Maternity/OB HESI Practice Part #1
12. The nurse has completed discharge teaching with new parents who have been discharged home bottle-feeding a normal term newborn. Which of the following responses indicates the need for further teaching? 1. "Our baby will require feedings through the night for several weeks/months after birth." 2. "The baby should burp during and after each feeding with no projective vomiting." 3. "Our baby should have 1 to 3 soft, formed stools a day." 4. "We should weigh our baby daily to make sure he is gaining weight."
12. 4. Healthy infants are weighed during their visits to their primary care provider, so it is not necessary to monitor weights at home. Infants may require 1 to 3 feedings during the night initially. By 3 months, 90% of babies sleep through the night. Projective vomiting may indicate pyloric stenosis and should not be seen in a normal newborn. Bottle-fed infants may stool 1 to 3 times daily.
4. Prewarm the bed. The primary health care provider prescribes ampicillin 100 mg/kg/dose for a newly admitted neonate. The neonate weighs 1,350 g. How many milligrams should the nurse administer? _______________ mg.
4. 135 mg The recommended dose of ampicillin for a neonate is 100 mg/kg/dose. First, determine the neonate's weight in kilograms, and then multiply the kilograms by 100 mg. The nurse should use this formula:
6. A septic preterm neonate's IV was removed due to infiltration. While restarting the IV, the nurse should carefully assess the neonate for: 1. Fever. 2. Hyperkalemia. 3. Hypoglycemia. 4. Tachycardia.
6. 3. Neonates that are septic use glucose at an increased rate. During the time the IV is not infusing, the neonate is using the limited glucose stores available to a preterm neonate and may deplete them. Hypoglycemia is too little glucose in the blood; without the constant infusion of IV glucose, hypoglycemia will result. Fevers and hyperkalemia are not related to glucose levels. Tachycardia is the result of untreated hypoglycemia.
37. A primiparous client who gave vaginal birth to a viable term neonate 48 hours ago has a midline episiotomy and repair of a third-degree laceration. When preparing the client for discharge, which of the following assessments would be most important? 1. Constipation. 2. Diarrhea. 3. Excessive bleeding. 4. Rectal fistulas.
37. 1. The client with a third-degree laceration should be assessed for constipation, because a third-degree laceration extends into a portion of the anal sphincter. Constipation, not diarrhea, is more likely because this condition is extremely painful, possibly causing the client to be reluctant to have a bowel movement. The laceration has been sutured and should not be bleeding at 48 hours postpartum. Rectal fistulas may develop at a later time, but not at 48 hours postpartum.
3. A neonate is born by primary cesarean section at 36 weeks' gestation. The temperature in the birthing room is 70°F (21.1°C). To prevent heat loss from convection, which action should the nurse take? 1. Dry the neonate quickly after birth. 2. Keep the neonate away from air conditioning vents. 3. Place the neonate away from outside windows. 4. Prewarm the bed.
3. 2. The neonate should be kept away from drafts, such as from air conditioning vents, which may cause heat loss by convection. Evaporation is one of the most common mechanisms by which the neonate will lose heat, such as when the moisture on the newly born neonate's body is converted to vapor. Radiation is heat loss between solid objects that are not in contact with one another such as walls and windows. Conduction is when heat is transferred between solid objects in contact with one another, such as when a neonate comes in contact with a cold mattress or scale.
11. The nurse is teaching the mother of a newborn to develop her baby's sensory system. To further improve the infant's most developed sense, the nurse should instruct the mother to: 1. Speak in a high-pitched voice to get the newborn's attention. 2. Place the newborn about 12 inches from maternal face for best sight. 3. Stroke the newborn's cheek with her nipple to direct the baby's mouth to nipple. 4. Give infant formula with a sweetened taste to stimulate feeding.
11. 3. Currently, touch is believed to be the most highly developed sense at birth. It is probably why neonates respond well to touch. Auditory sense typically is relatively immature in the neonate, as evidenced by the neonate's selective response to the human voice. By 4 months, the neonate should turn his eyes and head toward a sound coming from behind. Visual sense tends to be relatively immature. At birth, visual acuity is estimated at 20/100 to 20/150, but it improves rapidly during infancy and toddlerhood. Taste is well developed, with a preference toward glucose; however, touch is more developed at birth.
38. In preparation for discharge, the nurse discusses sexual issues with a primiparous client who had a routine vaginal birth with a midline episiotomy. The nurse should instruct the client that she can resume sexual intercourse: 1. In 6 weeks when the episiotomy is completely healed. 2. After a postpartum check by the health care provider. 3. Whenever the client is feeling amorous and desirable. 4. When lochia flow and episiotomy pain have stopped.
38. 4. For most clients, sexual intercourse can be resumed when the lochia has stopped flowing and episiotomy pain has ceased, usually about 3 weeks postpartum. Sexual intercourse may be painful until the episiotomy has healed. The client also needs instructions about the possibility that pregnancy may occur before the return of the client's menstrual flow. The postpartum check by the health care provider typically occurs 4 to 6 weeks after birth and most women have already had intercourse by this time. Typically, new mothers are exhausted and may not feel amorous or desirable for quite a while. In addition, the mother's physiologic responses may be diminished because of low hormonal levels, adjustments to the maternal role, and fatigue due to lack of rest and sleep.
55. When assessing the frequency of contractions of a multiparous client in active labor admitted to the birthing area, the nurse should assess the interval between which of the following? 1. Acme of one contraction to the beginning of the next contraction. 2. Beginning of one contraction to the end of the next contraction. 3. End of one contraction to the end of the next contraction. 4. Beginning of one contraction to the beginning of the next contraction.
55. 4. To assess the frequency of the client's contractions, the nurse should assess the interval from the beginning of one contraction to the beginning of the next contraction. The duration of a contraction is the interval between the beginning and the end of a contraction. The acme identifies the peak of a contraction.
18. The nurse is to draw a blood sample for glucose testing from a term neonate during the first hour after birth. The nurse should obtain the blood sample from the neonate's foot near which of the following areas?
. In a neonate, the lateral aspect of the heel is the most appropriate site for obtaining a blood specimen. Using this area prevents damage to the calcaneus bone, which is located in the middle of the heel. The middle of the heel is to be avoided because of the increased risk for damaging the calcaneus bone located there. The middle of the foot contains the medial plantar nerve and the medial plantar artery, which could be injured if this site is selected. Using the base of the big toe as the site for specimen collection would cause a great deal of discomfort for the neonate; therefore, it is not the preferred site.
19. After circumcision with a Plastibell, the nurse should instruct the neonate's mother to cleanse the circumcision site with which of the following? 1. Antibacterial soap. 2. Warm water. 3. Povidone-iodine (Betadine) solution. 4. Diluted hydrogen peroxide.
