pain. b . Take the infant's temperature. c . Obtain a bedside glucose reading. d . Reduce stimulation in the environment.
B These are signs of inadequate thermoregulation. The nurse should assess the infant's temperature first. The other actions do not address thermoregulation.
6. A neonate has white patches in her mouth that bled when the mother tried wiping them away. What action by the nurse is best? a . Tell the mother to leave the patches alone. b . Assess the mother for a perineal rash. c . Give the infant medicated pacifiers. d . Test the infant for toxoplasmosis.
B These patches are characteristic of maternal infection with candidiasis or yeast. The nurse assesses the mother's perineal area for a rash. Telling the mother to leave the rash alone may be appropriate information but does not get to the bottom of the issue. The nurse should not provide medication without knowing what is being treated. The baby does not have toxoplasmosis.
25. The nursing student observes a laboring woman doing lunges to the left side and asks for an explanation of this activity. What response by the nurse is best? a . It decreases the pain associated with back labor. b . It promotes rotation of the fetal occiput to an anterior position. c . It relieves the cramping associated with a prolonged labor. d . It causes the pelvic inlet to open wider in preparation for birth.
B This action encourages rotation of the fetal head to the anterior position. It does relieve back labor, but this response does not explain why. It does not relieve cramping or open the pelvic inlet.
8. A premature infant never seems to sleep longer than an hour at a time. Each time a light is turned on, an incubator closes, or people talk near her crib, she wakes up and cries inconsolably until held. The correct nursing diagnosis is ineffective coping related to a . severe immaturity. b . environmental stress. c . physiologic distress. d . behavioral responses.
B This nursing diagnosis is the most appropriate for this infant. Light and sound are known adverse stimuli that add to an already stressed premature infant. The nurse must monitor the environment closely for sources of overstimulation. The other diagnoses do not recognize that fact.
7. A steady trickle of bright red blood from the vagina in the presence of a firm fundus suggests a . uterine atony. b . lacerations of the genital tract. c . perineal hematoma. d . infection of the uterus.
B Undetected lacerations will bleed slowly and continuously. Bleeding from lacerations is uncontrolled by uterine contraction. The fundus is not firm with uterine atony. A hematoma would be internal. Swelling and discoloration would be noticed, but bright bleeding would not be. With an infection of the uterus there would be an odor to the lochia and systemic symptoms such as fever and malaise.
27. A woman who has a history of frequent substance abuse is close to delivering. What action by the nurse is best? a . Notify social services of the situation prior to the birth. b . Draw up and label a syringe of naloxone. c . Administer naloxone if the baby shows signs of withdrawal. d . Prepare to administer naloxone to the mother.
B When anticipating the delivery of a baby whose mother is addicted to opioids, the nurse prepares to give the newborn naloxone for respiratory depression. To administer the drug in the fastest way possible, the nurse prepares a syringe with the medication. Then when the baby's weight is known, the nurse discards the excess drug and administers the correct dose to the baby. Social services will need to be involved but not at this point; the medication is the priority. The naloxone may cause signs of withdrawal in the infant. The baby gets the naloxone, not the mother.
3. A woman has several relatives who had gestational hypertension and wants to decrease her risk for it. What information does the nurse provide this woman? (Select all that apply.) a. There is no way to reduce risk factors for gestational hypertension. b. Losing weight before you get pregnant will help prevent it. c. Eating a diet high in protein and iron may help prevent it. d. The father contributes no risk factors for hypertension in pregnancy e. Waiting until you are 35 to get pregnant cuts the risk in half.
B, C There are many risk factors for gestational hypertension, including obesity and anemia. The woman can take action to address these factors prior to becoming pregnant. The father's risks include the first baby and having fathered other preeclamptic pregnancies. Maternal age >35 increases the risk.
2. What assessment findings indicate to the nurses that a woman's preeclampsia should now be considered severe? (Select all that apply.) a. Urine output 40 mL/hour for the past 2 hours b. Serum creatinine 3.1 mg/dL c. Seeing "sparkly" things in the visual field d. Crackles in both lungs e. Soft, non-tender abdomen
B, C, D Signs of severe preeclampsia include elevated creatinine, seeing sparkles, and pulmonary edema (manifested by crackles). The urine output is above the minimum requirements, and a soft non-tender abdomen is a reassuring sign
1. The causes of preterm labor are not fully understood although many factors have been associated with early labor. These include (Select all that apply.) a . Singleton pregnancy b History of cone biopsy . c . Smoking d . Short cervical length e . Higher level of education
B, C, D A history of cone biopsies, smoking, and a short cervical length are all associated with early labor. Singleton pregnancy and higher level of education are not.
2. Newborns whose mothers are substance abusers frequently have what behaviors? (Select all that apply.) a . Circumoral cyanosis b . Decreased amounts of sleep c . Hyperactive Moro (startle) reflex d . Difficulty feeding e . Weak cry
B, C, D The infant exposed to drugs in utero often has poor sleeping patterns, hyperactive reflexes, and uncoordinated sucking and swallowing behavior. They do not have circumoral cyanosis and will have a high-pitched cry.
1. Some infants develop hypoxic-ischemic encephalopathy after asphyxia. Therapeutic hypothermia has been used to improve neurologic outcomes for these infants. Criteria for the use of this modality include (Select all that apply.) a . The infant must be 28 weeks gestation or greater. b . Have evidence of an acute hypoxic event. c . Be in a facility they can initiate treatment within 6 hours. d . The infant must be 36 or more weeks' gestation. e . The treatment must be initiated within the first 12 hours of life.
B, C, D The infant must be at least 36 weeks of gestation to meet the criteria for therapeutic hypothermia. Treatment should be initiated within the first 6 hours of life, ideally at a tertiary care center. The infant must have evidence of perinatal hypoxic-ischemic episodes.
2. An important nursing factor during the care of the infant in the NICU is assessment for signs of adequate parental attachment. The nurse must observe for signs that bonding is not occurring as expected. These include (Select all that apply.) a . using positive terms to describe the infant. b . showing interest in other infants equal to that of their own. c . naming the infant. d . decreasing the number and length of visits. e . refusing offers to hold and care for the infant.
B, D, E Bonding is not progressing as expected when parents show interest in other babies equal to that of their own, decreasing the number and length of visits, and refusing to hold and help care for the infant. Using positive terms to describe the baby and naming the infant are signs that bonding is occurring.
4. A woman just received an injection of carboprost, 2500 mcg IM. What actions by the nurse take priority? (Select all that apply.) a . Assess for nausea and vomiting b . Assess fetal well-being. c . Administer acetaminophen for headache. d . Monitor urine output. e . Notify the provider immediately.
B, E The usual dose of carboprost is 250 mcg, so this excessive dose could lead to uterine rupture. The nurse monitors the woman for signs of this and continually monitors the fetus for well-being. The provider would be notified and agency policy followed for variance reporting. Nausea, vomiting, and headache are side effects of the usual dose of the drug. This drug is excreted through urine, so monitoring urine output is important but not as critical as checking fetal well-being and notifying the provider.
14. When teaching the pregnant woman with class II heart disease, what information should the nurse provide? a . Advise her to gain at least 30 lb. b . Explain the importance of a diet high in calcium. c . Instruct her to avoid strenuous activity. d Inform her of the need to limit fluid intake.
C Activity may need to be limited so that cardiac demand does not exceed cardiac capacity. Weight gain should be kept at a minimum with heart disease. Iron and folic acid intake is important to prevent anemia. Fluid intake should not be limited during pregnancy. She may also be put on a diuretic. Fluid intake is necessary to prevent fluid deficits.
23. The primary symptom present in abruptio placentae that distinguishes it from placenta previa is a. vaginal bleeding. b. rupture of membranes. c. presence of abdominal pain. d. changes in maternal vital signs.
C Pain in abruptio placentae occurs in response to increased pressure behind the placenta and within the uterus. Placenta previa manifests with painless vaginal bleeding, but both may have vaginal bleeding. Rupture of membranes may occur with both conditions. Maternal vital signs may change with both if bleeding is pronounced.
