Maternity Concepts Generalized

A primiparous client diagnosed with cystitis at 48 hours postpartum who is receiving intravenous ampicillin asks the nurse, "Can I still continue to breastfeed my baby?" The nurse should tell the client:

"You can continue to breastfeed as long as you want to do so."

In the maternal attachment process, which statement best describes the anticipated actions in the taking-hold phase?

Kissing, embracing, and caring for the neonate

A client in the first stage of labor is being monitored using an external fetal monitor. After the nurse reviews the monitoring strip from the client's chart, into which of the following positions would the nurse assist the client?

Left Lateral

What assessment data of a laboring woman would require further intervention by the nurse?

Maternal heart rate 125 beats/minute

During the assessment, the nurse observes a gray pigmented nevus on the neonate's buttocks. The nurse documents this as which finding?

Mongolian spot

A primigravida in active labor is about 10 days postterm. The client desires a pudendal block anesthetic before childbirth. After the nurse explains this type of anesthesia to the client, which location if identified by the client as the area of relief would indicate to the nurse that the teaching was effective?

Perineum

The cervix of a 15-year-old primigravid client admitted to the labor area is 2 cm dilated and 50% effaced. Her membranes are intact, and contractions are occurring every 5 to 6 minutes. Which intervention should the nurse recommend at this time?

Walk around the hallway

While assessing a neonate weighing 3,175 g (7 lb) who was born at 39 weeks' gestation to a primiparous client who admits to opiate use during pregnancy, which finding would alert the nurse to possible opiate withdrawal?

high-pitched cry

A nurse visits a client at home on the 10th postpartum day. When assessing the client's uterus, which finding requires further evaluation?

A fundus palpable at the umbilicus A fundus palpable at the umbilicus 10 days postpartum is abnormal. The fundus is typically at this level 1 hour after delivery. By the 10th day postpartum, the uterus should no longer be palpable. Lochia alba is normal at 10 days postpartum. Minimal afterpains when nursing is a normal finding.

While caring for a multigravida in active labor with no anesthesia, the nurse midwife determines that the client's cervix is completely dilated. The nurse midwife should instruct the client to deliver the fetal head by pushing: a.) As soon as a contraction begins. b.) When she has an urge to push. c.) Near the end of a contraction. d.) Between contractions.

b.) When she has an urge to push.

A 29-week gestation client arrives in the labor and birth suite for an emergency cesarean section. The neonate is born and artificial surfactant is administered. Which action best explains the main function and goal of surfactant use?

Helps lungs remain expanded after the initiation of breathing improving oxygenation. Surfactant works by reducing surface tension in the lung. It allows the lung to remain slightly expanded, decreasing the amount of work required for inspiration. Improved oxygenation, as determined by arterial blood gases, is noted. Surfactant has not been shown to influence ciliary body maturation, regulate the neonate's breathing pattern, or lubricate the respiratory tract.

The nurse is caring for a client in labor who is receiving epidural anesthesia. The nurse assesses a blood pressure of 80/40 mm Hg. Which of the following interventions will the nurse include in the client's plan of care?

Increase client's fluid rate

A 19-year-old primigravid client at 38 weeks' gestation is 7 cm dilated, and the presenting part is at +1 station. The client tells the nurse, "I need to push!" What should the nurse do next?

Instruct the client to use a pant-blow pattern of breathing. Pushing during the first stage of labor, when the urge is felt but the cervix is not completely dilated, may produce cervical swelling, making labor more difficult. The client should be encouraged to use a pant-blow (or blow-blow) pattern of breathing to help overcome the urge to push.

A client with hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome is admitted to the labor and delivery unit. The client's condition rapidly deteriorates and despite efforts by the staff, the client dies. After the client's death, the nursing staff displays many emotions. With whom should the nurse-manager consult to help the staff cope with this unexpected death?

The chaplain, because his educational background includes strategies for handling grief

A client in labor received an epidural for pain management. Before receiving the epidural, the client's blood pressure was 124/76 mm Hg. Ten minutes after receiving the epidural, the client's blood pressure is 98/56 mm Hg, and the mother is vomiting. Before calling the health care provider (HCP), the nurse should:

Turn the client to her side. The nurse should turn the client to the side to reduce pressure on the abdominal aorta. The IV fluid rate would be increased, not decreased. There is no information indicating the client has a full bladder or requires a vaginal examination.