19. 2. After circumcision with a Plastibell, the most commonly recommended procedure is to clean the circumcision site with warm water with each diaper change. Other treatments are necessary only if complications, such as an infection, develop. Antibacterial soap or diluted hydrogen peroxide may cause pain and is not recommended. Povidone-iodine solution may cause stinging and burning, and therefore its use is not recommended.
28. A primiparous client has just given birth to a healthy male infant. The client and her husband are Muslim and the husband begins chanting a song in Arabic while holding the neonate. The nurse interprets the father's actions as indicative of which of the following? 1. Thanking Allah for giving him a male heir. 2. Singing to his son from the Koran in praise of Allah. 3. Expressing appreciation that his wife and son are healthy. 4. Performing a ritual similar to baptism in other religions.
28. 2. The father is praying to Allah because of the Muslim belief that the first sounds a child hears should be from the Koran in praise of and supplication to Allah. Although male children are revered in this culture, this practice is performed by Muslims whether the child is male or female. The father's actions are unrelated to his wife and son's being healthy. The nurse should allow the practice because doing so demonstrates cultural sensitivity and builds a trusting relationship with the family. The Muslim faith does not have a baptism rite whereby the child becomes a member of the faith.
46. A 31-year-old multigravid client at 39 weeks' gestation admitted to the hospital in active labor is receiving intravenous lactated Ringer's solution and a continuous epidural anesthetic. During the first hour after administration of the anesthetic, the nurse should monitor the client for: 1. Hypotension. 2. Diaphoresis. 3. Headache. 4. Tremors.
46. 1. When a client receives an epidural anesthetic, sympathetic nerves are blocked along with the pain nerves, possibly resulting in vasodilation and hypotension. Other adverse effects include bladder distention, prolonged second stage of labor, nausea and vomiting, pruritus, and delayed respiratory depression for up to 24 hours after administration. Diaphoresis and tremors are not usually associated with the administration of epidural anesthesia. Headache, a common adverse effect of many drugs, also is not associated with administration of epidural anesthesia
53. The nurse is assessing fetal presentation in a multiparous client. The illustration below indicates which of the following types of presentation? 1. Frank breech. 2. Complete breech. 3. Footling breech. 4. Vertex.
53. 1. Breech presentations account for 5% of all births and the most common is frank breech. In frank breech, there is flexion of the fetal thighs and extension of the knees. The feet rest at the side of the fetal head. In complete breech, there is flexion of the fetal thighs and knees; the fetus appears to be squatting. Footling breech occurs when there is an extension of the fetal knees and one or both feet protrude through the cervix. Vertex presentation occurs in 95% of births with the head engaged in the pelvis.
22. A primiparous client, 20 hours after childbirth, asks the nurse about starting postpartum exercises. Which of the following would be most appropriate to include in the nurse's instructions? 1. Start in a sitting position, then lie back, and return to a sitting position, repeating this five times. 2. Assume a prone position, and then do push-ups by using the arms to lift the upper body. 3. Flex the knees while supine, and then inhale deeply and exhale while contracting the abdominal muscles. 4. Flex the knees while supine, and then bring chin to chest while exhaling and reach for the knees by lifting the head and shoulders while inhaling.
22. 3. After an uncomplicated birth, postpartum exercises may begin on the first postpartum day with exercises to strengthen the abdominal muscles. These are done in the supine position with the knees flexed, inhaling deeply while allowing the abdomen to expand and then exhaling while contracting the abdominal muscles. Exercises such as sit-ups (sitting, then lying back, and returning to a sitting position) and push-ups or exercises involving reaching for the knees are ordinarily too strenuous for the first postpartum day. Sit-ups may be done later in the postpartum period, after approximately 3 to 6 weeks.
56. While a client is being admitted to the birthing unit she states, "My water broke last night, but my labor started two hours ago." Which of the following is a concern? Select all that apply. 1. Maternal vital signs: T 99.5 (37.5), HR 80, R 24, BP 130/80 mm Hg. 2. Blood and mucus on perineal pad. 3. Baseline fetal heart rate of 140 with a range between 110 and 160 with
56. 3,4,5. The range of fetal heart rate fluctuating too high and low could indicate fetal distress. The green peripad fluid indicates meconium, which could be associated with fetal distress. Increased fetal activity during labor may also indicate distress. The maternal vital signs noted and a perineal pad with blood and mucus are normal findings. CN: Reduction of risk potential; CL: Analyze
14. While making a home visit to a primiparous client and her 3-day-old son, the nurse observes the mother changing the baby's disposable diaper. Before putting the clean diaper on the neonate, the mother begins to apply baby powder to the neonate's buttocks. Which of the following statements about baby powder should the nurse relate to the mother? 1. It may cause pneumonia to develop. 2. It helps prevent diaper rash. 3. It keeps the diaper from adhering to the skin. 4. It can result in allergies later in life.
14. 1. The nurse should inform the mother that baby powder can enter the neonate's lungs and result in pneumonia secondary to aspiration of the particles. The best prevention for diaper rash is frequent diaper changing and keeping the neonate's skin dry. The new disposable diapers have moisture-collecting materials and generally do not adhere to the skin unless the diaper becomes saturated. Typically, allergies are not associated with the use of baby powder in neonates.
15. After teaching a new mother about the care of her neonate after circumcision with a Gomco clamp, which of the following statements by the mother indicates to the nurse that the mother needs additional instructions? 1. "The petroleum gauze may fall off into the diaper." 2. "A few drops of blood oozing from the site is normal." 3. "I'll leave the gauze in place for 24 hours." 4. "I'll remove any yellowish crusting gently with water."
15. 4. The mother needs further instruction when she says that a yellowish crust should be removed with water. The yellowish crust is normal and indicates scar formation at the site. It should not be removed, because to do so might cause increased bleeding. The petroleum gauze prevents the diaper from sticking to the circumcision site, and it may fall off in the diaper. If this occurs, the mother should not attempt to replace it but should simply apply plain petroleum jelly to the site. The gauze should be left in place for 24 hours, and the mother should continue to apply petroleum jelly with each diaper change for 48 hours after the procedure. A few drops of oozing blood is normal, but if the amount is greater than a few drops the mother should apply pressure and contact the primary health care provider. Any bleeding after the first day should be reported.
21. After instructing a primiparous client about episiotomy care, which of the following client statements indicates successful teaching? 1. "I'll use hot, sudsy water to clean the episiotomy area." 2. "I wipe the area from front to back using a blotting motion." 3. "Before bedtime, I'll use a cold water sitz bath." 4. "I can use ice packs for 3 to 4 days after birth."