5. A nurse in labor and delivery learns about metabolic changes that occur throughout pregnancy in diabetes. What information does the nurse know? a . Insulin crosses the placenta to the fetus only in the first trimester, after which the fetus secretes its own. b . Women with insulin-dependent diabetes are prone to hyperglycemia during the first trimester, because they are consuming more sugar. c . During the second and third trimesters, pregnancy exerts a diabetogenic effect that ensures an abundant supply of glucose for the fetus. d . Maternal insulin requirements steadily decline during pregnancy.
C Pregnant women develop increased insulin resistance during the second and third trimesters. Insulin never crosses the placenta; the fetus starts making its own around the tenth week. As a result of normal metabolic changes during pregnancy, insulin-dependent women are prone to hypoglycemia. Maternal insulin requirements may double or quadruple by the end of pregnancy.
7. Which factor is known to increase the risk of gestational diabetes mellitus? a . Underweight before pregnancy b . Maternal age younger than 25 years c . Previous birth of large infant d . Previous diagnosis of type 2 diabetes mellitus
C Previous birth of a large infant suggests gestational diabetes mellitus. Obesity (BMI of 30 or greater) creates a higher risk for gestational diabetes. A woman younger than 25 generally is not at risk for gestational diabetes mellitus. The person with type 2 diabetes mellitus already is a diabetic and will continue to be so during and after pregnancy.
15. The prenatal clinic nurse monitored women for preeclampsia. If all four women were in the clinic at the same time, which one should the nurse see first? a. Blood pressure increase to 138/86 mm Hg b. Weight gain of 0.5 kg during the past 2 weeks c. A dipstick value of 3+ for protein in her urine d. Pitting pedal edema at the end of the day
C Proteinuria is defined as a concentration of 1+ or greater via dipstick measurement. A dipstick value of 3+ is indicative of severe preeclampsia and should alert the nurse that additional testing or assessment should be made. Generally, hypertension is defined as a BP of 140/90 or higher. Preeclampsia may be manifested as a rapid weight gain. Gaining 0.5 kg during the past 2 weeks does not qualify as rapid. Edema occurs in many normal pregnancies as well as in women with preeclampsia. Therefore, the presence of edema is no longer considered diagnostic of preeclampsia.
21. What finding on a prenatal visit at 10 weeks might suggest a hydatidiform mole? a. Complaint of frequent mild nausea b. Blood pressure of 120/80 mm Hg c. Fundal height measurement of 18 cm d. History of bright red spotting for 1 day, weeks ago
C The uterus in a hydatidiform molar pregnancy is often larger than would be expected on the basis of the duration of the pregnancy. Many women have nausea in the first trimester. A woman with a molar pregnancy may have early-onset pregnancy-induced hypertension. The history of bleeding is normally described as being brownish.
13. The labor of a pregnant woman with preeclampsia is going to be induced. The nurse reviews the woman's latest laboratory test findings, which reveal a low platelet count, an elevated aspartate transaminase (AST) level, and a falling hematocrit. What action by the nurse is most important? a. Palpate the woman's abdomen for tenderness. b. Document findings and begin the Pitocin infusion. c. Instruct the woman to ask for help getting out of bed. d. Assess the woman's drinking history.
C This woman has HELLP syndrome, with is characterized by low platelet counts and hepatic dysfunction. She is at risk for bleeding, so the nurse instructs her to call for assistance in getting in and out of bed. The nurse does not palpate the abdomen even though the woman may complain of abdominal pain because of possible rupture of a subcapsular hematoma. The findings should be documented but the nurse should intervene based on the abnormal findings. The liver enzymes are not elevated because of alcohol intake.
6. The student nurse is assessing a woman with abruptio placentae. The student reports to the registered nurse "I can't really palpate her abdomen, it's as hard as a board." What action by the nurse is the priority? a. Tell the student to document the findings. b. Have the student teach the woman relaxation techniques. c. Assess the woman's fundal height and vital signs. d. Administer a dose of opioid pain medication.
C A hard, board-like abdomen in this setting is characteristic of concealed hemorrhage. The nurse assesses the woman's fundal height (which will rise with bleeding) and vital signs to detect shock. Documentation occurs after interventions are complete. Relaxation techniques may help the woman cope with the situation, but anxiety is not the reason for the findings. The woman may or may not need pain medication, and if she is going to need surgery, she should not get opioids until consents are signed.
25. A woman taking magnesium sulfate has respiratory rate of 10 breaths/min. In addition to discontinuing the medication, the nurse should a. vigorously stimulate the woman. b. instruct her to take deep breaths. c. administer calcium gluconate. d. increase her IV fluids.
C Calcium gluconate reverses the effects of magnesium sulfate. Stimulation, instruction on taking deep breaths, and increasing her fluid rate will not increase the respirations.
14. The nurse is explaining how to assess edema to the nursing students working on the antepartum unit. Which score indicates edema of lower extremities, face, hands, and sacral area? a. +1 edema b. +2 edema c. +3 edema d. +4 edema
C Edema of the extremities, face, and sacral area is classified as +3 edema. Edema classified as +1 indicates minimal edema of the lower extremities. Marked edema of the lower extremities is termed +2 edema. Generalized massive edema (+4) includes accumulation of fluid in the peritoneal cavity.
9. To manage her diabetes appropriately and ensure a good fetal outcome, the pregnant woman with diabetes will need to alter her diet by doing which of the following? a . Eating six small equal meals per day b . Reducing carbohydrates in her diet c . Eating her meals and snacks on a fixed schedule d . Increasing her consumption of protein
C Having a fixed meal schedule will provide the woman and the fetus with a steadier blood sugar level, provide better balance with insulin administration, and help prevent complications. It is more important to have a fixed meal schedule than equal division of food intake or increased protein intake. Approximately 45% of the food eaten should be in the form of carbohydrates.
10. What is the only known cure for preeclampsia? a. Magnesium sulfate b. Antihypertensive medications c. Delivery of the fetus d. Administration of acetylsalicylic acid (ASA) every day of the pregnancy
C If the fetus is viable and near term, delivery is the only known definitive treatment for preeclampsia. Magnesium sulfate is one of the medications used to treat but not to cure preeclampsia. Antihypertensive medications are used to lower the dangerously elevated blood pressures in preeclampsia and eclampsia. Low doses of ASA (81 mg) have been administered to women at high risk for developing preeclampsia.
28. Methotrexate is recommended as part of the treatment plan for which obstetric complication? a. Complete hydatidiform mole b. Missed abortion c. Unruptured ectopic pregnancy d. Abruptio placentae
C Methotrexate is an effective, nonsurgical treatment option for a hemodynamically stable woman whose ectopic pregnancy is unruptured and less than 3.5 cm in diameter. Methotrexate is not indicated or recommended as a treatment option for a complete hydatidiform mole, a missed abortion, or abruptio placentae.
24. A woman who had no prenatal care has just delivered after a brief labor. The baby has rough, dry skin; is large for gestational age; and has an umbilical hernia. What action by the nurse is most appropriate? a . Question the mother about substance abuse. b . Reassess the baby's gestational age. c . Inform the mother her thyroid levels will be checked. d . Perform a bedside blood glucose test on the mother.
C These signs in the newborn are indicative of hypothyroidism. The mother will have thyroid levels checked. Asking about substance abuse, reassessing gestational age, and obtaining a blood glucose reading are all unnecessary.
22. The nurse should suspect uterine rupture if a . fetal tachycardia occurs. b . the woman becomes dyspneic. c . contractions abruptly stop during labor. d . labor progresses unusually quickly.
C A large rupture of the uterus will disrupt its ability to contract. Fetal tachycardia is a sign of hypoxia. Dyspnea and unusually quick labor are not signs of rupture.
9. The nurse present at the delivery is reporting to the nurse who will be caring for the neonate after birth. What information might be included for an infant who had thick meconium in the amniotic fluid? a . The infant had Apgar scores of 6 and 8. b . An IV was started immediately after birth to treat dehydration. c . No meconium was found below the vocal cords when they were examined. d . The parents spent an hour bonding with the baby after birth.
C A laryngoscope is inserted to examine the vocal cords. If no meconium is below the cords, probably no meconium is present in the lower air passages, and the infant will not develop meconium aspiration syndrome. Apgar scores are important but not directly related to meconium. There is no relationship between dehydration and meconium fluid. Bonding is an expected occurrence.
