Maternal/Newborn EAQs
A nurse is providing discharge instructions to a client who has undergone anterior colporrhaphy. The nurse knows that the teaching has been understood if the client makes which statement?
"For discomfort I can try using warm compresses on my abdomen."
A primigravida is admitted to the birthing suite at term with contractions occurring every 5 to 8 minutes and a bloody show present. She and her partner attended childbirth preparation classes. Vaginal examination reveals that the cervix is dilated 3 cm and 75% effaced. The fetus is at +1 station in occiput anterior position, and the membranes are intact. The client is cheerful and relaxed and asks the nurse whether it is all right for her to walk around. In light of the nurse's observations regarding the contractions and the client's knowledge of the physiology and mechanism of labor, how should the nurse respond?
"It's all right for you to walk as long as you feel comfortable and your membranes are intact."
The nurse is performing a newborn assessment. Which finding indicates the need for follow-up care?
30-degree abduction of the infant's hips
A client at 7 weeks' gestation elects to undergo an induced abortion. After receiving oral mifepristone, she returns to the clinic 2 days later to have misoprostol inserted vaginally. How long after the procedure should the nurse have the client return for a follow-up visit?
4 to 8 days
On a return visit to the fertility clinic a couple requests fertility drugs because, despite having a 28-day menstrual cycle and temperature readings that demonstrate an ovulatory pattern, the woman has been unable to conceive. Which guidance should the nurse provide to this couple?
An examination of semen will be needed.
How does the nurse determine when true labor and not false labor is present?
Cervical dilation is evident
Which medication should be administered to prevent symptoms of withdrawal in a laboring client who routinely uses heroin?
Dolophine
An infant is born in the breech position, and assessment indicates the presence of Erb palsy (Erb-Duchenne paralysis). Which clinical manifestation supports this conclusion?
Flaccid arm with the elbow extended on the affected side
During a childbirth class the nurse determines that the women understand how to use effleurage correctly when they are observed doing what?
Massaging their abdomens gently with their fingertips
Before discharge, what suggestion should the nurse give to a nonnursing mother to help limit breast engorgement?
Place raw cabbage leaves over the breast.
A primigravida who is at 40 weeks' gestation arrives at the birthing center with abdominal cramping and a bloody show. Her membranes ruptured 30 minutes before arrival. A vaginal examination reveals 1 cm of dilation and the presenting part at -1 station. After obtaining the fetal heart rate and maternal vital signs, what should the nurse's priority intervention be?
Provide the client with comfort measures used for women in labor.
What is the most common complication for which a nurse must monitor preterm infants?
Respiratory distress
The nurse discusses fetal weight gain with a pregnant client. When does the fetus generally show a marked increase in size?
Third trimester
The newborn's total body response to noise or movement is often distressing to the parents. What should the nurse explain about this response?
This reflexive response is an expected part of development
A male newborn has been exposed to human immunodeficiency virus (HIV) in utero. Which assessment supports the diagnosis of HIV infection in the newborn?
Thrush that does not respond readily to treatment
he nurse is caring for a woman who just had a positive contraction stress test (CST). Which complication of pregnancy is of most concern when there is a positive CST?
Uteroplacental insufficiency
A neonate born at 32 weeks' gestation and weighing 3 lb (1361 g) is admitted to the neonatal intensive care unit. When should the nurse take the neonate's mother to visit the infant?
When the mother is well enough to be taken to the intensive care unit
The nurse is assessing a newborn of 33 weeks' gestation. Which sign alerts the nurse to notify the health care provider?
flaring nares
At 12 weeks' gestation a client with a history of several spontaneous abortions says to the nurse, "Every day I wonder whether I'll be able to have this baby." How should the nurse respond?
"It's understandable for you to be worried that you won't be able to carry this pregnancy to term. You've had a difficult time."
A client with mild preeclampsia is instructed to rest at home. She asks the nurse, "What do you mean by rest?" What is the most appropriate response? Correct
"Tell me what you consider rest."
The nurse assists a client to the bathroom to void several times during the first stage of labor. Why is this is an important component of nursing?
A full bladder may inhibit the progress of labor.
A 24-year-old client is admitted at 40 weeks' gestation. The cervix is dilated 5 cm and is 100% effaced, and the presenting part is at station 0. The nurse assesses that the fetal heart tones are just above the umbilicus. Which fetal presentation does the nurse document?
Breech
A client with chronic hypertension and superimposed preeclampsia gives birth at 39 weeks' gestation to a 4 lb 12 oz (2155 g) infant. What condition does the nurse anticipate when assessing this infant?
Intrauterine growth restriction
A nurse is assessing an infant with a tentative diagnosis of hypertrophic pyloric stenosis (HPS). For what clinical finding associated with this disorder should the nurse assess the infant?
Palpable mass in the epigastric area to the right of the umbilicus
A fetal monitor is applied to a client in labor. The nurse should take immediate action in response to which fetal heart rate?
Repeatedly drops abruptly to 90 beats/min unrelated to contractions
Which intervention does the nurse anticipate will be provided for the newborn of a mother with a long history of diabetes?
Special high-risk care
A nurse who is assessing a full-term newborn elicits the Moro reflex. Which method would the nurse utilize to best elicit this reflex?
Striking the surface of the infant's crib suddenly
A nurse is obtaining a health history from a client with newly diagnosed cervical cancer. Which aspect of the client's life is most important for the nurse to explore at this time?
support system