21. 2. The nurse should instruct the client to cleanse the perineal area with warm water and to wipe from front to back with a blotting motion. Warm water is soothing to the tender tissue, and wiping from front to back reduces the risk of contamination. Hot, sudsy water may increase the client's discomfort and may even burn the client in a very tender area. After the first 24 hours, warm water sitz baths taken three or four times a day for 20 minutes can help increase circulation to the area. Ice packs are helpful for the first 24 hours
60. When developing the plan of care for a multiparous client in active labor who receives an epidural anesthetic, which of the following would the nurse anticipate that the primary health care provider will prescribe if the client develops moderate hypotension? 1. Ephedrine. 2. Epinephrine. 3. Methylergonovine. 4. Atropine sulfate.
60. 1. The drug of choice when hypotension occurs as a result of epidural anesthesia is ephedrine sulfate because it provides a quick reversal of the vasodilator effects of the anesthesia. Epinephrine is typically used to treat anaphylactic shock. Methylergonovine is a vasoconstrictor that is used for severe postpartum hemorrhage. Atropine sulfate is used to dry the oral and respiratory secretions and may be used during operative procedures.
13. The nurse knows the mother of a neonate has understood her car seat safety instructions when she comments: 1. "I did not realize that even children between 1 to 2 years old are safer in rearfacing car seats." 2. "I should put my car seat in the front so I can watch my baby when I drive." 3. "I plan to use the car seat I saved from my last baby 10 years ago." 4. "The front-facing car seats do a better job supporting the head and neck of my baby."
13. 1. The head and neck are best supported in a rear-facing seat in infants and toddlers, and infants should remain rear facing for as long possible until they outgrow their car seat. In the United States, the American Academy of Pediatrics recommends a rear-facing car seat for children younger than 2 years. The middle of the back seat is safest for a car seat. Because plastic can become brittle over time, car seats have an expiration date that must be checked before use. Ten years would generally be outside of most car seats' expiration dates.
54. Two hours ago, a multigravid client was admitted in active labor with her cervix dilated at 5 cm and completely effaced and the fetus at 0 station. Currently, the client is experiencing nausea and vomiting, a slight chill with perspiration beads on her lip, and extreme irritability. The nurse should first: 1. Warm the temperature of the room by a few degrees. 2. Increase the rate of intravenous fluid administration. 3. Obtain a prescription for an intramuscular antiemetic medication. 4. Assess the client's cervical dilation and station.
54. 4. The nurse should assess the client's cervical dilation and station, because the client's symptoms are indicative of the transition phase of labor. Multiparous clients can proceed 5 to 9 cm/h during the active phase of labor. Warming the temperature of the room is not helpful because the client will soon be ready to begin expulsive pushing. Increasing the intravenous fluid rate is not warranted unless the client is experiencing dehydration. Administration of an antiemetic at this point in labor is not warranted and may result in neonatal depression should a rapid birth occur.
39. While caring for a multiparous client 4 hours after vaginal birth of a term neonate, the nurse notes that the mother's temperature is 99.8°F (37.2°C), the pulse is 66 bpm, and the respirations are 18 breaths/min. Her fundus is firm, midline, and at the level of the umbilicus. The nurse should: 1. Continue to monitor the client's vital signs. 2. Assess the client's lochia for large clots. 3. Notify the client's physician about the findings. 4. Offer the mother an ice pack for her forehead.
39. 1. The nurse needs to continue to monitor the client's vital signs. During the first 24 hours postpartum it is normal for the mother to have a slight temperature elevation because of dehydration. A temperature of 100.4°F (38°C) that persists after the first 24 hours may indicate an infection. Bradycardia during the first week postpartum is normal because of decreased blood volume, diuresis, and diaphoresis. The client's respiratory rate is within normal limits. Large clots are indicative of hemorrhage. However, the client's vital signs are within normal limits and her fundus is firm and midline. Therefore, large clots and possible hemorrhage can be ruled out. The physician does not need to be notified at this time. An ice pack is not necessary because the client's temperature is within normal limits.
59. A multigravid client admitted to the labor area is scheduled for a cesarean birth under spinal anesthesia. After instructions by the anesthesiologist, the nurse determines that the client has understood the instructions when she says which of the following? 1. "The medication will be administered while I am in prone position." 2. "The anesthetic may cause a severe headache which is treatable." 3. "My blood pressure may increase if I lie down too soon after the injection." 4. "I can expect immediate anesthesia that can be reversed very easily."
59. 2. Spinal anesthesia is used less commonly today because of preference for epidural block anesthesia. One of the adverse effects of spinal anesthesia is a "spinal headache" caused by leakage of spinal fluid from the needle insertion. This can be treated by applying a cool cloth to the forehead, keeping the client in a flat position, or using a blood patch that can clot and seal off any further leakage of fluid. Spinal anesthesia is administered with the client in a sitting position or side lying. Another adverse effect of spinal anesthesia is hypotension caused by vasodilation. General anesthesia provides immediate anesthesia, whereas the full effects of spinal anesthesia may not be felt for 20 to 30 minutes. General anesthesia can be discontinued quickly when the anesthesiologist administers oxygen instead of nitrous oxide. Epidural anesthesia may take 1 to 2 hours to wear off.
40. While assessing the episiotomy site of a primiparous client on the first postpartum day, the nurse observes a fairly large hemorrhoid at the client's rectum. After instructing the client about measures to relieve hemorrhoid discomfort, which of the following client statements indicates the need for additional teaching? 1. "I should try to gently manually replace the hemorrhoid." 2. "Analgesic sprays and witch hazel pads can relieve the pain." 3. "I should lie on my back as much as possible to relieve the pain." 4. "I should drink lots of water and eat foods that have a lot of roughage."
40. 3. The client needs more teaching when she states, "I should lie on my back as much as possible to relieve the pain." Instead, the client should lie in the Sims position as much as possible to aid venous return to the rectal area and to reduce discomfort. Gentle manual replacement of the hemorrhoid is an appropriate measure to help relieve the discomfort and prevent enlargement. Analgesic sprays and witch hazel pads are helpful in reducing the discomfort of hemorrhoids. Drinking lots of water and eating roughage aid in bowel elimination, minimizing the risk of straining and subsequent hemorrhoidal development or enlargement.
41. The nurse has just received report on a labor client: a G3 T1 P0 Ab1 L1who is 80/3/0, (80% effaced, 3 cm dilated, 0 station). The nurse anticipates the plan of care for the next shift will include which of the following? Select all that apply. 1. A birth before the change of shift in 12 hours. 2. Pushing the baby out should take 30 minutes or less. 3. Contractions will remain irregular until transition. 4. Transition will be shorter for this multiparous client. 5. This client will withdraw into herself during transition.