21. A woman who is 32 weeks pregnant telephones the nurse at her obstetrician's office and complains of constant backache. She asks what pain reliever is safe for her to take. The best nursing response is a . "Back pain is common at this time during pregnancy due to poor posture." b . "Acetaminophen is acceptable during pregnancy; however, do not take aspirin." c "You should come into the office and let the doctor check you." . d . "Try a warm bath or using a heating pad."
C A prolonged backache is one of the subtle symptoms of preterm labor. Early intervention may prevent preterm birth. The woman should be assessed before trying any home care measures.
19. Nursing measures that help prevent postpartum urinary tract infection include which of the following? a . Promoting bed rest for 12 hours after delivery b . Discouraging voiding until the sensation of a full bladder is present c . Forcing fluids to at least 3000 mL/day d . Encouraging the intake of orange, grapefruit, or apple juice
C Adequate fluid intake of 2500 to 3000 mL/day prevents urinary stasis, dilutes urine, and flushes out waste products. The woman should be encouraged to ambulate early. With pain medications, trauma to the area, and anesthesia, the sensation of a full bladder may be decreased. The woman needs to be encouraged to void frequently. Juices such as cranberry juice can discourage bacterial growth.
9. After a birth complicated by a shoulder dystocia, what action by the nurse is most appropriate? a . Give supplemental oxygen with a small face mask. b . Encourage the parents to hold the infant. c . Palpate the infant's clavicles. d . Perform a complete newborn assessment.
C Because of the shoulder dystocia, the infant's clavicles may have been fractured. Palpation is a simple assessment to identify crepitus or deformity that requires follow-up. There is no indication for oxygen. The infant needs to be assessed for clavicle fractures before excessive movement. A complete newborn assessment is necessary for all newborns, but assessment of the clavicle is top priority for this infant.
18. What factor found in maternal history should alert the nurse to the potential for a prolapsed umbilical cord? a . Oligohydramnios b . Pregnancy at 38 weeks of gestation c . Presenting part at station -3 d . Meconium-stained amniotic fluid
C Because the fetal presenting part is positioned high in the pelvis and is not well applied to the cervix, a prolapsed cord could occur if the membranes rupture. Hydramnios puts the woman at high risk for a prolapsed umbilical cord. A very small fetus, normally preterm, puts the woman at risk for a prolapsed umbilical cord. Meconium-stained amniotic fluid shows that the fetus already has been compromised, but it does not increase the chance of a prolapsed cord.
7. Transient tachypnea of the newborn (TTN) is thought to occur as a result of a . a lack of surfactant. b . hypoinflation of the lungs. c . delayed absorption of fetal lung fluid. d . a slow vaginal delivery associated with meconium-stained fluid.
C Delayed absorption of fetal lung fluid is thought to be the reason for TTN. Lack of surfactant and hypoinflation of the lungs are not related to TTN. A slow vaginal delivery will help prevent TTN.
8. A pregnant woman has been diagnosed with gestational hypertension and is crying. She asks the nurse if this means she has to take blood pressure medicine for the rest of her life. What answer by the nurse is best? a. "Yes, you will have hypertension for the rest of your life." b. "No, this always goes away after you deliver." c. "Maybe, we have to wait and see at your 6-week postpartum checkup." d. "I don't know. But if you need medicine you should take it."
C Gestational hypertension can last after delivery. If it has not resolved by postpartum week 6, it is considered chronic, and the woman will probably have to take medication. It may or may not resolve, but the nurse should not provide false reassurance or state that he or she does not know without finding more information. Telling the woman to take medicine if she needs it belittles her concerns.
16. Of all the signs seen in infants with respiratory distress syndrome, which sign is especially indicative of the syndrome? a . Pulse more than 160 beats/min b . Circumoral cyanosis c . Grunting d . Substernal retractions
C Grunting increases the pressure inside the alveoli to keep them open when surfactant is insufficient. This is a characteristic and often early sign of RDS. The other assessments are not specific to RDS.
10. With regard to eventual discharge of the high-risk newborn or transfer to a different facility, nurses and families should be aware that a . infants will stay in the NICU until they are ready to go home. b once discharged to home, the high-risk infant should be treated like any healthy . term newborn. c . parents of high-risk infants need special support and detailed contact information. d . if a high-risk infant and mother need transfer to a specialized regional center, it is better to wait until after birth and the infant is stabilized.
C High-risk infants can cause profound parental stress and emotional turmoil. Parents need support, special teaching, and quick access to various resources available to help them care for their baby. Parents and their high-risk infant should get to spend a night or two in a predischarge room, where care for the infant is provided away from the NICU. Just because high-risk infants are discharged does not mean they are normal, healthy babies. Follow-up by specialized practitioners is essential. Ideally, the mother and baby are transported with the fetus in utero; this reduces neonatal morbidity and mortality.
15. Which statement is true about large for gestational age (LGA) infants? a . They weigh more than 3500 g. b . They are above the 80th percentile on gestational growth charts. c . They are prone to hypoglycemia, polycythemia, and birth injuries. d . Postmaturity syndrome and fractured clavicles are the most common complications.
C Hypoglycemia, polycythemia, and birth injuries are common in LGA infants. LGA infants are determined by their weight compared to their age. They are above the 90th percentile on the gestational growth charts. Birth injuries are a problem, but postmaturity syndrome is not an expected complication with LGA infants.
26. The maternity nurse knows that which disorder can be triggered by a birth the woman views as traumatic? a . A phobia b . Panic disorder c . Posttraumatic stress disorder (PTSD) d . Obsessive-compulsive disorder (OCD)
C In PTSD, women perceive childbirth as a traumatic event. They have nightmares and flashbacks about the event, anxiety, and avoidance of reminders of the traumatic event. This will not lead to phobias, panic disorder, or OCD.
14. A nurse is assessing an SGA infant with asymmetric intrauterine growth restriction. What assessment finding correlates with this condition? a . One side of the body appears slightly smaller than the other. b . All body parts appear proportionate. c . The head seems large compared with the rest of the body. d . The extremities are disproportionate to the trunk.
C In asymmetric intrauterine growth restriction, the head is normal in size but appears large because the infant's body is long and thin due to lack of subcutaneous fat. The left and right side growth should be symmetric. With asymmetric intrauterine growth restrictions, the body appears smaller than normal compared to the head. The body parts are out of proportion, with the body looking smaller than expected due to the lack of subcutaneous fat. The body, arms, and legs have lost subcutaneous fat so they will look small compared to the head.
15. Which nursing measure is appropriate to prevent thrombophlebitis in the recovery period after a cesarean birth? a . Roll a bath blanket and place it firmly behind the knees. b . Limit oral intake of fluids for the first 24 hours. c . Assist the patient in performing gentle leg exercises. d . Ambulate the patient as soon as her vital signs are stable.
C Leg exercises and passive range of motion promote venous blood flow and prevent venous stasis while the patient is still on bed rest. The blanket behind the knees will cause pressure and decrease venous blood flow. Limiting oral intake will produce hemoconcentration, which may lead to thrombophlebitis. The patient may not have full return of leg movements, and ambulating is contraindicated until she has full motion and sensation.
25. A woman in the perinatal clinic asks the nurse how her asthma will affect her pregnancy and fetus. What response by the nurse is best? a. Asthma medications cannot be used during pregnancy. b. The only problem is that you will not be able to breastfeed. c. Medications for asthma do not appear to harm the fetus. d. Pregnancy tends to make asthma worse.
C Medications for asthma seem to be well tolerated during pregnancy. Breastfeeding is safe for the newborn. The course of asthma is variable in pregnancy.
5. Which patient situation presents the greatest risk for the occurrence of hypotonic dysfunction during labor? a . A primigravida who is 17 years old b . A 22-year-old multiparous woman with ruptured membranes c . A multiparous woman at 39 weeks of gestation who is expecting twins d . A primigravida woman who has requested no analgesia during her labor
C Overdistention of the uterus in a multiple pregnancy is associated with hypotonic dysfunction because the stretched uterine muscle contracts poorly. A young primigravida usually will have good muscle tone in the uterus. This prevents hypotonic dysfunction. There is no indication that this woman's uterus is overdistended, which is the main cause of hypotonic dysfunction. A primigravida usually will have good uterine muscle tone, and there is no indication of an overdistended uterus.
