Labor and Delivery Mid Term 2

Medications used to manage postpartum hemorrhage (PPH) include (Select all that apply): a. Pitocin. 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.

Screening questions for alcohol and drug abuse should be included in the overall assessment during the first prenatal visit for all women. The 4 Ps-Plus is a screening tool designed specifically to identify when there is a need for a more in-depth assessment. Which of the following is not included in the 4 Ps-Plus screening tool? a. Present b. Partner c. Past d. Pregnancy

A

Which opiate causes euphoria, relaxation, drowsiness, and detachment from reality and has possible effects on the pregnancy, including preeclampsia, intrauterine growth restriction, and premature rupture of membranes? a. Heroin b. Alcohol c. Phencyclidine palmitate (PCP) d. Cocaine

A

15. With one exception, the safest pregnancy is one during which the woman is drug and alcohol free. What is the optimal treatment for women addicted to opioids? a. Methadone maintenance treatment (MMT) b. Detoxification c. Smoking cessation d. 4 Ps Plus

A MMT is currently considered the standard of care for pregnant women who are dependent on heroin or other narcotics. Buprenorphine is another medication approved for the treatment of opioid addiction that is increasingly being used during pregnancy. Opioid replacement therapy has been shown to decrease opioid and other drug use, reduce criminal activity, improve individual functioning, and decrease the rates of infections such as hepatitis B and C, human immunodeficiency virus (HIV), and other STIs. Detoxification is the treatment used for alcohol addiction. Pregnant women requiring withdrawal from alcohol should be admitted for inpatient management. Women are more likely to stop smoking during pregnancy than at any other time in their lives. A smoking cessation program can assist in achieving this goal. The 4 Ps Plus is a screening tool specifically designed to identify pregnant women who need in-depth assessment related to substance abuse.

4. Despite warnings, prenatal exposure to alcohol continues to far exceed exposure to illicit drugs. Which condition is rarely associated with fetal alcohol syndrome (FAS)? a. Respiratory conditions b. Intellectual impairment c. Neural development disorder d. Alcohol-related birth defects (ARBDs)

A Respiratory difficulties are not attributed to exposure to alcohol in utero. Other abnormalities related to FAS include mental retardation, neurodevelopment disorders, and ARBDs.

3. Nursing care measures are commonly offered to women in labor. Which nursing measure reflects the application of the gate-control theory? a. Massage the womans back. b. Change the womans position. c. Give the prescribed medication. d. Encourage the woman to rest between contractions.

A (According to the gate-control theory, pain sensations travel along sensory nerve pathways to the brain, but only a limited number of sensations, or messages, can travel through these nerve pathways at one time. Distraction techniques, such as massage or stroking, music, focal points, and imagery, reduce or completely block the capacity of the nerve pathways to transmit pain. These distractions are thought to work by closing down a hypothetic gate in the spinal cord, thus preventing pain signals from reaching the brain. The perception of pain is thereby diminished. Changing the womans position, administering pain medication, and resting between contractions do not reduce or block the capacity of the nerve pathways to transmit pain using the gate-control theory.)

16. The nurse should be cognizant of which important information regarding nerve block analgesia and anesthesia? a. Most local agents are chemically related to cocaine and end in the suffix caine. b. Local perineal infiltration anesthesia is effective when epinephrine is added, but it can be injected only once. c. Pudendal nerve block is designed to relieve the pain from uterine contractions. d. Pudendal nerve block, if performed correctly, does not significantly lessen the bearing-down reflex.

A (Common agents include lidocaine and chloroprocaine. Injections can be repeated to prolong the anesthesia. A pudendal nerve block relieves pain in the vagina, vulva, and perineum but not the pain from uterine contractions. A pudendal nerve block lessens or shuts down the bearing-down reflex.)

22. A client is experiencing back labor and complains of intense pain in her lower back. Which measure would best support this woman in labor? a. Counterpressure against the sacrum b. Pant-blow (breaths and puffs) breathing techniques c. Effleurage d. Conscious relaxation or guided imagery

A (Counterpressure is steady pressure applied by a support person to the sacral area with the fist or heel of the hand. This technique helps the woman cope with the sensations of internal pressure and pain in the lower back. The pain management techniques of pant-blow, effleurage, and conscious relaxation or guided imagery are usually helpful for contractions per the gate-control theory.)

10. The nurse should be cognizant of which physiologic effect of pain? a. Predominant pain of the first stage of labor is visceral pain that is located in the lower portion of the abdomen. b. Referred pain is the extreme discomfort experienced between contractions. c. Somatic pain of the second stage of labor is more generalized and related to fatigue. d. Pain during the third stage is a somewhat milder version of the pain experienced during the second stage.

A (Predominant pain comes from cervical changes, the distention of the lower uterine segment, and uterine ischemia. Referred pain occurs when the pain that originates in the uterus radiates to the abdominal wall, lumbosacral area of the back, iliac crests, and gluteal area. Second-stage labor pain is intense, sharp, burning, and localized. Third-stage labor pain is similar to that of the first stage.)

24. Which alterations in the perception of pain by a laboring client should the nurse understand? a. Sensory pain for nulliparous women is often greater than for multiparous women during early labor. b. Affective pain for nulliparous women is usually less than for multiparous women throughout the first stage of labor. c. Women with a history of substance abuse experience more pain during labor. d. Multiparous women have more fatigue from labor and therefore experience more pain.

A (Sensory pain is greater for nulliparous women because their reproductive tract structures are less supple. Affective pain is greater for nulliparous women during the first stage but decreases for both nulliparous and multiparous during the second stage. Women with a history of substance abuse experience the same amount of pain as those without such a history. Nulliparous women have longer labors and therefore experience more fatigue.)

4. Breathing patterns are taught to laboring women. Which breathing pattern should the nurse support for the woman and her coach during the latent phase of the first stage of labor if the couple has attended childbirth preparation classes? a. Slow-paced breathing b. Deep abdominal breathing c. Modified-paced breathing d. Patterned-paced breathing

A (Slow-paced breathing is approximately one half the womans normal breathing rate and is used during the early stages of labor when a woman can no longer walk or talk through her contractions. No such pattern called deep abdominal breathing exists in childbirth preparation. Modified-paced breathing is shallow breathing that is twice the womans normal breathing rate. It is used when labor progresses and the woman can no longer maintain relaxation through paced breathing. Patterned-pace breathing is a fast, 4:1 breathe, breathe, breathe, blow pattern that is used during the transitional phase of labor just before pushing and delivery.)

19. Conscious relaxation is associated with which method of childbirth preparation? a. Grantly Dick-Read childbirth method b. Lamaze method c. Bradley method d. Psychoprophylactic method

A (With the Grantly Dick-Read method, women are taught to consciously and progressively relax different muscle groups throughout the body until a high degree of skill at relaxation is achieved. The Lamaze method combines controlled muscular relaxation with breathing techniques. The Bradley method advocates natural labor, without any form of anesthesia or analgesia, assisted by a husband-coach and using breathing techniques for labor. The psychoprophylactic method is another name for the Lamaze method.)

5. While developing an intrapartum care plan for the client in early labor, which psychosocial factors would the nurse recognize upon the clients pain experience? (Select all that apply.) a. Culture b. Anxiety and fear c. Previous experiences with pain d. Intervention of caregivers e. Support systems

A, B, C, E (Culture: A womans sociocultural roots influence how she perceives, interprets, and responds to pain during childbirth. Some cultures encourage loud and vigorous expressions of pain, whereas others value self-control. The nurse should avoid praising some behaviors (stoicism) while belittling others (noisy expression). Anxiety and fear: Extreme anxiety and fear magnify the sensitivity to pain and impair a womans ability to tolerate it. Anxiety and fear increase muscle tension in the pelvic area, which counters the expulsive forces of uterine contractions and pushing efforts. Previous experiences with pain: Fear and withdrawal are a natural response to pain during labor. Learning about these normal sensations ahead of time helps a woman suppress her natural reactions of fear regarding the impending birth. If a woman previously had a long and difficult labor, she is likely to be anxious. She may also have learned ways to cope and may use these skills to adapt to the present labor experience. Support systems: An anxious partner is less able to provide help and support to a woman during labor. A womans family and friends can be an important source of support if they convey realistic and positive information about labor and delivery. Although the intervention of caregivers may be necessary for the well-being of the woman and her fetus, some interventions add discomfort to the natural pain of labor (i.e., fetal monitor straps, IV lines).)