41. 1,2,4,5. A multiparous client usually gives birth within 12 hours of the time labor began. The pushing phase statistically takes 30 minutes or less and many multiparous clients go immediately from 10-cm dilation to birth. Contractions become regular and increase in frequency, intensity, and duration as labor progresses for both primiparous and multiparous clients. Transition will be shorter for a multiparous client than it will for a primiparous client, as the entire labor process takes less time for someone who has had a baby before. This client will withdraw into herself during transition and this is a common characteristic for those in the transition phase.
20. Approximately 90 minutes after birth, the nurse should encourage the mother of a term neonate to do which of the following? 1. Feed the neonate. 2. Allow the neonate to sleep. 3. Get to know the neonate. 4. Change the neonate's diaper.
20. 2. As part of the neonate's physiologic adaptation to birth, at 90 minutes after birth the neonate typically is in the rest or sleep phase. During this time, the heart and respiratory rates slow and the neonate sleeps, unresponsive to stimuli. At this time, the mother should rest and allow the neonate to sleep. Feedings should be given during the first period of reactivity, considered the first 30 minutes after birth. During this period, the neonate's respirations and heart rate are elevated. Getting to know the neonate typically occurs within the first hour after birth and then when the neonate is awake and during feedings. Changing the neonate's diaper can occur at any time, but at 90 minutes after birth the neonate is usually in a deep sleep, unresponsive, and probably hasn't passed any meconium.
49. Approximately 15 minutes after birth of a viable term neonate, a multiparous client has chills. Which of the following should the nurse do next? 1. Assess the client's pulse rate. 2. Decrease the rate of intravenous fluids. 3. Provide the client with a warm blanket. 4. Assess the amount of blood loss.
49. 3. A chill shortly after birth is a common, normal occurrence. Warm blankets can help provide comfort for the client. It has been suggested that the shivering response is caused by a difference between internal and external body temperatures. A different theory proposes that the woman is reacting to fetal cells that have entered the maternal bloodstream through the placental site. Assessing the client's pulse rate will provide no further information about the chill. Decreasing the IV rate will not influence the length of time the client trembles. Assessing blood loss is a standard of care at this point postpartum but has no correlation to the chill.
7. The nurse makes a home visit to a 3-day-old full-term neonate who weighed 3,912 g (8 lb, 10 oz) at birth. Today the neonate, who is being bottle-fed, weighs 3,572 g (7 lb, 14 oz). Which of the following instructions should the nurse give to the mother? 1. Continue feeding every 3 to 4 hours since the weight loss is normal. 2. Contact the primary health care provider if the weight loss continues over the next few days. 3. Switch to a soy-based formula because the current one seems inadequate. 4. Change to a higher-calorie formula to prevent further weight loss.
7. 1. This 3-day-old neonate's weight loss falls within a normal range, and therefore no action is needed at this time. Full-term neonates tend to lose 5% to 10% of their birth weight during the first few days after birth, most likely because of minimal nutritional intake. With bottle-feeding, the neonate's intake varies from one feeding to another. Additionally, the neonate experiences a loss of extracellular fluid. Typically, neonates regain any weight loss by 7 to 10 days of life. If the weight loss continues after that time, the primary health care provider should be called.
50. The primary health care provider plans to perform an amniotomy on a multiparous client admitted to the labor area at 41 weeks' gestation for labor induction. After the amniotomy, the nurse should first: 1. Monitor the client's contraction pattern. 2. Assess the fetal heart rate (FHR) for 1 full minute. 3. Assess the client's temperature and pulse. 4. Document the color of the amniotic fluid.
50. 2. After an amniotomy, the nurse should plan to first assess the FHR for 1 full minute. One of the complications of amniotomy is cord compression and/or prolapsed cord, and a FHR of 100 bpm or less should be promptly reported to the primary health care provider. A cord prolapse requires prompt birth by cesarean section. The client's contraction pattern should be monitored once labor has been established. The client's temperature, pulse, and respirations should be assessed every 2 to 4 hours after rupture of the membranes to detect an infection. The nurse should document the color, quantity, and odor of the amniotic fluid, but this can be done after the FHR is assessed and a normal pattern is present.
35. A postpartum client gave birth 6 hours ago without anesthesia and just voided 100 mL. The nurse palpates the fundus two fingerbreadths above the umbilicus and off to the right side. What should the nurse do first? 1. Administer ibuprofen. 2. Reassess in 1 hour. 3. Catheterize the client. 4. Obtain a prescription for a fluid bolus.
35. 3. A uterine fundus located off to one side and above the level of the umbilicus is commonly the result of a full bladder. Although the client had voided, the client may be experiencing urinary retention with overflow. If anesthesia has been used for birth, the inability to void may be related to the lingering effects of anesthesia; however, that is not the case here. Physicians commonly write a one-time order for catheterization, after which, typically, enough edema has subsided to make it easier and less painful for the client to void and completely empty her bladder. Administering ibuprofen would have no effect on the uterine fundus. Waiting to reassess in 1 hour could be detrimental since the client's distended bladder is interfering with uterine involution, predisposing her to possible hemorrhage. Administering a bolus of fluid would be inappropriate because it would only add to the client's full bladder.
43. A nurse is preparing a change-of-shift report and has been caring for a multigravid client with a normally progressing labor. Which of the following information should be part of this report? Select all that apply. 1. Interpretation of the fetal monitor strip. 2. Analgesia or anesthesia being used. 3. Anticipated method of birth control. 4. Amount of vaginal bleeding or discharge. 5. Support persons with the client. 6. Prior birth history.
43. 1,2,4,5,6. Knowledge of how the fetus is tolerating contractions as well as the frequency, intensity, and duration of contractions, as indicated on the fetal monitor strip, are extremely important. The type of analgesia or anesthesia being used, the client's response, and her pain rating should be included as well. The amount of vaginal bleeding indicates whether this labor is in the normal range. Vaginal discharge indicates if membranes are ruptured and the color, odor, and amount of amniotic fluid. The support persons with the client are an integral part of the labor process and greatly influence how she manages labor emotionally and, commonly, physically. A complete change-of-shift report would include the client's name, age, gravida and parity, current and prior illnesses that may influence this hospitalization, prior labor and birth history if applicable, last vaginal examination time and findings, vaginal bleeding, support persons with client, current IVs and other medications being used, and pertinent laboratory test results. Future plan for birth control would be the least important information to be given to the next shift because it will not impact the labor care plan.