27. To provide adequate postpartum care, the nurse should be aware that peripartum depression (PPD) a . is the "baby blues," plus the woman has a visit with a counselor or psychologist. b . does not affect the father who can then care for the baby. c . is distinguished by pervasive sadness that lasts at least 2 weeks. d . will disappear on its own without outside help.
C PPD is characterized by a persistent depressed state. The woman is unable to feel pleasure or love although she is able to care for her infant. She often experiences generalized fatigue, irritability, little interest in food and sleep disorders. PPD is more serious and persistent than postpartum baby blues. Fathers are often affected. Most women need professional help to get through PPD, including pharmacologic intervention.
7. Overstimulation may cause increased oxygen use in a preterm infant. Which nursing intervention helps to avoid this problem? a . Group all care activities together to provide long periods of rest. b . While giving your report to the next nurse, stand in front of the incubator and talk softly about how the infant responds to stimulation. c . Teach the parents signs of overstimulation, such as turning the face away or stiffening and extending the extremities and fingers. d . Keep charts on top of the incubator so the nurses can write on them there.
C Parents should be taught these signs of overstimulation so they will learn to adapt their care to the needs of their infant. This may understimulate the infant during those long periods and overtire the infant during the procedures. Talking in front of the incubator could overstimulate the baby. Placing objects on top of the incubator or using it as a writing surface increases the noise inside.
4. A preterm infant is on a respirator with intravenous lines and much equipment around her when her parents come to visit for the first time. What action by the nurse is most important? a . Suggest that the parents visit for only a short time to reduce their anxieties. b . Reassure the parents that the baby is progressing well. c . Encourage the parents to touch her. d . Discuss the care they will give her when she goes home.
C Physical contact with the infant is important to establish early bonding. The nurse as the support person and teacher is responsible for shaping the environment and making the care giving responsive to the needs of both the parents and the infant. The nurse should encourage the parents to touch their baby and show them how to do so safely. Bonding needs to occur, and this can be fostered by encouraging the parents to spend time with the infant. It is important to keep the parents informed about the infant's progression, but the nurse needs to be honest with the explanations. Discussing home care needs to wait until the parents are ready and discharge is closer with known needs.
12. In planning for home care of a woman with preterm labor, the nurse needs to address which concern? a . Nursing assessments will be different from those done in the hospital setting. b . Restricted activity and medications will be necessary to prevent recurrence of preterm labor. c . Prolonged bed rest may cause negative physiologic effects. d . Home health care providers will be necessary.
C Prolonged bed rest may cause adverse effects such as weight loss, loss of appetite, muscle wasting, weakness, bone demineralization, decreased cardiac output, risk for thrombophlebitis, alteration in bowel functions, sleep disturbance, and prolonged postpartum recovery. Nursing assessments will differ somewhat from those performed in the acute care setting, but this is not the concern that needs to be addressed. Restricted activity and medication may prevent preterm labor but not in all women. Many, but not all, women will receive home health nurse visits.
3. Decreased surfactant production in the preterm lung is a problem because surfactant a . causes increased permeability of the alveoli. b . provides transportation for oxygen to enter the blood supply. c . keeps the alveoli open during expiration. d . dilates the bronchioles, decreasing airway resistance.
C Surfactant prevents the alveoli from collapsing each time the infant exhales, thus reducing the work of breathing. It does not cause increased permeability, provide transportation of oxygen or dilate the bronchioles.
14. The mother-baby nurse must be able to recognize what sign of thrombophlebitis? a . Visible varicose veins b . Positive Homans sign c . Local tenderness, heat, and swelling d . Pedal edema in the affected leg
C Tenderness, heat, and swelling are classic signs of thrombophlebitis that appear at the site of the inflammation. Varicose veins may predispose the woman to thrombophlebitis but are not a sign. A positive Homans sign may be caused by a strained muscle or contusion. Edema may be caused by other factors, and the edema with thrombophlebitis may be more extensive. Edema may be more involved than pedal.
21. What action does the nurse add to the plan of care for an infant experiencing symptoms of drug withdrawal? a . Keeping the newborn sedated b . Feeding every 4 to 6 hours to allow extra rest c . Swaddling the infant snugly d . Playing soft music during feeding
C The infant should be wrapped snugly to reduce self-stimulation behaviors and protect the skin from abrasions. The baby is not kept sedated. The infant should be fed in small, frequent amounts and burped well to diminish aspiration and maintain hydration. The infant should not be stimulated (such as with music), because this will increase activity and potentially increase CNS irritability.
21. A mother with mastitis is concerned about breastfeeding while she has an active infection. The nurse should explain that a . the infant is protected from infection by immunoglobulins in the breast milk. b . the infant is not susceptible to the organisms that cause mastitis. c . the organisms that cause mastitis are not passed to the milk. d . the organisms will be inactivated by gastric acid.
C The organisms are localized in the breast tissue and are not excreted in the breast milk. The mother is just producing the immunoglobulin from this infection, so it is not available for the infant. Because of an immature immune system, infants are susceptible to many infections. However, this infection is in the breast tissue and is not excreted in the breast milk. The organism will not get into the infant's gastrointestinal system.
22. The nurse is observing a parent holding a preterm infant. The infant is sneezing, yawning, and extending the arms and legs. What action by the nurse is best? a . Cover the infant with a warmed blanket. b . Encourage the parent to do kangaroo care. c . Encourage the parent to place the infant back in the warmer d Have the parent fold the infant's arms across the chest.
C These are signs that the preterm infant is overstimulated. The parent should place the infant back in her warmer, and the nurse can turn down the lights and limit noise. The other suggestions will not help decrease stimulation.
24. Near the end of the first week of life, an infant who has not been treated for any infection develops a copper-colored, maculopapular rash on the palms and around the mouth and anus. The newborn is showing signs of a . gonorrhea. b . herpes simplex virus infection. c . congenital syphilis. d . HIV.
C This rash is indicative of congenital syphilis. The lesions may extend over the trunk and extremities. This is not characteristic of gonorrhea, herpes, or HIV.
24. When a woman is diagnosed with postpartum psychosis, one of the main concerns is that she may a . have outbursts of anger. b . neglect her hygiene. c . harm her infant. d . lose interest in her husband.
C Thoughts of harm to one's self or the infant are among the most serious symptoms of PPD and require immediate assessment and intervention. The other problems can be attributed to postpartum psychosis, but the major concern is harm to the infant.
25. Providing care for the neonate born to a mother who abuses substances can present a challenge for the health care team. Nursing care for this infant requires a multisystem approach. The first step in the provision of this care is a . pharmacologic treatment. b . reduction of environmental stimuli. c . neonatal abstinence syndrome scoring. d . adequate nutrition and maintenance of fluid and electrolyte balance.
C Various scoring systems exist to determine the number, frequency, and severity of behaviors that indicate neonatal abstinence syndrome. The score is helpful in determining the necessity of drug therapy to alleviate withdrawal. Pharmacologic treatment is based on the severity of withdrawal symptoms. Swaddling, holding, and reducing environmental stimuli are essential in providing care to the infant who is experiencing withdrawal. However, the scoring helps provide definitive care. Fluids and electrolyte balance are appropriate for any infant.
7. A woman is having her first child. She has been in labor for 15 hours. Two hours ago, her vaginal examination revealed the cervix to be dilated to 5 cm and 100% effaced, and the presenting part was at station 0. Five minutes ago, her vaginal examination indicated that there had been no change. What abnormal labor pattern is associated with this description? a . Prolonged latent phase b . Protracted active phase c . Secondary arrest d . Protracted descent
C With a secondary arrest of the active phase, the progress of labor has stopped. This patient has not had any anticipated cervical change, indicating an arrest of labor. Dilation at 5 cm is past the latent phase. This does not describe a "protracted" labor.