2. Which alternative approaches to relaxation have proven successful when working with the client in labor? (Select all that apply.) a. Aromatherapy b. Massage c. Hypnosis d. Cesarean birth e. Biofeedback

A, B, C, E (Approaches to relaxation can include neuromuscular relaxation, aromatherapy, music, massage, imagery, hypnosis, or touch relaxation. Cesarean birth is a method of delivery, not a method of relaxation.)

3. A woman has requested an epidural block for her pain. She is 5 cm dilated and 100% effaced. The baby is in a vertex position and is engaged. The nurse increases the womans IV fluid for a preprocedural bolus. Before the initiation of the epidural, the woman should be informed regarding the disadvantages of an epidural block. Which concerns should the nurse share with this client? (Select all that apply.) a. Ability to move freely is limited. b. Orthostatic hypotension and dizziness may occur. c. Gastric emptying is not delayed. d. Higher body temperature may occur. e. Blood loss is not excessive.

A, B, D (The womans ability to move freely and to maintain control of her labor is limited, related to the use of numerous medical interventions (IV lines and electronic fetal monitoring [EFM]). Significant disadvantages of an epidural block include the occurrence of orthostatic hypotension, dizziness, sedation, and leg weakness. Women who receive an epidural block have a higher body temperature (38 C or higher), especially when labor lasts longer than 12 hours, and may result in an unnecessary neonatal workup for sepsis. An advantage of an epidural block is that blood loss is not excessive. Other advantages include the following: the woman remains alert and able to participate, good relaxation is achieved, airway reflexes remain intact, and only partial motor paralysis develops.)

Possible alternative and complementary therapies for postpartum depression (PPD) for breastfeeding mothers include (Select all that apply): a. Acupressure. b. Aromatherapy. c. St. John's wort. d. Wine consumption. e. Yoga.

A, B, E Possible alternative/complementary therapies for postpartum depression include acupuncture, acupressure, aromatherapy, therapeutic touch, massage, relaxation techniques, reflexology, and yoga. St. John's wort has not been proven to be safe for women who are breastfeeding. Women who are breastfeeding and/or have a history of PPD should not consume alcohol.

4. The class of drugs known as opioid analgesics (butorphanol, nalbuphine) is not suitable for administration to women with known opioid dependence. The antagonistic activity could precipitate withdrawal symptoms (abstinence syndrome) in both mothers and newborns. Which signs would indicate opioid or narcotic withdrawal in the mother? (Select all that apply.) a. Yawning, runny nose b. Increase in appetite c. Chills or hot flashes d. Constipation e. Irritability, restlessness

A, C, E (The woman experiencing maternal opioid withdrawal syndrome will exhibit yawning, runny nose, sneezing, anorexia, chills or hot flashes, vomiting, diarrhea, abdominal pain, irritability, restlessness, muscle spasms, weakness, and drowsiness. Assessing both the mother and the newborn and planning the care accordingly are important steps for the nurse to take.)

2. Screening questions for alcohol and drug abuse should be included in the overall assessment during the first prenatal visit for all women. The 4 Ps Plus is a screening tool specifically designed to identify the need for a more in-depth assessment. Which are the correct components of the 4 Ps Plus? (Select all that apply.) a. Parents b. Partner c. Present d. Past e. Pregnancy

ABDE

6. According to research, which risk factor for PPD is likely to have the greatest effect on the client postpartum? a. Prenatal depression b. Single-mother status c. Low socioeconomic status d. Unplanned or unwanted pregnancy

ANS: A Prenatal depression has been found to be a major risk factor for PPD. Single-mother status and low socioeconomic status are both small-relationship predictors for PPD. Although an unwanted pregnancy may contribute to the risk for PPD, it does not pose as great an effect as prenatal depression.

5. As a powerful central nervous system (CNS) stimulant, which of these substances can lead to miscarriage, preterm labor, placental separation (abruption), and stillbirth? a. Heroin b. Alcohol c. Phencyclidine (1-phenylcyclohexylpiperidine; PCP) d. Cocaine

ANS: D Cocaine is a powerful CNS stimulant. Effects on pregnancy associated with cocaine use include abruptio placentae, preterm labor, precipitous birth, and stillbirth. Heroin is an opiate; its use in pregnancy is associated with preeclampsia, intrauterine growth restriction, miscarriage, premature rupture of membranes, infections, breech presentation, and preterm labor. The most serious effect of alcohol use in pregnancy is FAS. The major concern regarding PCP use in pregnant women is its association with polydrug abuse and its neurobehavioral effects on the neonate.

1. When caring for a pregnant woman with cardiac problems, the nurse must be alert for the signs and symptoms of cardiac decompensation. Which critical findings would the nurse find on assessment of the client experiencing this condition? a. Regular heart rate and hypertension b. Increased urinary output, tachycardia, and dry cough c. Shortness of breath, bradycardia, and hypertension d. Dyspnea, crackles, and an irregular, weak pulse

B An increased appetite and a lack of interest would reassure the nurse that the client is not experiencing an episode of mania. Clinical manifestations of a manic episode include at least three of the following: grandiosity, decreased need for sleep, pressured speech, flight of ideas, distractibility, psychomotor agitation, and excessive involvement in pleasurable activities. The pregnant woman exhibiting symptoms of a manic episode will likely have a decreased interest in eating and an increased level of interest in pleasurable activities without regard for negative consequences. Psychomotor agitation and a lack of sleep, hyperactivity and distractibility, and pressured speech and grandiosity are all clinical manifestations of a manic episode.

3. During an inpatient psychiatric hospitalization, what is the most important nursing intervention? a. Contacting the client's significant other b. Supervising and guiding visits with her infant c. Allowing no contact with anyone who annoys her d. Having the infant with the mother at all times

B In the hospital setting, the reintroduction of the infant to the mother can and should occur at the mother's own pace. A schedule is set that increases the number of hours the mother cares for her infant over several days, culminating in the infant staying overnight in the mother's room. These supervised and guided visits allow the mother to experience meeting the infant's needs and giving up sleep for the infant. Reintroducing the mother to her infant while in a supervised setting is essential. Another important task for a mother under psychiatric care is to reestablish positive interactions with others.

14. The use of methamphetamine (meth) has been described as a significant drug problem in the United States. The nurse who provides care to this client population should be cognizant of what regarding methamphetamine use? a. Methamphetamines are similar to opiates. b. Methamphetamines are stimulants with vasoconstrictive characteristics. c. Methamphetamines should not be discontinued during pregnancy. d. Methamphetamines are associated with a low rate of relapse.

B Methamphetamines are stimulants with vasoconstrictive characteristics similar to cocaine and are similarly used. As is the case with cocaine users, methamphetamine users are urged to immediately stop all use during pregnancy. Unfortunately, because methamphetamine users are extremely psychologically addicted, the rate of relapse is extremely high.

27. What is the correct terminology for the nerve block that provides anesthesia to the lower vagina and perineum? a. Epidural b. Pudendal c. Local d. Spinal block

B (A pudendal block anesthetizes the lower vagina and perineum to provide anesthesia for an episiotomy and the use of low forceps, if needed. An epidural provides anesthesia for the uterus, perineum, and legs. A local provides anesthesia for the perineum at the site of the episiotomy. A spinal block provides anesthesia for the uterus, perineum, and down the legs.)

13. Anxiety is commonly associated with pain during labor. Which statement regarding anxiety is correct? a. Even mild anxiety must be treated. b. Severe anxiety increases tension, increases pain, and then, in turn, increases fear and anxiety, and so on. c. Anxiety may increase the perception of pain, but it does not affect the mechanism of labor. d. Women who have had a painful labor will have learned from the experience and have less anxiety the second time because of increased familiarity.

B (Anxiety and pain reinforce each other in a negative cycle that will slow the progress of labor. Mild anxiety is normal for a woman in labor and likely needs no special treatment other than the standard reassurances. Anxiety increases muscle tension and ultimately can sufficiently build to slow the progress of labor. Unfortunately, an anxious, painful first labor is likely to carry over, through expectations and memories, into an anxious and painful experience in the second pregnancy.)