57. While the nurse is caring for a multiparous client in active labor at 36 weeks' gestation, the client tells the nurse, "I think my water just broke." Which of the following should the nurse do first? 1. Turn the client to the right side. 2. Assess the color, amount, and odor of the fluid. 3. Assess the fetal heart rate pattern. 4. Check the client's cervical dilation.
57. 3. After spontaneous rupture of the amniotic fluid, the gushing fluid may carry the umbilical cord out of the birth canal. Sudden deceleration of the fetal heart rate commonly signifies cord compression and/or prolapse of the cord, which would require immediate birth. This client is particularly at risk because the fetus is preterm and the fetal head may not be engaged. Turning the client to the right side is not a priority action. However, changing the client's position would be appropriate if variable decelerations are present. The nurse should assess the color, amount, and odor of the fluid, but this can be done once the fetal heart rate is assessed and no problems are detected. Cervical dilation should be checked but only after the fetal heart rate pattern is assessed.
44. A multigravid client is admitted at 4-cm dilation and requesting pain medication. The nurse gives the client nalbuphine 15 mg. Within 5 minutes, the client tells the nurse she feels like she needs to have a bowel movement. The nurse should first: 1. Have naloxone hydrochloride (Narcan) available in the birthing room. 2. Complete a vaginal examination to determine dilation, effacement, and station. 3. Prepare for birth. 4. Document the client's relief due to pain medication.
44. 2. The feeling of needing to have a bowel movement is commonly caused by pressure on the receptors low in the perineum when the fetal head is creating pressure on them. This feeling usually indicates advances in fetal station and that the client may be close to birth. The nurse should respond initially to the client's signs and symptoms by checking to validate current effacement, dilation, and station. If the fetus is ready to be born, having the room ready for the birth and having naloxone hydrochloride (Narcan) available are important. Narcan completely or partially reverses the effects of natural and synthetic opioids, including respiratory depression. Documenting pain relief takes time away from the vaginal examination, preparing for birth, and obtaining Narcan. The birth may be occurring rapidly. Being prepared for the birth is a higher priority than documentation for this client.
45. A multigravid laboring client has an extensive documented history of drug addiction. Her last reported usage was 5 hours ago. She is 2 cm dilated with contractions every 3 minutes of moderate intensity. The primary health care provider prescribes nalbuphine 15 mg slow IV push for pain relief followed by an epidural when the client is 4 cm dilated. Within 10 minutes of receiving the nalbuphine, the client states she thinks she is going to have her baby now. Of the following drugs available at the time of the birth, which should the nurse avoid using with this client in this situation? 1. 1% lidocaine (Xylocaine). 2. Naloxone hydrochloride (Narcan). 3. Local anesthetic. 4. Pudendal block.
45. 2. Naloxone hydrochloride (Narcan) would not be used in a client who has a history of drug addiction. Narcan would abruptly withdraw this woman from the drug she is addicted to as well as the nalbuphine. The withdrawal would occur within a few minutes of injection and, if severe enough, could jeopardize the mother and fetus. Xylocaine is a local anesthetic and numbs rather than decreases the effects of Narcan. The local anesthetic and the pudendal block are both appropriate for this birth but are used to numb the maternal perineum for birth.
47. A 30-year-old G 3, P 2 is being monitored internally. She is being induced with IV oxytocin because she is postterm. The nurse notes the pattern below. The client is wedged to her side while lying in bed and is approximately 6 cm dilated and 100% effaced. The nurse should first: 1. Continue to observe the fetal monitor. 2. Anticipate rupture of the membranes. 3. Prepare for fetal oximetry. 4. Discontinue the oxytocin infusion
47. 4. The fetal monitor strip shows late decelerations. The first intervention would be to turn off the oxytocin because the medication is causing the contractions. The stress caused by the contractions demonstrates that the fetus is not being perfused during the entire contraction (as shown by the late decelerations). There is no time to continue to observe in this situation; intervention is a priority. The client is attached to an internal fetal monitor, which would be possible only if her membranes had already ruptured. If the fetus continues to experience stress, fetal oximetry may be initiated.
48. The nurse, while shopping in a local department store, hears a multiparous woman say loudly, "I think the baby's coming." After asking someone to call 911, the nurse assists the client to give birth to a term neonate. While waiting for the ambulance, the nurse suggests that the mother initiate breast-feeding, primarily for which of the following reasons? 1. To begin the parental-infant bonding process. 2. To prevent neonatal hypothermia. 3. To provide glucose to the neonate. 4. To contract the mother's uterus.
48. 4. After an emergency birth, the nurse suggests that the mother begin breastfeeding to contract the uterus. Breast-feeding stimulates the natural production of oxytocin. In a multiparous client, uterine atony is a potential complication because of the stretching of the uterine fibers following each subsequent pregnancy. Although breastfeeding does help to begin the parental-infant bonding process, this is not the primary reason for the nurse to suggest breast-feeding. Prevention of neonatal hypothermia is accomplished by placing blankets on both the neonate and the mother. Although colostrum in breast milk provides the neonate with nutrients and immunoglobulins, the primary reason for breast-feeding is to stimulate the natural production of oxytocin to contract the uterus.
51. A multigravid client who is 10 cm dilated is admitted to the labor and birth unit. In addition to supporting the client, priority nursing care includes: 1. Turning on the infant warmer. 2. Increasing IV fluids. 3. Determining the client's preferences for pain control. 4. Providing client education regarding care of the newborn.
51. 1. Nursing care for this client includes providing support, preparing for childbirth, assessing for potential complications, and providing for care of the newborn. Turning on the warmer is the best choice for providing for the care of the newborn. Oxygen and IV fluids may be indicated if variable or late decelerations are noted on the fetal heart monitor, but decelerations are not indicated in the question. It is likely too late for pharmacologic pain relief for a multigravid client. Education regarding care of the newborn is not appropriate at this time.
58. The nurse has obtained a urine specimen from a G 6, P 5 client admitted to the labor unit. The woman asks to go to the bathroom and reports that she feels she has to move her bowels. Which actions would be appropriate? Select all that apply. 1. Assisting her to the bathroom. 2. Applying an external fetal monitor to obtain fetal heart rate. 3. Assessing her stage of labor. 4. Asking if she had back labor pains like this with any of her other childbirth experiences. 5. Allowing her support person to take her to the bathroom to maintain privacy. 6. Checking the degree of fetal descent.
58. 3,6. The pressure from the fetus descending into the birth canal can cause the client to feel she needs to move her bowels and could be near childbirth. Failure to assess the stage of labor and degree of fetal descent before allowing the client to go to the bathroom may lead to progression of labor and could result in a birth in the bathroom. Applying a fetal monitor may reassure the nurse that the fetus is doing well; however, it does not help to determine if the fetus is ready to be born, which is the higher priority in this situation. Regardless of the client's prior experience with back labor pain, the fetal head moving lower into the birth canal causes pressure in the lower back area similar to the feeling of pressure with a bowel movement.