23. A primigravida has just delivered a healthy infant girl. The nurse is about to administer erythromycin ointment in the infant's eyes when the mother asks, "What is that medicine for?" The nurse responds a . "It is an eye ointment to help your baby see you better." b . "It is to protect your baby from contracting herpes from your vaginal tract." c . "Erythromycin is given to prevent a gonorrheal infection." d . "This medicine will protect your baby's eyes from drying out."
C With the prophylactic use of erythromycin, the incidence of gonococcal conjunctivitis has declined to less than 0.5%. Eye prophylaxis is administered at or shortly after birth to prevent ophthalmia neonatorum. Erythromycin has no bearing on enhancing vision and is not used for herpes infections or lubrication.
6. A primigravida at 40 weeks of gestation is having uterine contractions every 1.5 to 2 minutes and says that they are very painful. Her cervix is dilated 2 cm and has not changed in 3 hours. The woman is crying and wants an epidural. What is the likely status of this woman's labor? a . She is exhibiting hypotonic uterine dysfunction. b . She is experiencing a normal latent stage. c . She is exhibiting hypertonic uterine dysfunction. d . She is experiencing pelvic dystocia.
C Women who experience hypertonic uterine dysfunction, or primary dysfunctional labor, often are anxious first-time mothers who are having painful and frequent contractions that are ineffective at causing cervical dilation or effacement to progress. With hypotonic uterine dysfunction, the woman initially makes normal progress into the active stage of labor and then the contractions become weak and inefficient or stop altogether. This is not a normal latent stage. Pelvic dystocia can occur whenever contractures of the pelvic diameters reduce the capacity of the bony pelvis, including the inlet, midpelvis, outlet, or any combination of these planes.
4. When caring for a pregnant woman with suspected cardiomyopathy, the nurse must be alert for signs and symptoms of cardiac decompensation, which include (Select all that apply.) a. A regular heart rate b. Hypertension c. Shortness of breath d. Weakness e. Crackles in the lung bases
C, D, E Some symptoms of cardiomyopathy include shortness of breath, weakness, and crackles in the lung bases. A regular heart rate may or may not be present. Hypertension is not a typical finding
safety alert for PKU
Children with PKU must avoid the sweetener aspartame (NutraSweet) because it is converted to phenylalanine in the body
30. A woman with preeclampsia has a seizure. What action by the nurse takes priority? a. Insert an oral airway. b. Suction the mouth to prevent aspiration. c. Administer oxygen by mask. d. Stay with the patient and call for help.
D If a patient seizes, the nurse should stay with her and call for help. Nursing actions during a seizure are directed toward ensuring a patent airway and patient safety. Insertion of an oral airway during seizure activity is no longer the standard of care. The nurse should attempt to keep the airway patent by turning the patient's head to the side to prevent aspiration. Once the seizure has ended, it may be necessary to suction the patient's mouth. Oxygen may or may not be needed after the seizure has ended.
13. What form of heart disease in women of childbearing years usually has a benign effect on pregnancy? a . Cardiomyopathy b . Rheumatic heart disease c . Congenital heart disease d . Mitral valve prolapse
D Mitral valve prolapse is a benign condition that is usually asymptomatic. Cardiomyopathy produces congestive heart failure during pregnancy. Rheumatic heart disease can lead to heart failure during pregnancy. Some congenital heart diseases will produce pulmonary hypertension or endocarditis during pregnancy.
11. Which clinical sign is not included in the symptoms of preeclampsia? a. Hypertension b. Edema c. Proteinuria d. Glycosuria
D Spilling glucose into the urine is not one of the three classic symptoms of preeclampsia. Hypertension is usually the first sign noted. Edema occurs but is considered a non-specific sign. Edema can lead to rapid weight gain. Proteinuria should be assessed through a 24- hour UA.
22. What routine nursing assessment is contraindicated in the patient admitted with suspected placenta previa? a. Monitoring FHR and maternal vital signs b. Observing vaginal bleeding or leakage of amniotic fluid c. Determining frequency, duration, and intensity of contractions d. Determining cervical dilation and effacement
D Vaginal examination of the cervix may result in perforation of the placenta and subsequent hemorrhage and is therefore contraindicated. Monitoring FHR and maternal vital signs is a necessary part of the assessment for this woman. Monitoring for bleeding and rupture of membranes is not contraindicated in this woman. Monitoring contractions is not contraindicated in this woman.
5. A placenta previa in which the placental edge just reaches the internal os is called a. total. b. partial. c. complete. d. marginal.
D A placenta previa that does not cover any part of the cervix is termed marginal. With a total placenta previa the placenta completely covers the os. With a partial previa the lower border of the placenta is within 3 cm of the internal cervical os but does not completely cover the os. A complete previa is termed total. The placenta completely covers the internal cervical os.
1. Which actions by the nurse may prevent infections in the labor and delivery area? a . Vaginal examinations every hour while the woman is in active labor b . Use of clean techniques for all procedures c . Cleaning secretions from the vaginal area by using back-to-front motion d . Keeping underpads and linens as dry as possible
D Bacterial growth prefers a moist, warm environment. Vaginal examinations should be limited to decrease transmission of vaginal organisms into the uterine cavity. Use an aseptic technique if membranes are not ruptured; use a sterile technique if membranes are ruptured. Vaginal drainage should be removed with a front-to-back motion to decrease fecal contamination.
18. In which situation is a dilation and curettage (D&C) indicated? a. Complete abortion at 8 weeks b. Incomplete abortion at 16 weeks c. Threatened abortion at 6 weeks d. Incomplete abortion at 10 weeks
D D&C is used to remove the products of conception from the uterus and can be used safely until week 14 of gestation. After that there is a greater risk of excessive bleeding, and this procedure may not be used. If all the products of conception have been passed (complete abortion), a D&C is not used. If the pregnancy is still viable (threatened abortion), a D&C is not used.
26. A 32-year-old primigravida is admitted with a diagnosis of ectopic pregnancy. Nursing care is based on the knowledge that a. bed rest and analgesics are the recommended treatment. b. she will be unable to conceive in the future. c. a D&C will be performed to remove the products of conception. d. hemorrhage is the major concern.
D Severe bleeding occurs if the fallopian tube ruptures. The recommended treatment is to remove the pregnancy before hemorrhaging. If the tube must be removed, her fertility will decrease but she will not be infertile. A D&C is done on the inside of the uterine cavity. The ectopic pregnancy is located within the tubes.
19. The fetus in a breech presentation is often born by cesarean delivery because a . the buttocks are much larger than the head. b . postpartum hemorrhage is more likely if the woman delivers vaginally. c . internal rotation cannot occur if the fetus is breech. d . compression of the umbilical cord is more likely.
D After the fetal legs and trunk emerge from the woman's vagina, the umbilical cord can be compressed between the maternal pelvis and the fetal head if a delay occurs in the birth of the head. The head is the largest part of a fetus. There is no relationship between breech presentation and postpartum hemorrhage. Internal rotation can occur with a breech.
1. The infant of a mother with diabetes is hypoglycemic. What type of feeding should be instituted first? a . Glucose water in a bottle b . D 5 W intravenously c . Formula via nasogastric tube d . Breast milk
D Breast milk is metabolized more slowly and provides longer normal glucose levels. Breast milk is best for nearly all babies. High levels of dextrose correct the hypoglycemia but will stimulate the production of more insulin. Oral feedings are tried first; intravenous lines should be a later choice if the hypoglycemia continues. Formula does provide longer normal glucose levels but would be administered via bottle, not by tube feeding unless the baby is unable to take oral feedings.
11. Which combination of expressing pain could be demonstrated in a neonate? a . Low-pitched crying, tachycardia, eyelids open wide b . Cry face, flaccid limbs, closed mouth c . High-pitched, shrill cry, withdrawal, change in heart rate d . Cry face, eye squeeze, increase in blood pressure
D Cry face, eye squeeze, and an increase in blood pressure indicate pain. The other manifestations are not those of pain in the neonate.
13. If nonsurgical treatment for late postpartum hemorrhage is ineffective, which surgical procedure is appropriate to correct the cause of this condition? a . Hysterectomy b . Laparoscopy c . Laparotomy d . D&C
D D&C allows examination of the uterine contents and removal of any retained placental fragments or blood clots. Hysterectomy, laparoscopy, and laparotomy are not indicated.
