Mom Baby E1 and E2
A nurse is caring for a client who is in the first stage of labor and is encouraging the client to void every 2 hours. Which of the following statements would the nurse make?
"A distended bladder reduces pelvic space needed for birth"
The nurse is assessing a pregnant client who has a long history of asthma. She states, "I'm trying not to use my asthma medications because I certainly don't want my baby exposed to them." What is the nurse's best response?
"Actually, having uncontrolled asthma is much riskier for your baby than the medication."
A pregnant woman in the 36th week of gestation reports that her feet are quite swollen at the end of the day. After careful assessment, the nurse determines that this is an expected finding at this stage of pregnancy. Which intervention is appropriate for the nurse to suggest?
"Try elevating your legs when you sit."
A nurse is explaining the Agar scoring to new mother and her partner. What should the nurse point out about this scoring method? Select all that apply
- It is done at 1 and 5 minutes after birth. -The baby is considered vigorous if the 5-minute score is above 7. -The Apgar score is an immediate assessment of newborn cardiopulmonary adaptation.
The nurse is requested to assist the provider with an external version. What intervention should the nurse perform prior to and immediately after the external version?
A non stress test
The nurse has just informed a client that her pregnancy test is positive and she will need further assessment to determine the complete status of the situation. Which initial emotional response does the nurse expect the client to exhibit
Ambivalence
Prenatal diagnostic test performed to obtain amniotic fluid to examine the fetal cells it contains for the study or discovery of genetic conditions of the unborn child.
Amniocentesis
The nurse institutes measures to maintain thermoregulation based on the understanding that newborns have limited ability to regulate body temperature because they:
Are unable to shiver effectively to increase heat production
A nurse is caring for a postpartum client who has a history of thrombosis during pregnancy and is at high risk of developing a pulmonary embolism. For which sign or symptom should the nurse monitor the client to prevent the occurrence of pulmonary embolism?
Calf swelling
A 10-week pregnant woman with diabetes has a glycosylated hemoglobin (HbA1c) level of 13%. At this time the nurse should be most concerned about which possible fetal outcomes?
Congenital anomalies
The nurse is helping her client to recognize signs of hunger in her newborn. The nurse knows that her client needs additional teaching when she states that which sign is one of the early signs of hunger?
Crying
The nurse places a newborn with jaundice under the phototherapy lights in the nursery to achieve which goal?
Decrease the serum bilirubin level
A 24-year-old sexually active client is brought to the emergency department complaining of severe unilateral lower pelvic pain, vaginal bleeding, and fatigue. The nurse notes on assessment cool, clammy skin, confusion, and maternal vital signs: HR 130, RR 28, and BP 98/60 mm Hg. What do you suspect is happening? and What would you do first? Select all that apply.
Ectopic pregnancy Establish IV (large bore needle to get blood if needed) Side note: elevate legs
A nurse suspects that a client is developing HELLP syndrome. The nurse notifies the health care provider based on which finding?
Elevated liver enzymes
Assessment of a pregnant woman reveals a pigmented line down the middle of her abdomen. The nurse documents this as which finding?
Linea nigra
A nurse is caring for a client who is at 42 weeks gestation and in active labor. Which of the following findings is the fetus is at risk for developing?
Meconium aspiration
A 34 year old woman at 36 weeks gestation has been scheduled for an NST with biophysical profile. She asks the nurse why the test needs to be performed. The nurse tells her that the test is performed because it:
Observes her baby's activities in utero to ensure that her baby is getting enough oxygen
Decreased amniotic fluid is called
Oligohydraminos
A woman with gestational hypertension experiences a seizure. Which intervention would the nurse identify as the priority?
Oxygenation
The fetus of a woman in labor is determined to be in a persistent occiput posterior position. Which intervention would the nurse prioritize?
Pain relief measures
A postpartum woman is having difficulty voiding for the first time after giving birth. Which action would be least effective in helping to stimulate voiding?
Placing her hand in a basin of cool water
The nurse performs a nonstress test (NST) on a client at 36 weeks' gestation. What criteria does the nurse look for on the tracing to determine that the NST is reactive?