Which behavior should cause the nurse to suspect that a client's labor is moving quickly and that the physician should be notified? a) An increased sense of rectal pressure b) Episodes of nausea and vomiting c) A decrease in intensity of contractions d) An increase in fetal heart rate variability

a) An increased sense of rectal pressure

While performing continuous electronic monitoring of a client in labor, the nurse should document which information about uterine contractions? a) Duration, frequency, and intensity b) Dilation, effacement, position c) Dilation, duration, and frequency d)Frequency, duration, maternal position

a) Duration, frequency, and intensity

A woman who is breastfeeding tells the nurse that she plans to return to work in 6 months and will probably wean her baby then. The client asks the nurse, "How will I stop producing milk when I want to wean the baby?" What information should the nurse give the client?

gradual decrease in milk supply as the baby nurses less

The nurse should be especially alert for what problem when caring for a term neonate, who weighed 10 lb (4,500 g) at birth, 1 hour after a vaginal birth?

hypoglycemia The neonate would be considered large for gestational age (LGA) because the neonate weighs more than 4,000 g (90th percentile). Therefore, the nurse needs to assess for the possibility of complications. Hypoglycemia is a problem for the LGA neonate because glycogen stores are quickly used to maintain the weight. Other common complications for an LGA neonate include hyperbilirubinemia from the bruising and polycythemia, cephalhematoma, caput succedaneum, molding, phrenic nerve paralysis, and a fractured clavicle. However, hyperbilirubinemia would not be evident 1 hour after birth. Hypercalcemia is not usually found in the LGA neonate. Hypocalcemia is common in infants of diabetic mothers. Hypermagnesemia may occur in neonates whose mothers received large doses of magnesium sulfate to treat severe preeclampsia.

Four hours after cesarean birth of a neonate weighing 8 lb, 13 oz (4,000 g), the primiparous client asks, "If I get pregnant again, will I need to have a cesarean?" When responding to the client, the nurse should base the response to the client about vaginal birth after cesarean (VBAC) on which standard of practice?

VBAC may be possible if the client has not had a classic uterine incision.

The nurse has provided an in-service presentation to ancillary staff about standard precautions on the birthing unit. The nurse determines that one of the staff members needs further instructions when the nurse observes which action?

Wearing of sterile gloves to bathe a neonate at 2 hours of age One of the staff members needs further instructions when the nurse observes the staff member wearing sterile gloves to bathe a neonate at 2 hours of age. Clean gloves should be worn, not sterile gloves. Sterile gloves are more expensive than clean gloves and are not necessary when bathing a neonate. Wearing protective goggles during a cesarean birth is a standard blood precaution. Bloody sheets should be placed in a designated container. Scalpel blades, needles, syringes, and other equipment used during birthing should be disposed of safely in appropriate, labeled containers.

A neonate is admitted to the neonatal intensive care unit for observation with a diagnosis of probable meconium aspiration syndrome (MAS). The neonate weighs 10 lb, 4 oz (4,650 g) and is at 41 weeks' gestation. What would be the priority problem for this neonate?

impaired gas exchange

The nurse is performing effleurage for a primigravid client in early labor. Which technique should the nurse use? Effleurage: a form of massage involving a circular stroking movement made with the palm of the hand.

light stroking of the skin surface

A labor and birth nurse is assessing the fetal heart rate of a client who is at term. Which of the following rates would cause the nurse to intervene?

60-79 beats per minute This fetal heart rate (FHR) could indicated fetal distress and should be evaluated first. In a full-term fetus, the baseline FHR normally ranges from 121-160 beats per minute. The greatest concern would be the lowest fetal heart rate range.

An alarm signals, indicating that a neonate's security identification band requires attention. The nurse responds immediately and finds that the parents removed the identification bands from the neonate. Which action should the nurse take next?

Compare the information on the neonate's identification bands with that of the mother's, then reattach the identification bands to one of the neonate's extremities. The nurse should immediately compare the information on the mother's identification band with that of the neonate's and then reattach the neonate's bands. This safety practice prevents infant abduction. Replacing the bands without first verifying identification is irresponsible. Reprimanding the parents will be detrimental to the nurse-parent relationship. The nurse isn't qualified to compare footprints.

A client states that her "water broke." Which action requires the nurse to have specialialized training?

Conducting a bedside ultrasound for an amniotic fluid index

frank breech presentation

In this position, the baby's buttocks are aimed at the birth canal with its legs sticking straight up in front of his or her body and the feet near the head

A nurse is instructing the client to do Kegel exercises. What should the nurse tell the client to do to perform these pelvic floor exercises?

Stop the flow of urine while urinating.

During the postpartum period, a nurse should assess for signs of normal involution. Which statement would indicate that a client is progressing normally?

The uterus is descending at the rate of one fingerbreadth per day.

The nurse instructs the client about the procedures that will be performed on the neonate immediately after birth to prevent meconium aspiration. The nurse determines that the instructions have been effective when the client states that which procedure will be done to her baby?

"Suctioning will be needed if the baby is floppy." Suctioning is only required if a baby is floppy or presents with poor respiratory effort. Meconium aspiration blocks the air flow to the alveoli, leading to potentially life-threatening respiratory complications.

A multigravid client admitted to the labor area is scheduled for a cesarean birth under spinal anesthesia. Which client statement indicates teaching about spinal anesthesia has been understood?

"The anesthetic may cause a severe headache, which is treatable."

An infant is born with facial abnormalities, growth restriction, developmental delays, and vision abnormalities. These abnormalities are likely caused by maternal:

Alcohol consumption.

A client has just given birth to her first child, a healthy, full-term girl. The client is Rho(D)-negative and her neonate is Rh-positive. What intervention will be performed to reduce the risk of Rh incompatibility?