2. A newborn who is 20 hours old has a respiratory rate of 66, is grunting when exhaling, and has occasional nasal flaring. The newborn's temperature is 98°F (36.6°C); he is breathing room air and is pink with acrocyanosis. The mother had membranes that were ruptured 26 hours before birth. Based on these data, the nurse should include which of the following in the management of the infant's care? 1. Continue recording vital signs, voiding, stooling, and eating patterns every 4 hours. 2. Place a pulse oximeter and contact the primary health care provider for a prescription to draw blood cultures. 3. Arrange a transfer to the neonatal intensive care unit with diagnosis of possible sepsis. 4. Draw a complete blood count (CBC) with differential and feed the infant.
2. 2. The concern with this infant is sepsis based on prolonged rupture of membranes before birth. Blood cultures would provide an accurate diagnosis of sepsis, but will take 48 hours from the time drawn. Frequent monitoring of infant vital signs, looking for changes, and maintaining contact with the parents is also part of care management while awaiting culture results. Continuing with vital signs, voiding, stooling, and eating every 4 hours is the standard of care for a normal newborn, but a respiratory rate greater than 60, grunting, and occasional flaring are not normal. Although not normal, the need for the intensive care unit is not warranted as newborns with sepsis can be treated with antibiotics at the maternal bedside. The CBC does not establish the diagnosis of sepsis but the changes in the WBC levels can identify an infant at risk. Many experts suggest that waiting until an infant is 6 to 12 hours old to draw a CBC will give the most accurate results.
23. A multiparous client whose fundus is firm and midline at the umbilicus 8 hours after a vaginal birth tells the nurse that when she ambulated to the bathroom after sleeping for 4 hours, her dark red lochia seemed heavier. Which of the following would the nurse include when explaining to the client about the increased lochia on ambulation? 1. Her bleeding needs to be reported to the physician immediately. 2. The increased lochia occurs from lochia pooling in the vaginal vault. 3. The increase in lochia may be an early sign of postpartum hemorrhage. 4. This increase in lochia usually indicates retained placental fragments.
23. 2. Lochia can be expected to increase when the client first ambulates. Lochia tends to pool in the uterus and vagina when the client is recumbent and flows out when the client arises. If the client had reported that her lochia was bright red, the nurse would suspect bleeding. In this situation, the client would be put back in bed and the physician would be notified. Early postpartum hemorrhage occurs during the first 24 hours, but typically the fundus is soft or "boggy." The client's fundus here is firm and midline. Late postpartal hemorrhage, occurring after the first 24 hours, is usually caused by retained placental fragments or abnormal involution of the placental site.
24. Four hours after giving spontaneous vaginal birth under epidural anesthesia to a viable neonate, the client states she needs to urinate. The nurse should next: 1. Catheterize the client to obtain an accurate measurement. 2. Palpate the bladder to determine distention. 3. Assess the fundus to see if it is at the midline. 4. Measure the first two voidings and record the amount.
24. 4. After birth, the nurse should plan to measure the client's first two voidings and record the amount to make sure that the client is emptying the bladder. Frequent voidings of less than 150 mL suggest that the client is experiencing urinary retention. In addition, if urinary retention is occurring, the bladder may be palpable and the fundus may be displaced from midline. The client does not need to be catheterized unless there is evidence of urinary retention. Palpation of the bladder before voiding is unnecessary. However, if the client has difficulty voiding or exhibits signs of urinary retention, then bladder palpation is indicated. The fundus can be displaced by a full bladder and should be assessed after the client voids.
26. A primiparous client who gave birth 12 hours ago under epidural anesthesia with a midline episiotomy tells the nurse that she is experiencing a great deal of discomfort when she sits in a chair with the baby. Which of the following instructions would be most appropriate? 1. "Ask for some pain medication before you sit down." 2. "Squeeze your buttock muscles together before sitting down." 3. "Keep a relaxed posture before sitting down with your full weight." 4. "Ask the physician for some analgesic cream or spray."
26. 2. The nurse should instruct the client to squeeze or contract the muscles of the buttocks together before sitting down in the chair; this contracts the pelvic floor muscles, which reduces the tension on the tender perineal area. Then the client should put her full weight slowly down on the chair. Pain medication may only be prescribed for every 3 to 4 hours, so the client may not be able to receive pain medication every time she desires to sit in the chair. The episiotomy pain usually fades by the fifth or sixth postpartum day. Maintaining a relaxed posture before sitting does not contract the pelvic floor muscles. Most physicians prescribe an analgesic cream or spray when a client has an episiotomy, but they provide only temporary relief.
27. Which of the following would the nurse include in the primiparous client's discharge teaching plan about measures to provide visual stimulation for the neonate? 1. Maintain eye contact while talking to the baby. 2. Paint the baby's room in bright colors accented with teddy bears. 3. Use brightly colored animals and cartoon figures on the wall. 4. Move a brightly colored rattle in front of the baby's eyes.
27. 1. Neonates like to look at eyes, and eye-to-eye contact is a highly effective way to provide visual stimulation. The parent's eyes are circular, move from side to side, and become larger and smaller. Neonates have been observed to fix on them. In general, neonates prefer circular objects of darkness against a white background. Sharp black and white images of geometric figures are appropriate. Use of bright colors on the walls and moving a colorful rattle do not provide as much visual stimulation as eye-to-eye contact with talking. Brightly colored animals and cartoon figures are more appropriate at approximately 1 year of age.
30. On the first postpartum day, the primiparous client reports perineal pain of 5 on a scale of 1 to 10 that was unrelieved by ibuprofen 800 mg given 2 hours ago. The nurse should further assess the client for: 1. Puerperal infection. 2. Vaginal lacerations. 3. History of drug abuse. 4. Perineal hematoma.
30. 4. If the client continues to have perineal pain after an analgesic medication has been given, the nurse should inspect the client's perineum for a hematoma, because this is the usual cause of such discomfort. Ibuprofen is a nonsteroidal anti-inflammatory medication used to relieve mild pain. Pain from a perineal hematoma can be moderate to severe, possibly requiring a stronger analgesic, such as acetaminophen with codeine (Tylenol with Codeine). Ice applied to the perineum during the first 24 hours postpartum may decrease the severity of hematoma formation. Application of warm heat, such as a sitz bath three times daily for 20 minutes, also can help to relieve the discomfort when implemented after the first 24 hours. Typically hematomas resolve themselves within 6 weeks. A puerperal infection would be indicated if the client's temperature were 100.4°F (41°C) or higher. Also, lochia most likely would be foul smelling. A continuous trickle of lochia rubra would suggest a possible vaginal laceration. No evidence is presented to suggest a history of drug abuse.