26. Developing a realistic birth plan with the pregnant woman regarding her care is important for the nurse. How would the nurse explain the major advantage of nonpharmacologic pain management? a. Greater and more complete pain relief is possible. b. No side effects or risks to the fetus are involved. c. The woman will remain fully alert at all times. d. Labor will likely be more rapid.

B (Because nonpharmacologic pain management does not include analgesics, adjunct drugs, or anesthesia, it is harmless to the mother and the fetus. However, pain relief is lessened with nonpharmacologic pain management during childbirth. Although the womans alertness is not altered by medication, the increase in pain may decrease alertness. Pain management may or may not alter the length of labor. At times when pain is decreased, the mother relaxes and labor progresses at a quicker pace.)

8. What is the role of the nurse as it applies to informed consent? a. Inform the client about the procedure, and ask her to sign the consent form. b. Act as a client advocate, and help clarify the procedure and the options. c. Call the physician to see the client. d. Witness the signing of the consent form.

B (Nurses play a part in the informed consent process by clarifying and describing procedures or by acting as the womans advocate and asking the primary health care provider for further explanations. The physician is responsible for informing the woman of her options, explaining the procedure, and advising the client about potential risk factors. The physician must be present to explain the procedure to the client. However, the nurses responsibilities go further than simply asking the physician to see the client. The nurse may witness the signing of the consent form. However, depending on the states guidelines, the womans husband or another hospital health care employee may sign as a witness.)

18. According to professional standards (the Association of Womens Health, Obstetric and Neonatal Nurses [AWHONN], 2007), which action cannot be performed by the nonanesthetist registered nurse who is caring for a woman with epidural anesthesia? a. Monitoring the status of the woman and fetus b. Initiating epidural anesthesia c. Replacing empty infusion bags with the same medication and concentrate d. Stopping the infusion, and initiating emergency measures

B (Only qualified, licensed anesthesia care providers are permitted to insert a catheter, initiate epidural anesthesia, verify catheter placement, inject medication through the catheter, or alter the medication or medications including type, amount, or rate of infusion. The nonanesthetist nurse is permitted to monitor the status of the woman, the fetus, and the progress of labor. Replacement of the empty infusion bags or syringes with the same medication and concentration is permitted. If the need arises, the nurse may stop the infusion, initiate emergency measures, and remove the catheter if properly educated to do so. Complications can require immediate interventions. Nurses must be prepared to provide safe and effective care during an emergency situation.)

6. What should the laboring client who receives an opioid antagonist be told to expect? a. Her pain will decrease. b. Her pain will return. c. She will feel less anxious. d. She will no longer feel the urge to push.

B (Opioid antagonists such as naloxone (Narcan) promptly reverse the CNS-depressant effects of opioids. In addition, the antagonist counters the effect of the stress-induced levels of endorphins. An opioid antagonist is especially valuable if the labor is more rapid than expected and the birth is anticipated when the opioid is at its peak effect. The woman should be told that the pain that was relieved by the opioid analgesic will return with the administration of the opioid antagonist. Her pain level will increase rather than decrease. Opioid antagonists have no effect on anxiety levels. They are primarily administered to reverse the excessive CNS depression in the mother, newborn, or both. An opioid antagonist (e.g., naloxone) has no effect on the mothers urge or ability to push. The practice of giving lower doses of IV opioids has reduced the incidence and severity of opioid-induced CNS depression; therefore, opioid antagonists are used less frequently.)

9. A first-time mother is concerned about the type of medications she will receive during labor. The client is in a fair amount of pain and is nauseated. In addition, she appears to be very anxious. The nurse explains that opioid analgesics are often used along with sedatives. How should the nurse phrase the rationale for this medication combination? a. The two medications, together, reduce complications. b. Sedatives enhance the effect of the pain medication. c. The two medications work better together, enabling you to sleep until you have the baby. d. This is what your physician has ordered for you.

B (Sedatives may be used to reduce the nausea and vomiting that often accompany opioid use. In addition, some ataractic drugs reduce anxiety and apprehension and potentiate the opioid analgesic affects. A potentiator may cause two drugs to work together more effectively, but it does not ensure zero maternal or fetal complications. Sedation may be a related effect of some ataractic drugs; however, sedation is not the goal. Furthermore, a woman is unlikely to be able to sleep through transitional labor and birth. Although the physician may have ordered the medication, This is what your physician has ordered for you is not an acceptable comment for the nurse to make.)

25. The nurse should be aware of what important information regarding systemic analgesics administered during labor? a. Systemic analgesics cross the maternal blood-brain barrier as easily as they do the fetal blood-brain barrier. b. Effects on the fetus and newborn can include decreased alertness and delayed sucking. c. Intramuscular (IM) administration is preferred over IV administration. d. IV patient-controlled analgesia (PCA) results in increased use of an analgesic.

B (The effects of analgesics depend on the specific drug administered, the dosage, and the timing. Systemic analgesics cross the fetal blood-brain barrier more readily than the maternal blood-brain barrier. IV administration is preferred over IM administration because the drug acts faster and more predictably. PCA results in a decrease in the use of an analgesic.)

29. What is the rationale for the use of a blood patch after spinal anesthesia? a. Hypotension b. Headache c. Neonatal respiratory depression d. Loss of movement

B (The subarachnoid block may cause a postspinal headache resulting from the loss of cerebrospinal fluid from the puncture in the dura. When blood is injected into the epidural space in the area of the dural puncture, it forms a seal over the hole to stop the leaking of cerebrospinal fluid. Hypotension is prevented by increasing fluid volume before the procedure. Neonatal respiratory depression is not an expected outcome with spinal anesthesia. Loss of movement is an expected outcome of spinal anesthesia.)

1. Maternal hypotension is a potential side effect of regional anesthesia and analgesia. What nursing interventions could the nurse use to increase the clients blood pressure? (Select all that apply.) a. Place the woman in a supine position. b. Place the woman in a lateral position. c. Increase IV fluids. d. Administer oxygen. e. Perform a vaginal examination.

B, C, D (Nursing interventions for maternal hypotension arising from analgesia or anesthesia include turning the woman to a lateral position, increasing IV fluids, administering oxygen via face mask, elevating the womans legs, notifying the physician, administering an IV vasopressor, and monitoring the maternal and fetal status at least every 5 minutes until the woman is stable. Placing the client in a supine position causes venous compression, thereby limiting blood flow to and oxygenation of the placenta and fetus. A sterile vaginal examination has no bearing on maternal blood pressure.)

The nurse would conclude that grieving parents had progressed to the reorganization/recovery phase during a follow-up visit a year later if: a. The parents say they feel no pain. b. The parents are discussing sex and a future pregnancy, even if they have not sorted out their feelings yet. c. The parents have abandoned those moments of bittersweet grief. d. The parents' questions have progressed from "Why?" to "Why us?"

B. The parents are discussing sex and a future Many couples have conflicting feelings about sexuality and future pregnancies. A little pain is always present, certainly past the first year, when recovery begins to peak. Bittersweet grief describes the brief grief response that occurs with reminders of a loss, often on anniversary dates. Most couples never abandon it. Recovery is ongoing. Typically a couple's search for meaning progresses from "Why?" in the acute phase to "Why me?" in the intense phase to "What does this loss mean to my life?" in the reorganizational phase.

During pregnancy, alcohol withdrawal may be treated using: a. Disulfiram (Antabuse). b. Corticosteroids. c. Benzodiazepines. d. Aminophylline.

C

Nurses must be cognizant of the growing problem of methamphetamine use during pregnancy. When caring for a woman who uses methamphetamines, it is important for the nurse to be aware of which factor related to the abuse of this substance? a. Methamphetamine is a depressant. b. All methamphetamines are vasodilators. c. Methamphetamine users are extremely psychologically addicted. d. Rehabilitation is usually successful.