Presence of 2 accelerations in 20 minutes
What are the different ways a woman could try to ripen her cervix (either naturally at home or ordered by her provider in the hospital setting) who has a low Bishop score for a future pitocin induction? (Select all that apply)
Seaweed pge, misoprolol, foley bulb
A client who is breast-feeding her newborn tells the nurse, "I notice that when I feed him, I feel fairly strong contraction-like pain. Labor is over. Why am I having contractions now?" Which response by the nurse would be most appropriate?
The baby's sucking releases a hormone that causes the uterus to contract."
A primiparous client is being seen in the clinic for her first prenatal visit. It is determined that she is 11 weeks pregnant. The nurse develops a teaching plan to educate the client about what she will most likely experience during this period. Which possible effect would the nurse include?
Urinary frequency
The generation-to-generation continuum of violence refers to the fact that:
Violence is a learned behavior, and children who witness intimate partner violence are more likely to become abusers themselves
A 2-week postpartum client reports that her breast is very painful when she nurses. She states that she feels like she has the flu and has an elevated temperature. Which of the following statement made by the nurse is accurate?
You may have an infection and will need to be started on abx
A woman who gave birth 24 hours ago tells the nurse, "I've been urinating so much over the past several hours." Which response by the nurse would be most appropriate?
Your body is undergoing many changes that cause your bladder to fill quickly.
A nurse is describing the hormones involved in the menstrual cycle to a group of young adult women who are planning to get pregnant. The nurse determines the teaching was successful when the group identifies the follicle-stimulating hormone as being secreted by the:
anterior pituitary gland.
The nurse administers Rho(D) immune globulin to an Rh-negative client after delivery of an Rh-positive newborn based on the understanding that this drug will prevent her from
developing Rh sensitivity
A nurse notes a pregnant woman has just entered the second stage of labor. Which interaction should the nurse prioritize at this time to assist the client?
encouraging the woman to push when she has a strong desire to do so
The nurse dries the neonate thoroughly and promptly changes wet linens. The nurse does so to minimize heat loss via which mechanism?
evaporation
The nurse assesses a 5 hour old newborn. Which finding would the nurse interpret as suggesting a problem with oxygenation?
nasal flaring
A woman has just given birth to a healthy term newborn. Upon assessing the umbilical cord, the nurse would identify what findings as normal? Select all that apply.
one vein + two arteries
When caring for a client a forceps-assisted birth, the nurse would be alert for:
potential lacerations and bleeding
A client has arrived to the birthing center in labor, requesting a VBAC. The nurse knows that she would be a good candidate after reading the client's previous history based on which finding?
previous lower abdominal incision
A client who is 4 months pregnant is at the prenatal clinic for her initial visit. Her history reveals she has 7-year-old twins who were born at 34 weeks gestation, a 2-year-old son born at 39 weeks gestation, and a spontaneous abortion 1 year ago at 6 weeks gestation. Using the GTPAL method, the nurse would document her obstetric history as:
41113
The nurse is assessing the respirations of several newborns. The nurse would notify the health care provider for the newborn with which respiratory rate at rest?
68 breaths per minute
Twenty minutes after birth, a baby begins to move his head from side to side, making eye contact with the mother, and pushes his tongue out several times. The nurse interprets this as
A good time to initiate breast-feeding
A nurse suspects that a pregnant client may be experiencing abruptio placenta based on assessment of which finding? Select all that apply. A. Insidious onset B. Absent fetal heart tones C. Dark red vaginal bleeding D. Rigid uterus E. Absence of pain
Absent fetal heart tones Dark red vaginal bleeding Rigid uterus
Mrs Carter is admitted to the labor and birth unit for active labor. The lab results of cervical culture for group B streptococcal were positive. What priority intervention will be initiated?
Ampicillin or cefazolin intravenous is given before delivery.
While making rounds in the nursery, the nurse sees a 6-hour-old baby girl gagging and turning bluish. What would the nurse do first?
Aspirate the oral and nasal pharynx with a bulb syringe. - > aspirate nose first then mouth since babies are obligatory nose breathers
When caring for a client with premature rupture of membranes (PROM), the nurse observes an increase in the client's pulse. What should the nurse do next?
Assess patient's Temp
A nurse is caring for a pregnant client with asthma. Which intervention would the nurse perform first?