14. With regard to the care management of preterm labor, nurses should be aware that a . teaching pregnant women the symptoms probably causes more harm through false alarms. b . Braxton Hicks contractions often signal the onset of preterm labor. c . because preterm labor is likely to be the start of an extended labor, a woman with symptoms can wait several hours before contacting the primary caregiver. d . the diagnosis of preterm labor is based on gestational age, uterine activity, and progressive cervical change.
D Gestational age of 20 to 37 weeks, uterine contractions, and a thinning cervix are all indications of preterm labor. It is essential that nurses teach women how to detect the early symptoms of preterm labor. Braxton Hicks contractions resemble preterm labor contractions, but they are not true labor. Waiting too long to see a health care provider could result in essential medications failing to be administered.
11. When caring for a postpartum woman experiencing hypovolemic shock, the nurse recognizes that the most objective and least invasive assessment of adequate organ perfusion and oxygenation is a . absence of cyanosis in the buccal mucosa. b . cool, dry skin. c . diminished restlessness. d . decreased urinary output.
D Hemorrhage may result in hypovolemic shock. Shock is an emergency situation in which the perfusion of body organs may become severely compromised, and death may occur. The presence of adequate urinary output indicates adequate tissue perfusion. The assessment of the buccal mucosa for cyanosis can be subjective in nature. The presence of cool, pale, clammy skin is an indicative finding associated with hypovolemic shock. Restlessness indicates decreased cerebral perfusion.
5. A nurse is participating in a neonatal resuscitation. What action by the nurse takes priority? a . Suction the mouth and nose. b . Stimulate the infant by rubbing the back. c Perform the Apgar test. . d . Place the infant in a preheated warmer.
D In a resuscitation situation, the nurse places the newborn in a preheated warmer immediately to reduce cold stress. Next position the infant in a "sniffing" position. Suctioning is the third step. Drying the infant is fourth, although if more than one health care provider is present, drying can occur simultaneously with the other actions.
11. A mother with diabetes has done some reading about the effects of the condition on her newborn. Which statement shows a misunderstanding that should be clarified by the nurse? a . "Although my baby is large, some women with diabetes have very small babies because the blood flow through the placenta may not be as good as it should be." b . "My baby will be watched closely for signs of low blood sugar, especially during the early days after birth." c . "The red appearance of my baby's skin is due to an excessive number of red blood cells." d . "My baby's pancreas may not produce enough insulin because the cells became smaller than normal during my pregnancy."
D Infants of diabetic mothers may have hypertrophy of the islets of Langerhans, which may cause them to produce more insulin than they need. The other statements are correct and show good understanding.
10. A laboring patient in the latent phase is experiencing uncoordinated, irregular contractions of low intensity. How should the nurse respond to complaints of constant cramping pain? a . "You are only 2 cm dilated, so you should rest and save your energy for when the contractions get stronger." b . "You must breathe more slowly and deeply so there is greater oxygen supply for your uterus. That will decrease the pain." c . "Let me take off the monitor belts and help you get into a more comfortable position." d . "I have notified the doctor that you are having a lot of discomfort. Let me rub your back and see if that helps."
D Intervention is needed to manage the dysfunctional pattern. Offering support and comfort is important to help the patient cope with the situation. Telling the woman to rest is belittling her complaints. Breathing will not reduce the pain. Fetal monitoring should continue as the woman changes positions.
17. Which action should be initiated to limit hypovolemic shock when uterine inversion occurs? a . Administer oxygen at 31 L/min by nasal cannula. b . Administer an oxytocin by intravenous push. c . Monitor fetal heart rate every 5 minutes. d . Increase the intravenous infusion rate.
D Intravenous fluids are necessary to replace the lost blood volume that occurs in uterine inversion. The woman may need blood products as well. Administering oxygen will not prevent hypovolemic shock. Oxytocin should not be given until the uterus is repositioned. A uterine inversion occurs during the third stage of labor.
16. A woman who had two previous cesarean births is in active labor, when she suddenly complains of pain between her scapulae. The nurse's priority action is to a . reposition the woman with her hips slightly elevated. b . observe for abnormally high uterine resting tone. c . decrease the rate of nonadditive intravenous fluid. d . notify the provider promptly and prepare the woman for surgery.
D Pain between the scapulae may occur when the uterus ruptures, because blood accumulates under the diaphragm. This is an emergency that requires surgical intervention so the nurse notifies the provider and prepares the woman for surgery. Repositioning the woman with her hips slightly elevated is the treatment for a prolapsed cord. That position in this scenario would cause respiratory difficulties. Since the uterus is no longer able to contract, high resting tones cannot be assessed. However, high resting tones during labor indicate a risk for uterine rupture. The woman is now at high risk for shock. Nonadditive intravenous fluids should be increased.
8. Glucose metabolism is profoundly affected during pregnancy because a . pancreatic function in the islets of Langerhans is affected by pregnancy. b . the pregnant woman uses glucose at a more rapid rate than the nonpregnant woman. c . the pregnant woman increases her dietary intake significantly. d . placental hormones are antagonistic to insulin, resulting in insulin resistance.
D Placental hormones, estrogen, progesterone, and human placental lactogen (HPL) create insulin resistance. Insulin also is broken down more quickly by the enzyme placental insulinase. Pancreatic functioning is not affected by pregnancy. The glucose requirements differ because of the growing fetus. The pregnant woman should increase her intake by 200 calories a day.
22. The nursing student learns that transmission of HIV from mother to baby occurs in which fashion? a . From the maternal circulation only in the third trimester b . From the use of unsterile instruments c . Only through the ingestion of amniotic fluid d . Through the ingestion of breast milk from an infected mother
D Postnatal transmission of HIV through breastfeeding may occur. Transplacental transmission can occur at any time during pregnancy. Unsterile instruments are possible sources of transmission but highly unlikely. Transmission of HIV may also occur during birth from blood or secretions. Transmission of HIV from the mother to the infant may occur transplacentally at various gestational ages. This is highly unlikely as most health care facilities must meet sterility standards for all instrumentation.
23. Which condition is a transient, self-limiting mood disorder that affects new mothers after childbirth? a . Postpartum depression b . Postpartum psychosis c . Postpartum bipolar disorder d . Postpartum blues
D Postpartum blues, or "baby blues," is a transient self-limiting disease that is believed to be related to hormonal fluctuations after childbirth. Postpartum depression is not the normal worries (blues) that many new mothers experience. Many caregivers believe that postpartum depression is underdiagnosed and underreported. Postpartum psychosis is a rare condition that usually surfaces within 3 weeks of delivery. Hospitalization of the woman is usually necessary for treatment of this disorder. Bipolar disorder is one of the two categories of postpartum psychosis, characterized by both manic and depressive episodes.
16. One of the first symptoms of puerperal infection to assess for in the postpartum woman is a . fatigue continuing for longer than 1 week. b . pain with voiding. c . profuse vaginal bleeding with ambulation. d . temperature of 38° C (100.4° F) or higher after 24 hours.
D Postpartum or puerperal infection is any clinical infection after childbirth. The definition used in the United States continues to be the presence of a fever of 38° C (100.4° F) or higher on 2 successive days of the first 10 postpartum days, starting 24 hours after birth. Fatigue is a later finding associated with infection. Pain with voiding may indicate a UTI, but it is not typically one of the earlier symptoms of infection. Profuse lochia may be associated with endometritis, but it is not the first symptom associated with infection.
2. Compared to the term infant, the preterm infant has a . few blood vessels visible though the skin. b . more subcutaneous fat. c . well-developed flexor muscles. d . greater surface area in proportion to weight.
D Preterm infants have greater surface area in proportion to their weight. They often have visible blood vessels because their skin is thin and they have less fat. More fat and well- developed flexor muscles are characteristic of a more mature infant.
12. Which is true about newborns classified as small for gestational age (SGA)? a . They weigh less than 2500 g. b . They are born before 38 weeks of gestation. c . Placental malfunction is the only recognized cause of this condition. d . They are below the 10th percentile on gestational growth charts.