31. The nurse assigns an unlicensed assistive personnel to care for a client who is 1 day postpartum. Which of the following would be appropriate to delegate to this person? Select all that apply. 1. Changing the perineal pad and reporting the drainage. 2. Assisting the mother to latch the infant onto the breast 3. Checking the location of the fundus prior to ambulating the client. 4. Reinforcing good hygiene while assisting the client with washing the perineum. 5. Discussing postpartum depression with the client who is found crying. 6. Assisting the client with ambulation shortly after birth.
31. 1, 4, 6. Delegating care to unlicensed assistive personnel requires that the nurse knows which tasks are within their capability. Changing the perineal pad and reporting drainage, reinforcing hygiene with perineal care, and assisting with ambulation are within the individual's capacity. Unlicensed assistive personnel should never be asked to complete any assessments, such as checking fundal location or performing skilled procedures on a client. In addition, it would be beyond the scope of the job of unlicensed assistive personnel to assist the mother with latching on and discussing postpartum depression with the client. State Boards of nursing list the procedures and tasks that unlicensed assistive personnel can complete when directed.
32. While the nurse is caring for a primiparous client on the first postpartum day, the client asks, "How is that woman doing who lost her baby from prematurity? We were in labor together." Which of the following responses by the nurse would be most appropriate? 1. Ignore the client's question and continue with morning care. 2. Tell the client "I'm not sure how the other woman is doing today." 3. Tell the client "I need to ask the woman's permission before discussing her wellbeing." 4. Explain to the client that "Nurses are not allowed to discuss other clients on the unit."
32. 4. Legal regulations and ethical decision making require that the nurse maintain confidentiality at all times. The nurse's best response is to explain to the client that nurses are not allowed to discuss other clients on the unit. Ignoring the client's question is inappropriate because doing so would interfere with the development of a trusting nurse-client relationship. Confidentiality must be maintained at all times. Telling the client that the nurse isn't sure may imply that the nurse will find out and then tell the client about the other woman. Asking the other woman's permission to discuss her with another client is inappropriate because confidentiality must be maintained at all times.
34. While assessing the fundus of a multiparous client 36 hours after birth of a term neonate, the nurse notes a separation of the abdominal muscles. The nurse should tell the client: 1. She will have a surgical repair at 6 weeks postpartum. 2. To remain on bed rest until resolution occurs. 3. The separation will resolve on its own with the right posture and diet. 4. To perform exercises involving head and shoulder raising in a lying position.
34. 4. The client is experiencing diastasis recti, a separation of the longitudinal muscles (recti) of the abdomen that is usually palpable on the third postpartum day. An exercise involving raising the head and shoulders about 8 inches (20.3 cm) with the client lying on her back with knees bent and hands crossed over the abdomen is preferred. This exercise helps to pull the abdominal muscles together and the client gradually works up to performing this exercise 50 times per day. However, until the diastasis has closed, the client should avoid exercises that rotate the trunk, twist the hips, or bend the trunk to one side, because further separation may occur. The condition does not need a surgical repair, and limited activity and bed rest are not necessary. Correct posture and adequate diet assist the body to return to its prepregnancy state more quickly but do not resolve the separation of abdominal muscles.
Commercial formulas contain 20 calories per 30 mL. A 1-day-old infant was fed 45 mL at 2 AM, 5:30 AM, 8 AM, 11 AM, 2 PM, 4:30 PM, 8 PM, and 10:30 PM. What is the total amount of calories the infant received today? ______________ calories.
8. 240 calories
25. A primiparous client who gave birth vaginally 8 hours ago desires to take a shower. The nurse anticipates remaining near the client to assess for which of the following? 1. Fatigue. 2. Fainting. 3. Diuresis. 4. Hygiene needs
CN: Health promotion and maintenance; CL: Synthesize 25. 2. Clients sometimes feel faint or dizzy when taking a shower for the first time after birth because of the sudden change in blood volume in the body. Primarily for this reason, the nurse remains nearby while the client takes her first shower after birth. If the client becomes dizzy or expresses symptoms of feeling faint, the nurse should get the client back to bed as soon as possible. If the client faints while in the shower, the nurse should cover the client to protect her privacy, stay with the client, and call for assistance. Fatigue postpartum is common and will precede taking a shower. Diuresis is a normal physiologic response during the postpartum period and not associated with showering. Hygiene needs also precede the shower.
1. A primiparous woman has recently given birth to a term infant. Priority teaching for the client includes information on: 1. Sudden Infant Death Syndrome (SIDS). 2. Breast-feeding. 3. Infant bathing. 4. Infant sleep-wake cycles.
1. 2. Breast-fed infants should eat within the first hour of life and approximately every 2 to 3 hours. Successful breast-feeding will likely require sustained support, encouragement, and instruction from the nurse. Information on SIDS, infant bathing, and sleep-wake cycles are also important topics for the new parent, but can be done at any time prior to discharge.
10. After the nurse explains to the mother of a male neonate scheduled to receive an injection of vitamin K soon after birth about the rationale for the medication, which of the following statements by the mother indicates successful teaching? 1. "My baby doesn't have the normal bacteria in his intestines to produce this vitamin." 2. "My baby is at a high risk for a problem involving his blood's ability to clot." 3. "The red blood cells my baby formed during pregnancy are destroying the vitamin K." 4. "My baby's liver is not able to produce enough of this vitamin so soon after birth."
10. 1. For vitamin K synthesis in the intestines to begin, food and normal intestinal flora are needed. However, at birth, the neonate's intestines are sterile. Therefore, vitamin K is administered via injection to prevent a vitamin K deficiency that may result in a bleeding tendency. When administered, vitamin K promotes formation in the liver of clotting factors II, VII, IX, and X. Neonates are not normally susceptible to clotting disorders, unless they are diagnosed with hemophilia or demonstrate a deficiency of or a problem with clotting factors. Hemolysis of fetal red blood cells does not destroy vitamin K. Hemolysis may be caused by Rh or ABO incompatibility, which leads to anemia and necessitates an exchange transfusion. Vitamin K synthesis occurs in the intestines, not the liver.
16. After completing discharge instructions for a primiparous client who is bottlefeeding her term neonate, the nurse determines that the mother understands the instructions when the mother says that she should contact the primary health care provider if the neonate exhibits which of the following? 1. Ability to fall asleep easily after each feeding. 2. Spitting up of a tablespoon of formula after feeding. 3. Passage of a liquid stool with a watery ring. 4. Production of one to two light brown stools daily.