Assessing O2 sat
Which action is a priority when caring for a woman during the fourth stage of labor?
Assessing the uterine fundus
A nurse is providing care to a couple who have experiences intrauterine fetal demise. Which action would be least effective in assisting the couple at this time?
Avoid any discussion of the situation with the couple
A patient in labor and delivery has just been diagnosed with pre-eclampsia. Which sign and symptom should the nurse prioritize when assessing the client? Select all that apply.
BP 140/90 mm Hg headache Protein in urine
A nurse is assessing a newborn's reflexes. The nurse strokes the lateral sole of the newborn's foot from the heel to the ball of the foot to elicit which reflex?
Babinski
A woman who delivered a healthy newborn was relating a story about her neighbor to her nurse. It was noted that the neighbor would cry spontaneously and uncontrollably and feel anxious and sad yet also report that she was happy and recovering normally after bringing the baby home. What is the nurse's best explanation about what the neighbor was most likely experiencing?
Baby blues
On the first prenatal visit, examination of the woman's internal genitalia reveals a bluish coloration of the cervix and vaginal mucosa. The nurse documents this finding as:
Chadwick's sign
Procedure that involves the removal of a small tissue specimen from the fetal portion of the placenta. Because this tissue originates from the zygote, it reflects the genetic makeup of the fetus ; it is performed between 10 and 13 weeks gestation, either transcervically or transabdominally. Match this description to the correct answer below.
Chorionic villus
A nurse is conducting a class for pregnant women with with diabetes. Which factor would the nurse emphasize as being most important in helping to reduce the maternal/fetal/neonatal complications associated with pregnancy and diabetes?
Degree of glycemic control achieved during the pregnancy
A client reports bright red, painless vaginal bleeding during her 32nd week of pregnancy. A sonogram reveals that the placenta has implanted low in the uterus and is partially covering the cervical os. Which immediate care measures are initiated? Select all that apply.
Determine the time the bleeding began and about how much blood has been lost. Obtain baseline vital signs and compare to those vital signs previously obtained. Attach external monitoring equipment to record fetal heart sounds and kick counts.
The nurse is teaching a group of pregnant women how to cope with the discomfort from Braxton Hicks contractions. Which strategy would the nurse recommend?
Drink two glasses of water to rehydrate
A pregnant woman is scheduled to undergo an amniocentesis. When explaining this test to the client, the nurse would also include information about which test or procedure being done at the same time?
Empty the bladder.
The nurse is inspecting the mouth of a newborn and finds small, white cysts on the gums and hard palate. The nurse documents this finding as:
Epstein pearls
The nurse is developing a presentation for a community group of young adults discussing fetal development and pregnancy. The nurse would identify that the sex of offspring is determined at the time of:
Fertilization
A nurse is caring for an antenatal mother diagnosed with umbilical cord prolapse. For which should the nurse monitor the fetus?
Fetal hypoxia
A nurse is conducting an assessment of a woman who has experienced PROM. Which finding would lead the nurse to suspect infection as the cause of the client's PROM?
Foul Odor A foul odor of the amniotic fluid indicates infection. Yellow-green fluid would suggest meconium. A blue color on Nitrazine testing and ferning indicate the presence of amniotic fluid.
A nurse is completing a postpartum assessment. Which finding would alert the nurse to a potential problem?
Frequent scant voiding
The nurse assesses a client for signs of hypovolemic shock due to a postpartum hemorrhage. What signs indicate the presence of hypovolemic shock? Select all that apply.
Heart rate 120 beats/minute, respiratory rate 28 breaths/minute, blood pressure 80/40 mm Hg
HELLP Syndrome is an acronym for:
Hemolysis Elevated Liver enzymes Low Platelet count
At 31 weeks' gestation, a 37-year-old woman with a history of preterm birth reports cramps, vaginal pain, and low, dull backache accompanied by vaginal discharge and bleeding. Assessment reveals cervix 2.1 cm long, fetal fibronectin done, and cervix dilated 3 to 4 cm. Which interactions should the nurse prepare to assist with?
Hospitalization, tocolytic therapy, and IM corticosteroids
A pregnant client whose gestational diabetes has been poorly controlled during her pregnancy is in labor. The nurse would assess the neonate closely at birth for which condition?