D SGA infants are defined as below the 10th percentile in growth when compared with other infants of the same gestational age. SGA is not defined by weight. Infants born before 38 weeks are defined as preterm. There are many causes of SGA babies.
13. A nurse is caring for an SGA newborn. What nursing action is most important? a . Observe for respiratory distress syndrome. b . Observe for and prevent dehydration. c . Promote bonding. d . Prevent hypoglycemia by early and frequent feedings.
D The SGA infant has poor glycogen stores and is subject to hypoglycemia. Respiratory distress syndrome is seen in preterm infants. Dehydration is a concern for all infants and is not specific for SGA infants. Promoting bonding is a concern for all infants and is not specific for SGA infants.
28. What teaching does the nurse provide to help new mothers prevent postpartum depression? a . Stay home and avoid outside activities to ensure adequate rest. b . Be the only caregiver for your baby to facilitate infant attachment. c . Keep feelings of sadness and adjustment to your new role to yourself. d . Realize that this is a common occurrence that affects many women.
D The new mother should understand that postpartum depression is common. Rest is important, but she does not need to confine herself to the house. Others need to help care for the baby so the mother can rest. Women need to be open and discuss their feelings.
19. Because of the premature infant's decreased immune functioning, what nursing diagnosis should the nurse include in a plan of care for a premature infant? a . Delayed growth and development b . Ineffective thermoregulation c . Ineffective infant feeding pattern d . Risk for infection
D The nurse needs to know that decreased immune functioning increases the risk for infection. The other diagnoses are appropriate for the premature infant but not related directly to immune function.
15. Which nursing action must be initiated first when evidence of prolapsed cord is found? a . Notify the provider. b . Apply a scalp electrode. c . Prepare the mother for an emergency cesarean delivery. d . Reposition the mother with her hips higher than her head.
D The priority is to relieve pressure on the cord. Changing the maternal position will shift the position of the fetus so that the cord is not compressed. The provider needs to be notified but not until the nurse has taken some corrective action. Trying to relieve pressure on the cord should take priority over increasing fetal monitoring techniques. Emergency cesarean delivery may be necessary if relief of the cord is not accomplished, but attempting to relieve the pressure takes priority. Trying to relieve pressure on the cord should be the first priority.
19. A pregnant woman at 37 weeks of gestation has had ruptured membranes for 26 hours. A cesarean section is performed for failure to progress. The fetal heart rate before birth is 180 beats/min with limited variability. At birth, the newborn has Apgar scores of 6 and 7 at 1 and 5 minutes and is noted to be pale and tachypneic. Based on the maternal history, the cause of this newborn's distress is most likely a . hypoglycemia. b . phrenic nerve injury. c . respiratory distress syndrome. d . sepsis.
D The prolonged rupture of membranes and the tachypnea (before and after birth) both suggest sepsis. There is no evidence of phrenic nerve damage or respiratory distress syndrome. Early signs of sepsis may be difficult to distinguish from other problems such as hypoglycemia, but the prolonged rupture of membranes puts this baby at high risk of sepsis.
4. Four hours after delivery of a healthy neonate of an insulin-dependent diabetic woman, the baby appears jittery, irritable, and has a high-pitched cry. Which nursing action has top priority? a . Start an intravenous line with D 5 W. b . Notify the clinician stat. c . Document the event in the nurses' notes. d . Test for blood glucose level.
D These are signs of hypoglycemia in the newborn. The nurse should test the infant's blood glucose level and then feed the infant if it is low. It is not common practice to give intravenous glucose to a newborn prior to feeding. Feeding the infant is preferable because the formula or breast milk will last longer. The provider needs to be notified after corrective action has been taken. Documentation should occur but is not the priority.
18. A macrosomic infant is born after a difficult, forceps-assisted delivery. After stabilization, the infant is weighed, and the birth weight is 4550 g (9 pounds, 6 ounces). What action by the nurse is most appropriate? a . Leave the infant in the room with the mother. b . Take the infant immediately to the nursery. c . Perform a gestational age assessment. d . Monitor blood glucose levels frequently.
D This infant is macrosomic (over 4000 g) and is at high risk for hypoglycemia. Blood glucose levels should be monitored frequently, and the infant should be observed closely for signs of hypoglycemia. The infant can stay with the mother, but this is not the best answer since it does not include the close monitoring needed. Regardless of gestational age, this infant is macrosomic.
1. Which statement by a postpartum woman indicates that teaching about thrombus formation has been effective? a . "I'll stay in bed for the first 3 days after my baby is born." b . "I'll keep my legs elevated with pillows." c . "I'll sit in my rocking chair most of the time." d . "I'll put my support stockings on every morning before rising."
D Venous congestion begins as soon as the woman stands up. The stockings should be applied before she rises from the bed in the morning. As soon as possible, the woman should ambulate frequently. The mother should avoid knee pillows because they increase pressure on the popliteal space. Sitting in a chair with legs in a dependent position causes pooling of blood in the lower extremities.
DNC
DILATION AND VACCUM to clean out the remaining uterine contents
phenylketonuria means
Faulty metabolism of phenylalanine, an amino acid essential to life and found in all protein foods;a recessive disorder that causes an infant is unable to digest this essential acid and phenylalanine accumulates in blood and is found in the urine within the first week of life
diagnostic test for PKU
GUTHRIE TEST, blood for this test should be obtained 48 to 72 hours after birth (preferably after the infant has ingested proteins)
how to prevent retinopathy of prematurity
Maintaining sufficient levels of vitamin E and avoiding excessively high concentrations of oxygen; and cryosurgery may reduce long term complications
retinopathy of prematurity
Separation and fibrosis of the retina, can lead to blindness Damage to immature retinal blood vessels thought to be caused by high oxygen levels in arterial blood
Infection acronym that can be devastating to the fetus or newborn: TORCH
Toxoplasmosis-raw or uncooked mat, or cat feces Other (syphilis, varicella, parovirus, mumps, HIV) Rubella Cytomegalovirus Herpes Simplex
embolus
a mass composed of a thrombus and amniotic fluid
what is abruptio placentae
a premature separation of the placenta from the uterus and would need immediate medical attention
umbilical cord prolapse and main priority
a prolapsed umbilical cord slips down after the membranes rupture and becomes compressed between the fetus and pelvis prompt delivery of the fetus to relieve pressure on the cord without compression of the blood vessel
what is placenta previa
abnormal implantation of placenta, in the lower
preeclampsia causes decreased placental circulation results in infarctions that increase the risk for
abruptio placentae and HELLP syndrome
home care for preeclampsia
activity restrictions, blood pressure monitoring, urinalysis, fetal assessment, diet, kick counts, daily weights, more rest severe: bedrest and medications
necrotizing enterocolitis is
acute inflammation of the bowel that leads to bowel necrosis, results in bacterial invasion
complete abortion
all products of conception are expelled from the uterus
risk factors for bronchopulmonary dysplasia
atelectasis, edema, thickening of membranes
rh negative blood type is an
autosomal recessive trait
how long does postpartum depression last
begins after birth and lasts at least 2 weeks
intraventricular hemorrhage
bleeding in and around the brain's ventricles; hemorrhage is graded 1-3 according to the amount of bleeding
gestational hypertension is
blood pressure elevation after 20 weeks of pregnancy that is not accompanied by proteinuria; it is considered a working diagnosis because it can progress to preeclampsia
manifestations of placenta previa
bright red bleeding that occurs when the cervix dilates, resulting in painless bleeding
11. Nursing intervention for the pregnant diabetic is based on the knowledge that the need for insulin a . increases throughout pregnancy and the postpartum period. b . decreases throughout pregnancy and the postpartum period. c . varies depending on the stage of gestation. d . should not change because the fetus produces its own insulin.
c insulin needs decrease during the first trimester, when nausea, vomiting, and anorexia are a factor. They increase during the second and third trimesters, when the hormones of pregnancy create insulin resistance in maternal cells.