16. 3. The mother demonstrates understanding of the discharge instructions when she says that she should contact the primary health care provider if the baby has a liquid stool with a watery ring, because this indicates diarrhea. Infants can become dehydrated very quickly, and frequent diarrhea can result in dehydration. Normally, babies fall asleep easily after a feeding because they are satisfied and content. Spitting up a tablespoon of formula is normal. However, projectile or forceful vomiting in larger amounts should be reported. Bottle-fed infants typically pass one to two light brown stools each day.
17. The nurse instructs a primiparous client about bottle-feeding her neonate. Which of the following demonstrates that the mother has understood the nurse's instructions? 1. Placing the neonate on his back after the feeding. 2. Bubbling the baby after 1 oz (30 mL) of formula. 3. Putting three-fourths of the bottle nipple into the baby's mouth. 4. Pointing the nipple toward the neonate's palate.
17. 1. Placing the neonate on his back after the feeding is recommended to minimize the risk for sudden infant death syndrome (SIDS). Placing the neonate on the abdomen after feeding has been associated with SIDS. The mother should bubble or burp the baby after ½ oz (15 mL) of formula has been taken and then again when the baby is finished. Waiting until the baby has eaten 1 oz (30 mL) of formula can lead to regurgitation. The entire nipple should be placed on top of the baby's tongue and into the mouth to prevent excessive air from being swallowed. The nipple is pointed directly into the mouth, not toward the neonate's palate, to provide adequate sucking.
29. An adolescent primiparous client 24 hours postpartum asks the nurse how often she can hold her baby without "spoiling" him. Which of the following responses would be most appropriate? 1. "Hold him when he is fussy or crying." 2. "Hold him as much as you want to hold him." 3. "Try to hold him infrequently to avoid overstimulation." 4. "You can hold him periodically throughout the day."
29. 2. According to Erikson, infants are in the trust versus mistrust stage. Holding, talking to, singing to, and patting neonates helps them develop trust in caregivers. Tactile stimulation is important and should be encouraged. Holding neonates often is unlikely to spoil them because they are totally dependent on other human beings to meet their needs. Being held makes infants feel loved and cared for and should be encouraged. The mother can hold the neonate as often as she wants, not just when the baby is crying or fussy. Overstimulation typically does not result from holding an infant.
36. While the nurse is assessing the fundus of a multiparous client who gave birth 24 hours ago, the client asks, "What can I do to get rid of these stretch marks?" Which of the following responses would be most appropriate? 1. "As long as you don't get pregnant again, the marks will disappear completely." 2. "They usually fade to a silvery-white color over a period of time." 3. "You'll need to use a specially prescribed cream to help them disappear." 4. "If you lose the weight you gained during pregnancy, the marks will fade to a pale pink."
36. 2. Stretch marks, or striae gravidarum, are caused by stretching of the tissues, particularly over the abdomen. After birth, the tissues atrophy, leaving silver scars. These skin pigmentations will not disappear completely. The striae gravidarum may reappear as pink streaks if the client becomes pregnant again. Special creams are not warranted because they are not helpful and may be expensive. Weight loss does not make the marks disappear. Striae gravidarum tend to run in families.
42. A multigravida in active labor is 7 cm dilated. The fetal heart rate baseline is 130 bpm with moderate variability. The client begins to have variable decelerations to 100 to 110 bpm. What should the nurse do next? 1. Perform a vaginal examination. 2. Notify the primary health care provider of the decelerations. 3. Reposition the client and continue to evaluate the tracing. 4. Administer oxygen via mask at 2 L/min.
42. 3. The cause of variable decelerations is cord compression, which may be relieved by moving the client to one side or another. If the client is already on the left side, changing the client to the right side is appropriate. Performing a vaginal examination will let the nurse know how far dilated the client is but will not relieve the cord compression. If the decelerations are not relieved by position changes, oxygen should be initiated but the rate should be 8 to 10 L/min. Notifying the primary health care provider should occur if turning the client and administering oxygen do not relieve the decelerations.
9. A healthy neonate was just born in stable condition. In addition to drying the infant, what is the preferred method to prevent heat loss? 1. Placing the infant under a radiant warmer. 2. Wrapping the infant in warmer blankets. 3. Applying a knit hat. 4. Placing the infant skin-to-skin on the mother.
9. 4. Placing an infant on a mother's bare chest or abdomen facilitates transition to extrauterine life and is the preferred method of thermoregulation for stable infants. A radiant warmer should be used if an infant is unstable and needs medical intervention. Blankets may be placed over a newborn and mom's chest. A hat may be added to prevent heat loss from the head, but these methods are supplemental to skin-to-skin care.
33. A newly postpartum primiparous client asks the nurse, "Can my baby see?" Which of the following statements about neonatal vision should the nurse include in the explanation? 1. Neonates primarily focus on moving objects. 2. They can see objects up to 12 inches (30.5 cm) away. 3. Usually they see clearly by about 2 days after birth. 4. Neonates primarily distinguish light from dark.
33. 2. The neonate has immature oculomotor coordination, an inability to accommodate for distance, and poorly developed eyes, visual nerves, and brain. However, the normal neonate can see objects clearly within a range of 9 to 12 inches (22.9 to 30.5 cm), whether or not they are moving. Visual acuity at birth is 20/100 to 20/150, but it improves rapidly during infancy and toddlerhood. Newborns can distinguish colors as well as light from dark.
5. A neonate born at 30 weeks' gestation and weighing 2,000 g is admitted to the neonatal intensive care unit. What nursing measure will decrease insensible water loss in a neonate? 1. Bathing the baby as soon after birth as possible. 2. Use of eye patches with phototherapy. 3. Use of humidity in the incubator. 4. Use of a radiant warmer.
5. 3. Adding humidity to the incubator adds moisture to the ambient air, which helps to decrease the insensible water loss. Bathing and the use of eye patches has no impact on insensible water loss. The use of a radiant warmer will increase the insensible water loss by drawing moisture out of the skin.
52. Which of the following would the nurse expect as a common finding for a multiparous client giving birth to a viable neonate at 41 weeks' gestation with the aid of a vacuum extractor? 1. Caput succedaneum. 2. Cephalohematoma. 3. Maternal lacerations. 4. Neonatal intracranial hemorrhage
52. 1. Caput succedaneum is common after the use of a vacuum extractor to assist the client's expulsion efforts. This edema may persist up to 7 days. Vacuum extraction is not associated with cephalohematoma. Maternal lacerations may occur, but they are more common when forceps are used. Neonatal intracranial hemorrhage is a risk with both vacuum extraction and forceps births, but it is not a common finding.