C

12. A pregnant woman who abuses cocaine admits to exchanging sex to finance her drug habit. This behavior places the client at the greatest risk for what? a. Depression of the CNS b. Hypotension and vasodilation c. Sexually transmitted infections (STIs) d. Postmature birth

C Exchanging sex acts for drugs places the woman at increased risk for STIs because of multiple partners and the lack of protection. Cocaine is a CNS stimulant that causes hypertension and vasoconstriction. Premature delivery of the infant is one of the more common problems associated with cocaine use during pregnancy.

11. A woman at 24 weeks of gestation states that she has a glass of wine with dinner every evening. Why would the nurse counsel the client to eliminate all alcohol? a. Daily consumption of alcohol indicates a risk for alcoholism. b. She will be at risk for abusing other substances as well. c. The fetus is placed at risk for altered brain growth. d. The fetus is at risk for multiple organ anomalies.

C No period exists when consuming alcohol during pregnancy is safe. The documented effects of alcohol consumption during pregnancy include mental retardation, learning disabilities, high activity level, and short attention span. The brain grows most rapidly in the third trimester and is vulnerable to alcohol exposure during this time. Abuse of other substances has not been linked to alcohol use.

7. Which is the most accurate description of PPD without psychotic features? a. Postpartum baby blues requiring the woman to visit with a counselor or psychologist b. Condition that is more common among older Caucasian women because they have higher expectations c. Distinguishable by pervasive sadness along with mood swings d. Condition that disappears without outside help

C PPD is characterized by an intense pervasive sadness along with labile mood swings and is more persistent than postpartum baby blues. PPD, even without psychotic features, is more serious and persistent than postpartum baby blues. PPD is more common among younger mothers and African-American mothers. Most women need professional help to get through PPD, including pharmacologic intervention.

8. While providing care to the maternity client, the nurse should be aware that one of these anxiety disorders is likely to be triggered by the process of labor and birth. Which disorder fits this criterion? a. Phobias b. Panic disorder c. Posttraumatic stress disorder (PTSD) d. Obsessive-compulsive disorder (OCD)

C PTSD can occur as the result of a past trauma such as rape. Symptoms of PTSD include re-experiencing the event, numbing, irritability, angry outbursts, and exaggerated startle reflex. With the increased bodily touch and vaginal examinations that occur during labor, the client may have memories of the original trauma. The process of giving birth may result in her feeling out of control. The nurse should verbalize an understanding and reassure the client as necessary. Phobias are irrational fears that may lead a person to avoid certain events or situations. Panic disorders may occur in as many as 3% to 5% of women in the postpartum period and are described as episodes of intense apprehension, fear, and terror. Symptoms of a panic disorder may include palpitations, chest pain, choking, or smothering. OCD symptoms include recurrent, persistent, and intrusive thoughts. The mother may repeatedly check and recheck her infant once he or she is born, although she realizes that this behavior is irrational. OCD is optimally treated with medications.

9. Which substance used during pregnancy causes vasoconstriction and decreased placental perfusion, resulting in maternal and neonatal complications? a. Alcohol b. Caffeine c. Tobacco d. Chocolate

C Smoking in pregnancy is known to cause a decrease in placental perfusion and is the cause of low-birth-weight infants. Prenatal alcohol exposure is the single greatest preventable cause of mental retardation. Alcohol use during pregnancy can cause high blood pressure, miscarriage, premature birth, stillbirth, and anemia. Caffeine may interfere with certain medications and worsen arrhythmias. Chocolate, particularly dark chocolate, contains caffeine that may interfere with certain medications.

2. When a woman is diagnosed with postpartum depression (PPD) with psychotic features, what is the nurse's primary concern in planning the client's care? a. Displaying outbursts of anger b. Neglecting her hygiene c. Harming her infant d. Losing interest in her husband

C Thoughts of harm to herself or to the infant are among the most serious symptoms of PPD and require immediate assessment and intervention. Although outbursts of anger and neglecting personal hygiene are symptoms attributable to PPD, the major concern remains the potential of harm to herself or her infant. Although this client is likely to lose interest in her spouse, it is not the nurse's primary concern.

17. A woman in labor is breathing into a mouthpiece just before the start of her regular contractions. As she inhales, a valve opens and gas is released. She continues to inhale the gas slowly and deeply until the contraction starts to subside. When the inhalation stops, the valve closes. Which statement regarding this procedure is correct? a. The application of nitrous oxide gas is not often used anymore. b. An inhalation of gas is likely to be used in the second stage of labor, not during the first stage. c. An application of nitrous oxide gas is administered for pain relief. d. The application of gas is a prelude to a cesarean birth.

C (A mixture of nitrous oxide with oxygen in a low concentration can be used in combination with other nonpharmacologic and pharmacologic measures for pain relief. This procedure is still commonly used in Canada and in the United Kingdom. Nitrous oxide inhaled in a low concentration will reduce but not eliminate pain during the first and second stages of labor. Nitrous oxide inhalation is not generally used before a caesarean birth. Nitrous oxide does not appear to depress uterine contractions or cause adverse reactions in the newborn.)

14. Which statement is not an expected outcome for the client who attends a reputable childbirth preparation program? a. Childbirth preparation programs increase the womans sense of control. b. Childbirth preparation programs prepare a support person to help during labor. c. Childbirth preparation programs guarantee a pain-free childbirth. d. Childbirth preparation programs teach distraction techniques.

C (All methods try to increase a womans sense of control, prepare a support person, and train the woman in physical conditioning, which includes breathing techniques. These programs cannot, and reputable ones do not, promise a pain-free childbirth. Increasing a womans sense of control is the goal of all childbirth preparation methods. Preparing a support person to help in labor is a vitally important component of any childbirth education program. The coach may learn how to touch a womans body to detect tense and contracted muscles. The woman then learns how to relax in response to the gentle stroking by the coach. Distraction techniques are a form of care that are effective to some degree in relieving labor pain and are taught in many childbirth programs. These distractions include imagery, feedback relaxation, and attention-focusing behaviors.)

5. A laboring woman has received meperidine (Demerol) intravenously (IV), 90 minutes before giving birth. Which medication should be available to reduce the postnatal effects of meperidine on the neonate? a. Fentanyl (Sublimaze) b. Promethazine (Phenergan) c. Naloxone (Narcan) d. Nalbuphine (Nubain)

C (An opioid antagonist can be given to the newborn as one part of the treatment for neonatal narcosis, which is a state of central nervous system (CNS) depression in the newborn produced by an opioid. Opioid antagonists, such as naloxone (Narcan), can promptly reverse the CNS depressant effects, especially respiratory depression. Fentanyl (Sublimaze), promethazine (Phenergan), and nalbuphine (Nubain) do not act as opioid antagonists to reduce the postnatal effects of meperidine on the neonate.)

12. Nurses with an understanding of cultural differences regarding likely reactions to pain may be better able to help their clients. Which clients may initially appear very stoic but then become quite vocal as labor progresses until late in labor, when they become more vocal and request pain relief? a. Chinese b. Arab or Middle Eastern c. Hispanic d. African-American

C (Hispanic women may be stoic early in labor but more vocal and ready for medications later. Chinese women may not show reactions to pain. Medical interventions must be offered more than once. Arab or Middle Eastern women may be vocal in response to labor pain from the start; they may prefer pain medications. African-American women may openly express pain; the use of medications for pain is more likely to vary with the individual.)

20. A woman in labor has just received an epidural block. What is the most important nursing intervention at this time? a. Limit parenteral fluids. b. Monitor the fetus for possible tachycardia. c. Monitor the maternal blood pressure for possible hypotension. d. Monitor the maternal pulse for possible bradycardia.

C (The most important nursing intervention for a woman who has received an epidural block is for the nurse to monitor the maternal blood pressure frequently for signs of hypotension. IV fluids are increased for a woman receiving an epidural to prevent hypotension. The nurse also observes for signs of fetal bradycardia and monitors for signs of maternal tachycardia, secondary to hypotension.)

23. A woman has requested an epidural for her pain. She is 5 cm dilated and 100% effaced. The baby is in a vertex position and is engaged. The nurse increases the womans IV fluid for a preprocedural bolus. The nurse reviews her laboratory values and notes that the womans hemoglobin is 12 g/dl, hematocrit is 38%, platelets are 67,000, and white blood cells (WBCs) are 12,000/mm3. Which factor would contraindicate an epidural for this woman? a. She is too far dilated. b. She is anemic. c. She has thrombocytopenia. d. She is septic.