PKU treatment
close dietary management (low phenylalanine), frequent evaluation of blood phenylalanine level, synthetic food that provides enough protein for growth and tissue repair, provide specific formulas, teach parents importance of reading food labels, following up as required with health care provider for blood tests, referral to dietician, genetic counseling
what is a thrombus
collection of blood factors on a vessel wall
intraventricular hemorrhage diagnostic test
cranial ultrasound
manifestations of abruptio placentae
dark red bleeding with pain, enlarging uterus, uterine tenderness
signs of symptoms of hypovolemic shock
decreased fetal heart tones, low blood pressure, thirsty, palpitations, increased rr, decreased urine output, tachycardia
priority when treating a DIC
delivery of the fetus and placenta
rh positive blood type is a
dominant trait
management of preeclampsia
early and regular prenatal care with attention to the pattern of weight gain monitoring of BP and urinary protein
surfactant is a
fatty protein that is high in lecithin, its presence is necessary for the lungs to absorb oxygen; begins to form at 24 weeks gestation and by 34 weeks the baby should be able to breath adequately
missed abortion
fetus dies during first 20 weeks but is retained in the uterus; fetal death confirmed by ultrasound and then a DNC is preformed
late postpartum period are caused by and occur when
from 24hr up to 6 weeks postpartum; caused by subinvolution of the uterus, retained placental fragments
uterine atony manifestations
fundus is difficult to locate, "boggy fundus", becomes firm when massaged, excessive lochia(bleeding) and clots
herpesvirus type 2
genital herpes
IF mom is rh negative then you check the cord to test babies blood type and then
give rhogam IM injection 72 hours
what is the leading cause of perinatal infection with high mortality rate
group B strep infection
Risk factors for ectopic pregnancy
history of STDs, history of pelvic inflammatory disease, history of previous ectopic pregnancies, failed tubul ligation, intrauterine device, multiple induced abortions, maternal age older than 35 years, use of an IUD, anatomic and fallopian tubes, cigarette smoking, vaginal douching
preeclampsia manifestations
hypertension, 0.3 g in a 24 hr urine: proteinuria, dipstick is either equal or greater than 1+, edema
predisposing factors for abruptio placentae
hypertension, cocaine and alcohol use, cigarette smoking and poor nutrition, blows to the abdomen, trauma, motor vehicle accident, prior history of abruptio placentae, folate deficiency
what exposes the infant to greatest risk for GBS
if labor is long or the woman experiences premature rupture of membranes
antepartum preeclampsia management
if severe enough hospitalize
What is an ectopic pregnancy?
implantation of a fertilized ovum in an area outside the uterine cavity
safety alert: signs and symptoms for placental abruption
increase in fundal height, hard board like abdomen, high uterine baseline tone, persistent abdominal pain.
complications of placenta previa
infection bc of vaginal organisms postpartum hemorrhage bc if lower segment of uterus was site of attachment there are fewer muscle fibers so weaker contractions
why is preeclampsia dangerous
it can develop and progress rapidly symptoms can often go unnoticed the fetus may experience IUGR and persistent fetal hypoxemia
intrapartum preeclampsia management
lateral position, early epidural, narcotics
HELLP syndrome
life threatening with severe hypertension; stands for hemolysis, elevated liver enzymes, and low platelets
threatened abortion
light bleeding and spotting early in pregnancy, half do not survive
herpesvirus type one
likely to cause fever blisters or cold sores
prolonged pregnancy is defined as
longer than 42 weeks
low birth weight, very low and extremely low is considered
low birth-2500g(5lb, 8oz) very low-1500g(3lb, 5oz) extremely low-1000g or less(2lb 3oz)
manifestations of ectopic pregnancy
lower abdominal pain and light vaginal bleeding if tube ruptures possible sudden severe lower abdominal pain, vaginal bleeding, signs of hypovolemic shock, shoulder pain may also be felt
treatment for eclampsia
magnesium sulfate
three degrees of placenta previa
marginal- placenta is implanted in lower uterus , but its lower border is more than 3 cm from the internal cervical os partial-lower border of the placenta is within 3 cm of the internal cervical os but does not completely cover the os total-placenta completely covers internal cervical os
major danger placental abruption
maternal hemorrhage, clotting abnormalities or DIC, and hypovolemic shock fetal anoxia, preterm birth
inevitable abortion
membranes rupture, cervical dilation, active bleeding DNC
medication for an ectopic pregnancy and its action
methotrexate, bc it stops cells from dividing by interfering with the folic acid in your body
postpartum preeclampsia management
monitor for hypovolemia administer magnesium-have calcium gluconate readily
treatment for cytomegalovirus
no effective treatment is known, therapeutic abortion may be offered if CMV infection is discovered early in pregnancy
Cytomegalovirus infection
part of the herpes virus group; infection that can cause intellectual disability, seizures, blindness, deafness, dental abnormalities, petechiae
hyperemesis is
persistent excessive vomiting accompanied by dehydration, electrolyte imbalance, ketosis, acetonuria
placenta accreta
placenta does not attach cleanly
treatment for ectopic pregnancy AND MAIN PRIORITY
pregnancy test, transvaginal ultrasound, laparoscopic examination, priority is to CONTROL BLEEDING
respiratory distress syndrome
result of immature lungs, leads to decreased gas exchange
the mom will not receive rhogam if they are
rh positive
Preterm Premature Rupture of Membranes (PPROM)
rupture of membranes occurs before 37 weeks of gestation
what is eclampsia and when does it usually occur
seizure activity or coma in women diagnosed with preeclampsia eclamptic seizures can occur before, during, or after birth
incomplete abortion
some but not all of the products of conception are expelled from the uterus; some stuff remains inside the vagina DNE followed by DNC
gestational trophoblastic disease
spectrum of diseases that include benign hedatidiform mole and gestational trophoblastic tumors
initial infection of herpes virus effects on fetus
spontaneous abortion, intrauterine growth restriction, and preterm labor
what should you not do for placenta previa
sterile vaginal exam so you do not rupture the placenta
systemic signs of early hemorrhage
tachycardia maternal and fetal, decreasing blood pressure, restlessness, persistent late decels, decreasing baseline variability, vaginal bleeding or absent bleeding
manifestations of RDS
takes several hours fter birth to be manifested, respirations increase to 60 breaths/min or higher(tachypnea), accompanied by gruntlike sounds, nasal flaring, cyanosis, as well as intercostal and sternal retractions, edema, lassitude, and apnea; mechanical ventilation may be necessary
recurrent abortion
three or more consecutive spontaneous abortions
bronchopulmonary dysplasia is a
toxic response of lungs to oxygen therapy; often results of prolonged dependence to supplemental oxygen and ventilators with long term complications
true or false: Rh incompatibility can only occur if the woman is Rh negative and the fetus is Rh positive
true
interventions for hemorrhage
uterine fundus massage, check bladder for distention, check labs, admin fluids and meds
thrombophlebitis
vessel wall develops an inflammatory response t the thrombus
interventions for necrotizing enterocolitis
vital signs, measuring abdomen, auscultating for bowel sounds, carefully resuming fluids as ordered, infection prevention and control techniques, surgical removal of the necrosed bowel may be indicated
early postpartum hemorrhage time and amount of blood loss
within the first 24 hours, QBL: 1000ML
phenylketonuria manifestations
• Appears normal at birth • By the time urine test is positive, brain damage has already occurred • Delayed development apparent at 4-6 months • May have failure to thrive, eczema, or other skin conditions • Child has a musty odor • Personality disorder • Occurs mainly in blonde, blue-eyed children • Results from a lack of tyrosine (needed for melanin formation)
positioning for a preterm infant
• Prone and side-lying positions are used for preterm infants. • Increases oxygenation and reduces energy expenditure
uterine rupture clinical manifestations
•Abdominal pain and tenderness •Chest pain or pain in the shoulder area •Hypovolemic shock •Abnormal fetal heart rate patterns •Absent fetal heart sounds •Cessation of contractions •Palpation of the fetus outside of the uterus
Signs Associated with Intrapartum Infection
•Fetal tachycardia (greater than 160 bpm) •Maternal fever (38°C or 100.4°F) •Foul- or strong-smelling amniotic fluid •Cloudy or yellow amniotic fluid
Factors that increase the risk for prolapsed umbilical cord
•Ruptured membranes •Fetal presenting part at high station •Fetus that poorly fits pelvic inlet because of small size or abnormal presentation •Excessive volume of amniotic fluid (hydramnios)