Hypoglycemia (high glucose through mom's body and once baby is born it
When assessing a newborn 1 hour after birth, the nurse measures an axillary temperature of 95.8 F (35.4 C), an apical pulse of 114 beats/minute, and a respiratory rate of 60 breaths/minute. The nurse would identify which area as the priority?
Hypothermia
The nurse is caring for a client with an ectopic pregnancy. Which symptom is a sign that the tube has ruptured?
Hypovolemic shock
After teaching a couple about what to expect with their planned cesarean birth, which statement indicates the need for additional teaching?
Im going to have to wait a few days before I can start breast-feeding.
Listed below are all the ways a nurse can help resuscitate the fetus in utero if there is a prolonged deceleration in the fetal heart rate, EXCEPT which one?
Increase the pitocin rate to hasten delivery
A nurse in labor and delivery unit is completing an admission assessment for a client who is at 39 weeks of gestation. The client reports that she has been leaking fluid from her vagina for 2 days. Which of the following conditions is the client at risk for developing?
Infection
During labor, a woman undergoing induction with oxytocin should be monitored frequently. Which assessment findings should result in the Öxytocin being discontinued immediately and the health care provider notified? Select all that apply.
Large gushes of blood coming from vag Contractions that palpate strong with each contraction happening q 1 min Fetal heart pattern showing repetitive late decelerations
Assessment of a woman in labor reveals cervical dilation of 2-3 cm, cervical effacement of 30%, and contractions occurring every 7 to 8 minutes, lasting about 40 seconds. The nurse determines that this client is in:
Latent phase of the first stage
When teaching a class of pregnant women about the effects of substance abuse during pregnancy, the nurse would most likely include which effect?
Low birth weight infants
What is the intravenous medication that is given if the mother has preeclampsia and who is at risk for having ecclamptic seizures?
MagnesiumSulfate
A client with a 28-day cycle reports that according to an ovulation kit, she ovulated on May 10. When would the nurse expect the client's next menses to begin?
May 24
All of the following are signs and symptoms of preterm labor EXCEPT:
Mental confusion
A nurse strongly encourages a pregnant client to avoid eating swordfish and tilefish because these fish contain which component?
Mercury, which could harm the developing fetus if eaten in large amounts;
A woman calls the health care facility stating that she is in labor. The nurse would urge the client to come to the facility if the client reports which symptom?
Moderately strong contractions every 4 minutes, lasting about 1 minute
A newborn has been diagnosed with a group B streptococcal infection shortly after birth. The nurse understands that the newborn most likely acquired this infection from which cause?
Mother's birth canal
A nursing student correctly identifies the most desirable position for the baby to be situated in the uterus to promote an easy birth as which position?
Occiput anterior
A nurse is caring for a client in the postpartum period. When observing the client's condition, the nurse notices that the client tends to speak incoherentlv. The client's thouaht process is disoriented. and she frequently indulges in obsessive concerns. The nurse notes that the client has difficultly in relaxing and sleeping. The nurse interprets these findings as suggesting which condition?
Postpartum psychosis
When describing the menstrual cycle to a group of young women, the nurse explains that progesterone levels are highest during which phase of the endometrial (or uterine) cycle?
Proliferative
The nurse administers vitamin K intramuscularly to the newborn based on which rationale?
Promote blood clotting
Which information on a client's health history would the nurse identify as contributing to the client's risk for an ectopic pregnancy?
Recurrent Pelvic infections
A nurse is caring for a postpartum client whose most recent assessment reveals a growing large, purple area of edema on the left side of her perineum. What is the nurse's best action?
Report the finding promptly to the primary care provider.
A woman in labor received an opioid close to the time of birth. The nurse would assess the newborn for which effect?
Respiratory depression
A patient who is 16 weeks pregnant is passing pieces of body tissue along with blood clots, and dark red blood from the vagina. What should the phone triage nurse direct the patient to do at this time?
Seek immediate medical attention and bring the expressed vaginal material.
A client at 36 weeks' gestation tells the nurse, "I was at my desk and suddenly felt a pop and then my pants were wet." Based on the client's presentation, what does the nurse think happened to this client?