C (The platelet count indicates a coagulopathy, specifically, thrombocytopenia (low platelets), which is a contraindication to epidural analgesia and anesthesia. Typically, epidural analgesia and anesthesia are used in the laboring woman when a regular labor pattern has been achieved, as evidenced by progressive cervical change. The laboratory values show that the womans hemoglobin and hematocrit levels are in the normal range and show a slight increase in the WBC count that is not uncommon in laboring women.)

When helping the mother, father, and other family members actualize the loss of the infant, nurses should: a. Use the words lost or gone rather than dead or died. b. Make sure that the family understands that it is important to name the baby. c. If the parents choose to visit with the baby, apply powder and lotion to the baby and wrap the infant in a pretty blanket. d. Set a firm time for ending the visit with the baby so the parents know when to let go.

C. If the parents choose to visit with the baby, apply powder, and lotion to the baby and wrap the infant in al pretty infant. Presenting the baby in a nice way stimulates the parents' senses and provides pleasant memories of their baby. Nurses must use dead and died to assist the bereaved in accepting reality. Although naming the baby can be helpful, it is important not to create the sense that parents have to name the baby. In fact, some cultural taboos and religious rules prohibit the naming of an infant who has died. Parents need different time periods with their baby to say goodbye. Nurses need to be careful not to rush the process.

1. Reports have linked third trimester use of selective serotonin uptake inhibitors (SSRIs) with a constellation of neonatal signs. The nurse is about to perform an assessment on the infant of a mother with a history of a mood disorder. Which signs and symptoms in the neonate may be the result of maternal SSRI use? (Select all that apply.) a. Hypotonia b. Hyperglycemia c. Shivering d. Fever e. Irritability

CDE Neonatal signs of maternal SSRI use include continuous crying, irritability, jitteriness, shivering, fever, hypertonia, respiratory distress, feeding difficulty, hypoglycemia, and seizures. The onset of signs and symptoms ranges from several hours to several days after birth, but the signs generally resolve within 2 weeks.

To provide adequate postpartum care, the nurse should be aware that postpartum depression (PPD) with psychotic features: A. Is more likely to occur in women with more than two children. B. Is rarely delusional and then usually about someone trying to harm her (the mother). C. Although serious, is not likely to need psychiatric hospitalization. D. May include bipolar disorder (formerly called "manic depression").

D

10. As part of the discharge teaching, the nurse can prepare the mother for her upcoming adjustment to her new role by instructing her regarding self-care activities to help prevent PPD. Which statement regarding this condition is most helpful for the client? a. Stay home, and avoid outside activities to ensure adequate rest. b. Be certain that you are the only caregiver for your baby to facilitate infant attachment. c. Keep your feelings of sadness and adjustment to your new role to yourself. d. Realize that PPD is a common occurrence that affects many women.

D Should the new mother experience symptoms of the baby blues, it is important that she be aware that these symptoms are nothing to be ashamed of. As many as 10% to 15% of new mothers experience similar symptoms. Although obtaining enough rest is important for the mother, she should not distance herself from her family and friends. Her spouse or partner can communicate the best visiting times to enable the new mother to obtain adequate rest. It is also important that she not isolate herself at home by herself during this time of role adjustment. Even if breastfeeding, other family members can participate in the infant's care. If depression occurs, then the symptoms will often interfere with mothering functions; therefore, family support is essential. The new mother should share her feelings with someone else and avoid overcommitting herself or feel as though she has to be superwoman. A telephone call to the hospital "warm line" may provide reassurance with lactation issues and other infant care questions. Should symptoms continue, a referral to a professional therapist may be necessary.

13. What is the most dangerous effect on the fetus of a mother who smokes cigarettes while pregnant? a. Genetic changes and anomalies b. Extensive CNS damage c. Fetal addiction to the substance inhaled d. Intrauterine growth restriction

D The major consequences of smoking tobacco during pregnancy are low-birth-weight infants, prematurity, and increased perinatal loss. Cigarettes will not normally cause genetic changes or extensive CNS damage. Addiction to tobacco is not a usual concern related to the neonate.

28. The obstetric nurse is preparing the client for an emergency cesarean birth, with no time to administer spinal anesthesia. The nurse is aware of and prepared for the greatest risk of administering general anesthesia to the client. What is this risk? a. Respiratory depression b. Uterine relaxation c. Inadequate muscle relaxation d. Aspiration of stomach contents

D (Aspiration of acidic gastric contents with possible airway obstruction is a potentially fatal complication of general anesthesia. Respirations can be altered during general anesthesia, and the anesthesiologist will take precautions to maintain proper oxygenation. Uterine relaxation can occur with some anesthesia but can be monitored and prevented. Inadequate muscle relaxation can be improved with medication.)

2. A woman who is pregnant for the first time is dilated 3 cm and having contractions every 5 minutes. She is groaning and perspiring excessively; she states that she did not attend childbirth classes. What is the optimal intervention for the nurse to provide at this time? a. Notify the womans health care provider. b. Administer the prescribed narcotic analgesic. c. Assure her that her labor will be over soon. d. Assist her with simple breathing and relaxation instructions.

D (By reducing tension and stress, both focusing and relaxation techniques will allow the woman in labor to rest and conserve energy for the task of giving birth. For those who have had no preparation, instruction in simple breathing and relaxation can be given in early labor and is often successful. The nurse can independently perform many functions in labor and birth, such as teaching and support. Pain medication may be an option for this client. However, the initial response of the nurse should include teaching the client about her options. The length of labor varies among individuals, but the first stage of labor is the longest. At 3 cm of dilation with contractions every 5 minutes, this woman has a significant amount of labor yet to experience.)

1. An 18-year-old pregnant woman, gravida 1, para 0, is admitted to the labor and birth unit with moderate contractions every 5 minutes that last 40 seconds. The client states, My contractions are so strong, I dont know what to do. Before making a plan of care, what should the nurses first action be? a. Assess for fetal well-being. b. Encourage the woman to lie on her side. c. Disturb the woman as little as possible. d. Recognize that pain is personalized for each individual.

D (Each womans pain during childbirth is unique and is influenced by a variety of physiologic, psychosocial, and environmental factors. A critical issue for the nurse is how support can make a difference in the pain of the woman during labor and birth. This scenario includes no information that would indicate fetal distress or a logical reason to be overly concerned about the well-being of the fetus. The left lateral position is used to alleviate fetal distress, not maternal stress. The nurse has an obligation to provide physical, emotional, and psychosocial care and support to the laboring woman. This client clearly needs support.)

11. Which statement correctly describes the effects of various pain factors? a. Higher prostaglandin levels arising from dysmenorrhea can blunt the pain of childbirth. b. Upright positions in labor increase the pain factor because they cause greater fatigue. c. Women who move around trying different positions experience more pain. d. Levels of pain-mitigating beta-endorphins are higher during a spontaneous, natural childbirth.

D (Higher endorphin levels help women tolerate pain and reduce anxiety and irritability. Higher prostaglandin levels correspond to more severe labor pains. Upright positions in labor usually result in improved comfort and less pain. Moving freely to find more comfortable positions is important for reducing pain and muscle tension.)

21. A woman in the active phase of the first stage of labor is using a shallow pattern of breathing, which is approximately twice the normal adult breathing rate. She starts to complain about feeling lightheaded and dizzy and states that her fingers are tingling. Which intervention should the nurse immediately initiate? a. Contact the womans physician. b. Tell the woman to slow her pace of her breathing. c. Administer oxygen via a mask or nasal cannula. d. Help her breathe into a paper bag.

D (This woman is experiencing the side effects of hyperventilation, which include the symptoms of lightheadedness, dizziness, tingling of the fingers, or circumoral numbness. Having the woman breathe into a paper bag held tightly around her mouth and nose may eliminate respiratory alkalosis and enable her to rebreathe carbon dioxide and replace the bicarbonate ion.)

7. A client is in early labor, and her nurse is discussing the pain relief options she is considering. The client states that she wants an epidural no matter what! What is the nurses best response? a. Ill make sure you get your epidural. b. You may only have an epidural if your physician allows it. c. You may only have an epidural if you are going to deliver vaginally. d. The type of analgesia or anesthesia used is determined, in part, by the stage of your labor and the method of birth.