Administration of Rho(D) immune globulin I.M. to the mother within 72 hours

A multigravid client is receiving oxytocin augmentation. When the client's cervix is dilated to 6 cm, her membranes rupture spontaneously with meconium-stained amniotic fluid. Which action should the nurse perform first?

Assess the fetal heart rate. Assessing the fetal heart rate is always a priority after spontaneous rupture of membranes has occurred. Also a common sign of fetal distress related to an inadequate transfer of oxygen to the fetus is meconium-stained fluid. Because the fetus has suffered hypoxia, close fetal heart rate monitoring is necessary. In addition, all clients are monitored continuously after rupture of membranes for fetal distress caused by cord prolapse. If there are increasing signs of fetal distress (e.g., late decelerations), the health care provider (HCP) should be notified immediately. A cesarean birth may be performed for fetal distress. Increasing the rate of the oxytocin infusion could lead to further fetal distress. Turning the client to the left side, rather than a knee-chest position, improves placental perfusion. The HCP may wish to determine the extent of cervical dilation to make a decision about whether a cesarean birth is warranted, but continuous fetal heart rate monitoring is essential to determine fetal status.

biliary atresia

Biliary atresia is a life-threatening condition in infants in which the bile ducts inside or outside the liver do not have normal openings.

When assessing the fetal heart rate tracing, the nurse becomes concerned about the fetal heart rate pattern. In response to the loss of variability, the nurse repositions the client to her left side and administers oxygen. These actions are likely to improve which of the following?

Fetal Hypoxia

During labor, a primigravid client receives an epidural anesthetic, and the nurse assists in monitoring maternal and fetal status. Which finding suggests an adverse reaction to the anesthesia?

Maternal tachycardia

A nurse and an LPN are working in the labor and birth unit. Of the activities that must be done immediately, which should the nurse assign to the LPN?

Perform a straight catheterization for protein analysis.

A term neonate's mother is O-negative, and cord studies indicate that the neonate is A-positive. Which finding indicates that the neonate developed hemolytic disease?

Signs of kernicterus

A nurse is caring for a 1-day postpartum mother who's very talkative but isn't confident in her decision-making skills. The nurse is aware that this is a normal phase for the mother. What is this phase called?

Taking-in phase

What interval should the nurse use when assessing the frequency of contractions of a multiparous client in active labor admitted to the birthing area? a)beginning of one contraction to the beginning of the next contraction b) end of one contraction to the end of the next contraction c ) beginning of one contraction to the end of the next contraction d) acme of one contraction to the beginning of the next contraction

a) beginning of one contraction to the beginning of the next contraction

While a 31-year-old multigravida at 39 weeks' gestation in active labor is being admitted, her amniotic membranes rupture spontaneously. The client's cervix is 5 cm dilated and the presenting part is at 0 station. Which of the following should the nurse do first? a) Prepare the client for imminent birth. b) Note the color, amount, and odor of the amniotic fluid. c) Auscultate the client's blood pressure. d) Perform a vaginal examination to determine dilation.

b) Note the color, amount, and odor of the amniotic fluid.

The nurse is preparing to administer erythromycin ophthalmic ointment to a neonate soon after birth. The nurse should explain to the parents that this medication, in addition to preventing blindness caused by gonococcal organisms, also prevents neonatal blindness caused by which organism?

chlamydia trachomatis Explanation: The use of erythromycin ophthalmic ointment prevents blindness from gonococcal organisms and C. trachomatis. This ointment usually is less expensive than tetracycline. Beta-hemolytic streptococcus, E. coli, and S. aureus can cause a generalized infection in the neonate. However, these organisms typically are not responsible for causing neonatal blindness.

The health care provider (HCP) prescribes scalp stimulation of the fetal head for a primigravid client in active labor. When explaining to the client about this procedure, what would the nurse include as the purpose?

increase in the fetal heart rate and variability

The nurse is caring for a multigravida in active labor with a fetus in a frank breech presentation. The nurse should notify the primary care provider if the nurse observes: a) meconium-stained amniotic fluid during the second stage of labor. b) fetal bradycardia at any time during the labor process. c) intense uterine contractions during the transition phase of labor. d) maternal tachycardia during a contraction.

fetal bradycardia at any time during the labor process.

While assessing a neonate 30 minutes after birth, the nurse observes that the child has a short neck covered with webbing. The nurse should further assess the client for:

genetic deviations. The nurse notifies the pediatrician because a short, webbed neck is associated with genetic deviations or chromosomal disorders such as Turner's syndrome. Cleft palate is associated with embryonic developmental failures and an abnormal opening in the palate. Potter's syndrome (renal agenesis) is characterized by an atypical facial appearance consisting of a flat nose, recessed chin, epicanthal folds, low-set abnormal ears, limb abnormalities, and pulmonary hypoplasia. Neural tube defects are associated with spina bifida or myelomeningocele.

A primigravid client at 41 weeks' gestation is admitted to the hospital's labor and birth unit in active labor. After 25 hours of labor with membranes ruptured for 24 hours, the client gives birth to a healthy neonate vaginally with a midline episiotomy. Which problem should the nurse identify as the priority for the client?

risk for infection