Spontaneous rupture of membranes
The nurse is assisting a pregnant client who has just underwent a nonstress test that was ruled reactive. Which factor will the nurse point out when questioned by the client about the results?
The fetal heart rate increases with activity and indicated fetal well-being
A nurse is explaining the use of effleurage as a pain relief measure during labor. Which statement would the nurse most likely use when explaining this measure?
The technique involves light stroking of the abdomen with breathing.
What are the possible causes of postpartum hemorrhage? Select all that apply.
Thrombocytopenia, DIC, vonw, HELLP Adherent placenta Uterine stones from retained placenta Uterine atony from distended uterus from twins Trauma from forceps delivery or precipitous birth causing a vagina hematoma
A patient who comes to the emergency department states that she has not felt any fetal movement for several days. The health care provider who cannot hear a heartbeat suspects fetal death. Once fetal death is confirmed by ultrasound, the health care provider immediately induces labor. Why is it important in this case to induce labor as soon as possible?
To prevent coagulopathy or DIC
A client has not received any medication during her labor. She is having frequent contractions every 1 to 2 minutes and has become irritable with her coach and no longer will allow the nurse to palpate her fundus during contractions. Her cervix is 8 cm dilated and 90% effaced. The nurse interprets these findings as indicating:
Transition phase of the first stage of labor
The nurse is collecting the health history on a newly pregnant 37-year-old client. This client is at increased risk for which gene-mediated complication of the pregnancy?
Trisomy
Of the following, which are signs and symptoms of pre-eclampsia? Select all that apply.
Visual dis bp?160/100 HA Epigastric pain Brisk reflexes 24 hr Protein in urine would also be acceptable
It is determined that a client's blood Rh is negative and her partner's is Rh positive. To help prevent Rh isoimmunization, the nurse would expect to administer Rho(D) immune globulin at which time?
at 28 weeks' gestation and again within 72 hours after birth
An antenatal glucocorticoid should be administered intramuscularly to the pregnant woman to accelerate fetal lung maturation when there is risk for preterm birth. It is used to increase in the production and release of surfactant in the fetus. Which of the following is a glucocorticoid that could be given to accelerate fetal lung maturaty? (Select all that apply).
betamethasone
Which assessment findings, experienced by the client at 36 weeks' gestation, would the nurse document as diagnostic signs of severe preeclampsia? Select all that apply. blood pressure of 164/110 mm Hg elevated liver enzymes edema +4 proteinuria Elevated serum creatinine Thrombocytopenia H/A visual changes
blood pressure of 164/110 mm Hg elevated liver enzymes +4 proteinuria Elevated serum creatinine Thrombocytopenia H/A visual changes
The nurse is conducting a class for postpartum women about mood disorders. The nurse describes a transient, self-limiting mood disorder that affects mothers after childbirth. The nurse determines that the women understood the description when they identify the condition as postpartum:
blues.
A nurse is conducting an in-service presentation to a group of perinatal nurses about sexually transmitted infections and their effect on pregnancy. The nurse determines that the teaching was successful when the group identifies which infection as being responsible for ophthalmia neonatorum?
gonorrhea
A nurse teaches a postpartum woman about her risk for thromboembolism. The nurse determines that additional teaching is required when the woman identifies which as a factor that increases her risk?
increase in red blood cell production
A nurse is conducting a class for a group of teenage girls about female reproductive anatomy and physiology. Which structures would the nurse include as an external female reproductive organ? Select all that apply
mons pubis, labia, clitoris
When palpating the funds during a contraction, the nurse notes that it feels like a forehead. The nurse interprets this finding as indicating which type of contraction?
strong
What is a medication that can be used to stop labor if the baby is showing signs of fetal distress?
terbutaline
A new mother is changing the diaper of her 12-hour-old newborn and asks why the stool is black and sticky. Which response by the nurse would be most appropriate?
this is meconium stool and is normal for a newborn
A postpartum client is experiencing subinvolution. When reviewing the woman's labor and birth history, which contributor would the nurse identify as being a significant to this condition?
use of anesthetics
A client is in the third stage of labor. Which finding would alert the nurse that the placenta is separating?
uterus becomes globular