D (To avoid suppressing the progress of labor, pharmacologic measures for pain relief are generally not implemented until labor has advanced to the active phase of the first stage and the cervix is dilated approximately 4 to 5 cm. A plan of care is developed for each woman that addresses her particular clinical and nursing problems. The nurse collaborates with the primary health care provider and the laboring woman in selecting features of care relevant to the woman and her family. The decision whether to use an epidural to relieve labor pain is multifactorial. The nurse should not make a blanket statement guaranteeing the client one pharmacologic option over another until a complete history and physical examination has been obtained. A physicians order is required for pharmacologic options for pain management. However, expressing this requirement is not the nurses best response. An epidural is an effective pharmacologic pain management option for many laboring women. It can also be used for anesthesia control if the woman undergoes an operative delivery.)

15. Maternity nurses often have to answer questions about the many, sometimes unusual, ways people have tried to make the birthing experience more comfortable. Which information regarding nonpharmacologic pain relief is accurate? a. Music supplied by the support person has to be discouraged because it could disturb others or upset the hospital routine. b. Women in labor can benefit from sitting in a bathtub, but they must limit immersion to no longer than 15 minutes at a time. c. Effleurage is permissible, but counterpressure is almost always counterproductive. d. Electrodes attached to either side of the spine to provide high-intensity electrical impulses facilitate the release of endorphins.

D (Transcutaneous electrical nerve stimulation (TENS) may help and is most useful for lower back pain that occurs during the first stage of labor. Music may be very helpful for reducing tension and certainly can be accommodated by the hospital. Women can stay in a bath as long as they want, although repeated baths with breaks might be more effective than one long bath. Counterpressure can help the woman cope with lower back pain.)

A family is visiting two surviving triplets. The third triplet died 2 days ago. What action would indicate that the family had begun to grieve for the dead infant? a. They refer to the two live infants as twins. b. They ask about the dead triplet's current status. c. They bring in play clothes for all three infants. d. They refer to the dead infant in the past tense.

D. They refer to the dead infant in the past tense Accepting that the infant is dead (in the past tense of the word) demonstrates acceptance of the reality and that the family has begun to grieve. Referring to the two live infants as twins, asking about the dead infant's current status, and bringing clothing for all three infants indicate that the parents are still in denial.

Early postpartum hemorrhage is defined as a blood loss greater than: a. 500 mL in the first 24 hours after vaginal delivery. b. 750 mL in the first 24 hours after vaginal delivery. c. 1000 mL in the first 48 hours after cesarean delivery. d. 1500 mL in the first 48 hours after cesarean delivery.

a. 500 mL in the first 24 hours after vaginal delivery.

What PPH conditions are considered medical emergencies that require immediate treatment? a. Inversion of the uterus and hypovolemic shock b. Hypotonic uterus and coagulopathies c. Subinvolution of the uterus and idiopathic thrombocytopenic purpura d. Uterine atony and disseminated intravascular coagulation

a. Inversion of the uterus and hypovolemic shock Inversion of the uterus and hypovolemic shock are considered medical emergencies. Although hypotonic uterus and coagulopathies, subinvolution of the uterus and idiopathic thrombocytopenic purpura, and uterine atony and disseminated intravascular coagulation are serious conditions, they are not necessarily medical emergencies that requires immediate treatment.

According to Beck's studies, what risk factor for postpartum depression is likely to have the greatest effect on the woman's condition? a. Prenatal depression b. Single-mother status c. Low socioeconomic status d. Unplanned or unwanted pregnancy

a. Prenatal depression Prenatal depression has been found by Beck to have the greatest likely effect. Single-mother status and low socioeconomic status are small-relation predictors, as is an unwanted pregnancy.

The perinatal nurse caring for the postpartum woman understands that late postpartum hemorrhage (PPH) is most likely caused by: a. Subinvolution of the placental site. b. Defective vascularity of the decidua. c. Cervical lacerations. d. Coagulation disorders.

a. Subinvolution of the placental site. Late PPH may be the result of subinvolution of the uterus, pelvic infection, or retained placental fragments. Late PPH is not typically a result of defective vascularity of the decidua, cervical lacerations, or coagulation disorders.

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. Uterine atony is marked hypotonia of the uterus. It is the leading cause of postpartum hemorrhage. Uterine inversion may lead to hemorrhage, but it is not the most likely source of this client's bleeding. Furthermore, if the woman were experiencing a uterine inversion, it would be evidenced by the presence of a large, red, rounded mass protruding from the introitus. A vaginal hematoma may be associated with hemorrhage. However, the most likely clinical finding would be pain, not the presence of profuse bleeding. A vaginal laceration may cause hemorrhage, but it is more likely that profuse bleeding would result from uterine atony. A vaginal laceration should be suspected if vaginal bleeding continues in the presence of a firm, contracted uterine fundus.

A newborn in the neonatal intensive care unit (NICU) is dying as a result of a massive infection. The parents speak to the neonatologist, who informs them of their son's prognosis. When the father sees his son, he says, "He looks just fine to me. I can't understand what all this is about." The most appropriate response by the nurse would be: a. "Didn't the doctor tell you about your son's problems?" b. "This must be a difficult time for you. Tell me how you're doing." c. To stand beside him quietly. d. "You'll have to face up to the fact that he is going to die sooner or later."

b. "This must be a difficult time for you. Tell me how you're doing." The grief phase can be very difficult, especially for fathers. Parents should be encouraged to share their feelings as the initial steps in the grieving process. This father is in a phase of acute distress and is "reaching out" to the nurse as a source of direction in his grieving process. Shifting the focus is not in the best interest of the parent. Nursing actions may help the parents actualize the loss of their infant through sharing and verbalization of feelings of grief. "You'll have to face up to the fact that he is going to die sooner or later" is dispassionate and inappropriate statement.

Which woman is at greatest risk for early postpartum hemorrhage (PPH)? a. A primiparous woman (G 2 P 1 0 0 1) being prepared for an emergency cesarean birth for fetal distress b. A woman with severe preeclampsia who is receiving magnesium sulfate and whose labor is being induced c. A multiparous woman (G 3 P 2 0 0 2) with an 8-hour labor d. A primigravida in spontaneous labor with preterm twins

b. A woman with severe who is receiving magnesium sulfate and whose labor is being induced. Magnesium sulfate administration during labor poses a risk for PPH. Magnesium acts as a smooth muscle relaxant, thereby contributing to uterine relaxation and atony. Although many causes and risk factors are associated with PPH, the primiparous woman being prepared for an emergency c-section, the multiparous woman with 8-hour labor, and the primigravida in spontaneous labor do not pose risk factors or causes of early PPH.

A woman is diagnosed with having a stillborn. At first, she appears stunned by the news, cries a little, and then asks you to call her mother. The phase of bereavement the woman is experiencing is called: a. Anticipatory grief. b.Acute distress. c. Intense grief. d. Reorganization.

b. Acute distress. The immediate reaction to news of a perinatal loss or infant death encompasses a period of acute distress. Disbelief and denial can occur. However, parents also feel very sad and depressed. Intense outbursts of emotion and crying are normal. However, lack of affect, euphoria, and calmness may occur and may reflect numbness, denial, or personal ways of coping with stress. Anticipatory grief applies to the grief related to a potential loss of an infant. The parent grieves in preparation of the infant's possible death, although he or she clings to the hope that the child will survive. Intense grief occurs in the first few months after the death of the infant. This phase encompasses many different emotions, including loneliness, emptiness, yearning, guilt, anger, and fear. Reorganization occurs after a long and intense search for meaning. Parents are better able to function at work and home, experience a return of self-esteem and confidence, can cope with new challenges, and have placed the loss in perspective.

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. Assess the fundus for firmness.

The prevalence of urinary incontinence (UI) increases as women age, with more than one third of women in the United States suffering from some form of this disorder. The symptoms of mild to moderate UI can be successfully decreased by a number of strategies. Which of these should the nurse instruct the client to use first? a. Pelvic floor support devices b. Bladder training and pelvic muscle exercises c. Surgery d. Medications

b. Bladder training and pelvic muscle exercises Pelvic muscle exercises, known as Kegel exercises, along with bladder training can significantly decrease or entirely relieve stress incontinence in many women. Pelvic floor support devices, also known as pessaries, come in a variety of shapes and sizes. Pessaries may not be effective for all women and require scrupulous cleaning to prevent infection. Anterior and posterior repairs and even a hysterectomy may be performed. If surgical repair is performed, the nurse must focus her care on preventing infection and helping the woman avoid putting stress on the surgical site. Pharmacologic therapy includes serotonin-norepinephrine uptake inhibitors or vaginal estrogen therapy. These are not the first action a nurse should recommend.

A mother in late middle age who is certain she is not pregnant tells the nurse during an office visit that she has urinary problems and sensations of bearing down and of something in her vagina. The nurse would realize that the client most likely is suffering from: a. Pelvic relaxation. b. Cystoceles and/or rectoceles. c. Uterine displacement. d. Genital fistulas.

b. Cystoceles and/or rectoceles. Cystoceles are protrusions of the bladder downward into the vagina; rectoceles are herniations of the anterior rectal wall through a relaxed or ruptured vaginal fascia. Both can present as a bearing down sensation with urinary dysfunction. They occur more often in older women who have borne children.

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. Lacerations of the genital tract.

Which 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 any increase in the amount of lochia or 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. Notify the physician of any increase in the amount of lochia or a return to bright red bleeding.

During a follow-up visit, if parents have progressed to the second stage or phase of grieving, the nurse should not expect to see: a. Guilt, particularly in the mother. b. Numbness or lack of response. c. Bitterness or irritability. d. Fear and anxiety, especially about getting pregnant again.

b. Numbness or lack of response The second phase of grieving encompasses a wide range of intense emotions, including guilt, anger, bitterness, fear, and anxiety. What the nurse would hope not to see is numbness or unresponsiveness, as if the parents were still in denial or shock.

A primary nursing responsibility when caring for a woman experiencing an obstetric hemorrhage associated with uterine atony is to: a. Establish venous access. b. Perform fundal massage. c. Prepare the woman for surgical intervention. d. Catheterize the bladder.

b. Perform fundal massage. The initial management of excessive postpartum bleeding is firm massage of the uterine fundus. Although establishing venous access may be a necessary intervention, the initial intervention would be fundal massage. The woman may need surgical intervention to treat her postpartum hemorrhage, but the initial nursing intervention would be to assess the uterus. After uterine massage the nurse may want to catheterize the client to eliminate any bladder distention that may be preventing the uterus from contracting properly.

The perinatal nurse assisting with establishing lactation is aware that acute mastitis can be minimized by: a. Washing the nipples and breasts with mild soap and water once a day. b. Using proper breastfeeding techniques. c. Wearing a nipple shield for the first few days of breastfeeding. d. Wearing a supportive bra 24 hours a day.

b. Using proper breastfeeding techniques. Almost all instances of acute mastitis can be avoided by proper breastfeeding technique to prevent cracked nipples. Washing the nipples and breasts daily is no longer indicated. In fact, this can cause tissue dryness and irritation, which can lead to tissue breakdown and infection. Wearing a nipple shield does not prevent mastitis. Wearing a supportive bra 24 hours a day may contribute to mastitis, especially if an underwire bra is worn, because it may put pressure on the upper, outer area of the breast, contributing to blocked ducts and mastitis.

The nurse should be aware that a pessary would be most effective in the treatment of what disorder? a. Cystocele b. Uterine prolapse c. Rectocele d. Stress urinary incontinence

b. Uterine prolapse A fitted pessary may be inserted into the vagina to support the uterus and hold it in the correct position. A pessary is not used for a cystocele, a rectocele, or stress urinary incontinence.

Which options for saying goodbye would the nurse want to discuss with a woman who is diagnosed with having a stillborn girl? a. The nurse shouldn't discuss any options at this time; there is plenty of time after the baby is born. b. "Would you like a picture taken of your baby after birth?" c. "When your baby is born, would you like to see and hold her?" d. "What funeral home do you want notified after the baby is born?"

c. "When your baby is born, would you like to see and hold her?" Mothers and fathers may find it helpful to see the infant after delivery. The parents' wishes should be respected. Interventions and support from the nursing and medical staff after a prenatal loss are extremely important in the healing of the parents. Although this may be an intervention, the initial intervention should be related directly to the parents' wishes with regard to seeing or holding their dead infant. Although this information may be relevant, it is not the most appropriate option at this time. Burial arrangements can be discussed after the infant is born.

Despite popular belief, there is a rare type of hemophilia that affects women of childbearing age. von Willebrand disease is the most common of the hereditary bleeding disorders and can affect males and females alike. It results from a factor VIII deficiency and platelet dysfunction. Although factor VIII levels increase naturally during pregnancy, there is an increased risk for postpartum hemorrhage from birth until 4 weeks after delivery as levels of von Willebrand factor (vWf) and factor VIII decrease. The treatment that should be considered first for the client with von Willebrand disease who experiences a postpartum hemorrhage is: a. Cryoprecipitate. b.Factor VIII and vWf. c. Desmopressin d. Hemabate.

c. Desmopressin Desmopressin is the primary treatment of choice. This hormone can be administered orally, nasally, and intravenously. This medication promotes the release of factor VIII and vWf from storage. Cryoprecipitate may be used; however, because of the risk of possible donor viruses, other modalities are considered safer. Treatment with plasma products such as factor VIII and vWf are an acceptable option for this client. Because of the repeated exposure to donor blood products and possible viruses, this is not the initial treatment of choice. Although the administration of this prostaglandin is known to promote contraction of the uterus during postpartum hemorrhage, it is not effective for the client who presents with a bleeding disorder.

When a woman is diagnosed with postpartum depression (PPD) with psychotic features, 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. Harm her infant. Thoughts of harm to one's self or the infant are among the most serious symptoms of PPD and require immediate assessment and intervention. Although outbursts of anger, hygiene neglect, and loss of interest in her husband are attributable to PPD, the major concern would be the potential to harm herself or her infant.

Complicated bereavement: a. Occurs when, in multiple births, one child dies, and the other or others live. b. Is a state in which the parents are ambivalent, as with an abortion. c. Is an extremely intense grief reaction that persists for a long time. d. Is felt by the family of adolescent mothers who lose their babies.

c. Is an extremely intense grief reaction that persists for a long time.

To provide adequate postpartum care, the nurse should be aware that postpartum depression (PPD) without psychotic features: a. Means that the woman is experiencing the baby blues. In addition she has a visit with a counselor or psychologist. b. Is more common among older, Caucasian women because they have higher expectations. c. Is distinguished by irritability, severe anxiety, and panic attacks. d. Will disappear on its own without outside help.

c. Is distinguished by irritability, severe anxiety, and panic attacks. PPD is also characterized by spontaneous crying long after the usual duration of the baby blues. PPD, even without psychotic features, is more serious and persistent than postpartum baby blues. It is more common among younger mothers and African-American mothers. Most women need professional help to get through PPD, including pharmacologic intervention.

During the initial acute distress phase of grieving, parents still must make unexpected and unwanted decisions about funeral arrangements and even naming the baby. The nurse's role should be to: a. Take over as much as possible to relieve the pressure. b. Encourage grandparents to take over. c. Make sure the parents themselves approve the final decisions. d. Let them alone to work things out.

c. Make sure the parents themselves approve the final decisions. The nurse is always the client's advocate. Nurses can offer support and guidance and leave room for the same from grandparents. However, in the end nurses should strive to let the parents make the final decisions.

What infection is contracted mostly by first-time mothers who are breastfeeding? a. Endometritis b. Wound infections c. Mastitis d. Urinary tract infections

c. Mastitis Mastitis is infection in a breast, usually confined to a milk duct. Most women who suffer this are first-timers who are breastfeeding.

The first and most important nursing intervention when a nurse observes profuse postpartum bleeding is to: a. Call the woman's primary health care provider. b. Administer the standing order for an oxytocic. c. Palpate the uterus and massage it if it is boggy. d. Assess maternal blood pressure and pulse for signs of hypovolemic shock.

c. Palpate the uterus and massage it if it is boggy. The initial management of excessive postpartum bleeding is firm massage of the uterine fundus. Though calling the health care provider, administering an oxytocic, and assessing maternal BP are appropriate interventions, the primary intervention should be to assess the uterus. Uterine atony is the leading cause of postpartum hemorrhage (PPH).

Anxiety disorders are the most common mental disorders that affect women. While providing care to the maternity patient, the nurse should be aware that one of these disorders is likely to be triggered by the process of labor and birth. This disorder is: a. Phobias. b. Panic disorder. c. Post-traumatic stress disorder (PTSD). d. Obsessive-compulsive disorder (OCD).

c. Post-traumatic stress disorder (PTSD).

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 that cause mastitis are not passed to the milk.

A woman who has recently given birth complains of pain and tenderness in her leg. On physical examination the nurse notices warmth and redness over an enlarged, hardened area. The nurse should suspect __________ and should confirm the diagnosis by ___________. a. Disseminated intravascular coagulation; asking for laboratory tests b. von Willebrand disease; noting whether bleeding times have been extended c. Thrombophlebitis; using real-time and color Doppler ultrasound d. Coagulopathies; drawing blood for laboratory analysis

c. Thrombophlebitis; using real-time and color Doppler ultrasound Pain and tenderness in the extremities, which show warmth, redness, and hardness, likely indicate thrombophlebitis. A Doppler ultrasound is a common noninvasive way to confirm diagnosis.

After giving birth to a stillborn infant, the woman turns to the nurse and says, "I just finished painting the baby's room. Do you think that caused my baby to die?" The nurse's best response to this woman is: a. "That's an old wives' tale; lots of women are around paint during pregnancy, and this doesn't happen to them." b. "That's not likely. Paint is associated with elevated pediatric lead levels." c. Silence. d. "I can understand your need to find an answer to what caused this. What else are you thinking about?"

d. "I can understand your need to find an answer to what caused this. What else are you thinking about?" The statement, "I can understand your need to find an answer to what caused this. What else are you thinking about?" is very appropriate for the nurse. It demonstrates caring and compassion and allows the mother to vent her thoughts and feelings, which is therapeutic in the process of grieving. The nurse should resist the temptation to give advice or to use clichés in offering support to the bereaved. In addition, trying to give bereaved parents answers when no clear answers exist or trying to squelch their guilt feeling does not help the process of grief. Trying to give bereaved parents answers when no clear answers exist does not help the grief process. In addition, this response probably would increase the mother's feelings of guilt. One of the most important goals of the nurse is to validate the experience and feelings of the parents by encouraging them to tell their stories and listening with care. The nurse should encourage the mother to express her ideas.

A woman experienced a miscarriage at 10 weeks of gestation and had a dilation and curettage (D&C). She states that she is just fine and wants to go home as soon as possible. While you are assessing her responses to her loss, she tells you that she had purchased some baby things and had picked out a name. On the basis of your assessment of her responses, what nursing intervention would you use first? a. Ready her for discharge. b. Notify pastoral care to offer her a blessing. c. Ask her whether she would like to see what was obtained from her D&C. d. Ask her what name she had picked out for her baby.

d. Ask her what name she had picked out for her baby. One way of actualizing the loss is to allow parents to name the infant. The nurse should follow this client's cues and inquire about naming the infant. The client is looking for an opportunity to express her feelings of loss. The nurse should take this opportunity to offer support by allowing the woman to talk about her feelings. Furthermore, one way of actualizing the loss is to allow parents to name the infant. The nurse should follow this client's cues and inquire about naming the infant. Although it may be therapeutic to offer religious support, the nurse should take this opportunity to offer support by allowing the woman to talk about her feelings. Furthermore, one way of actualizing the loss is to allow parents to name the infant. Asking the woman if she would like to see what was obtained from her D&C is completely inappropriate.

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

The nurse caring for a family during a loss may notice that survival guilt sometimes is felt at the death of an infant by the child's: a. Siblings. b. Mother. c. Father. d. Grandparents.

d. Grandparents. Survival guilt sometimes is felt by grandparents, because they believe that the death upsets the natural order of things. They are angry that they are alive and their grandchild is not.

The most appropriate statement that the nurse can make to bereaved parents is: a. "You have an angel in heaven." b. "I understand how you must feel." c. "You're young and can have other children." d. "I'm sorry."

d. I'm sorry One of nurse's most important goals is to validate the experience and feelings of the parents by encouraging them to tell their stories and listening with care. At the very least, the nurse should acknowledge the loss with a simple but sincere comment such as, "I'm sorry." The initial impulse may be to reduce one's sense of helplessness and say or do something that you think will reduce their pain. Although such a response may seem supportive at the time, it can stifle the further expression of emotion. The nurse should resist the temptation to give advice or to use clichés when offering support to the bereaved. Saying, "You're young and can have other children" is not a therapeutic response for the nurse to make.

To provide adequate postpartum care, the nurse should be aware that postpartum depression (PPD) with psychotic features: a. Is more likely to occur in women with more than two children. b. Is rarely delusional and then is usually about someone trying to harm her (the mother). c. Although serious, is not likely to need psychiatric hospitalization. d. May include bipolar disorder (formerly called "manic depression").

d. May include bipolar disorder (formerly called "manic depression"). Manic mood swings are possible. PPD is more likely to occur in first-time mothers. Delusions may be present in 50% of women with PPD, usually about something being wrong with the infant. PPD with psychosis is a psychiatric emergency that requires hospitalization.

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

With shortened hospital stays, new mothers are often discharged before they begin to experience symptoms of the baby blues or postpartum depression. As part of the discharge teaching, the nurse can prepare the mother for this adjustment to her new role by instructing her regarding self-care activities to help prevent postpartum depression. The most accurate statement as related to these activities is to: a. Stay home and avoid outside activities to ensure adequate rest. b. Be certain that you are 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. Realize that this is a common occurrence that affects many women Should the new mother experience symptoms of the baby blues, it is important that she be aware that this is nothing to be ashamed of. As many as 15% of new mothers experience similar symptoms. Although it is important for the mother to obtain enough rest, she should not distance herself from family and friends. Her spouse or partner can communicate the best visiting times so the new mother can obtain adequate rest. It is also important that she not isolate herself at home during this time of role adjustment. Even if breastfeeding, other family members can participate in the infant's care. If depression occurs, the symptoms can often interfere with mothering functions and this support will be essential. The new mother should share her feelings with someone else. It is also important that she not overcommit herself or think she has to be "superwoman." A telephone call to the hospital warm line may provide reassurance with lactation issues and other infant care questions. Should symptoms continue, a referral to a professional therapist may be necessary.

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 on 2 successive days starting 24 hours after birth.

d. Temperature of 38° C (100.4° F) or higher on 2 successive days starting 24 hours after birth. Postpartum or puerperal infection is any clinical infection of the genital canal that occurs within 28 days after miscarriage, induced abortion, or 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 would be a late finding associated with infection. Pain with voiding may indicate a urinary tract infection, 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.

Nurses need to know the basic definitions and incidence data about postpartum hemorrhage (PPH). For instance: a. PPH is easy to recognize early; after all, the woman is bleeding. b. Traditionally it takes more than 1000 mL of blood after vaginal birth and 2500 mL after cesarean birth to define the condition as PPH. c. If anything, nurses and doctors tend to overestimate the amount of blood loss. d. Traditionally PPH has been classified as early or late with respect to birth.

d. Traditionally PPH has been classified as early or late with respect to birth. Early PPH is also known as primary, or acute, PPH; late PPH is known as secondary PPH. Unfortunately PPH can occur with little warning and often is recognized only after the mother has profound symptoms. Traditionally a 500-ml blood loss after a vaginal birth and a 1000-ml blood loss after a cesarean birth constitute PPH. Medical personnel tend to underestimate blood loss by as much as 50% in their subjective observations.

When caring for a postpartum woman experiencing hemorrhagic 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. Urinary output of at least 30 mL/hr.

d. Urinary output of at least 30 mL/hr. Hemorrhage may result in hemorrhagic 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 would be an indicative finding associated with hemorrhagic shock. Hemorrhagic shock is associated with lethargy, not restlessness.