NUR 131: Exam 3 Questions

Management for a urinary tract infection include:

- Antibiotics - Fluids to > urine acidity

Ovarian cancer screening test?

- CA 125 blood test - Intravaginal ultrasound - Pelvic exam

Signs and symptoms of Anaphylactoid Syndrome:

- Dyspnea - Hypotension - Cyanosis - Cardiac & Respiratory arrest - Seizures

What are the three different types of neonatal sepsis?

- Early onset (perinatal) - Shortly before or during birth - Late transmission (in hospital)

Taking-hold phase:

(first 2-3 days) - Focus on baby care and improving caregiving competency - Want to take charge but needs acceptance from others - Want to learn and practice - Dealing with physical and emotional discomforts, can experience "baby blues"

Taking-in phase:

(first 24-48hrs) - Focus on meeting personal needs - Rely on others for assistance - Excited, talkative - Need to review birth experience with others

Risk factors for Anaphylactoid Syndrome:

- Abruptio placenta - Placenta previa - Induction of labor

Cervical cancer screening test?

- Annual pap smear - HPV test

What is the management for mastitis?

- Antibiotics - Continue to breastfeed and/or pumping

Postpartum danger signs: When to call the provider?

- Fever or chills (temp > 100.4) - Excessive bleeding - Painful lumpy breasts accompanied by flu like symptoms - Urination frequency, urgency, or difficulty - Pain or tenderness in pelvic area, calves - Persistent perineal pain - Incision pain with any redness, pus, increased pain or swelling - Depression or harmful thoughts about self or infant

Letting go phase:

- Focus on family - Resuming previous roles (intimate partner, individual)

What are assessment findings for metritis (endometritis)?

- Foul-smelling lochia - Low abdominal/pelvic pain

Jaundice is a very common condition in newborns. What is the difference between physiologic and pathological jaundice? What are the risk factors for jaundice? What are the signs and symptoms of jaundice? Newborns undergoing phototherapy for jaundice require what kinds of assessment/care?

- Hyperbilirubinemia is an elevation of serum bilirubin levels resulting in jaundice. Jaundice normally appears in the head (especially the sclera and mucous membranes), and then progresses down the thorax, abdomen, and extremities. - Physiologic jaundice is considered benign (resulting from normal newborn physiology of increased bilirubin production due to the shortened lifespan and breakdown of fetal RBCs and liver immaturity). The infant with physiological jaundice has no other symptoms and shows signs of jaundice after 24 hr of age. - Pathologic jaundice is a result of an underlying disease. Pathologic jaundice appears before 24 hr of age or is persistent after day 7. In the term infant, bilirubin levels increase more than 0.5 mg/dL/hr, peaks at greater than 13 mg/dL, or is associated with anemia and hepatosplenomegaly. Pathologic jaundice is usually caused by a blood group incompatibility or an infection, but may be the result of RBC disorders.

After a C-section a patient is at risk of:

- Increased risk of infection - Increased risk for pain management and pain control - Increased risk for thrombosis - Increased risk for atelectasis (lung collapse)

When must rhoGAM be administered?

- Last half of pregnancy and after baby is born

Breast cancer screening test?

- Mammograms every 1-2 years - Clinical breast exams annually by provider - Breast self-exams monthly one week after menses

What do you assess for in an extremities assessment?

- Pain - Varicosities - Warmth or discoloration in calves - Presence of pedal pulses - Sensation and movement (C-section) - Edema - Deep tendon reflexes (DTR)

Signs and symptoms of postpartum psychosis:

- Pronounced sadness - Disorientation/Confusion - Loss of touch with reality - Paranoia/hallucination or delusions - Unable to care for self & baby

What are signs and symptoms of newborn distress?

- Sternal retraction - Nasal flaring - Grunting - Excessive mucus - Cyanosis - Chest asymmetry - Abdominal distention - Vomiting bile - Absence of urine or meconium within the first 24hr - Temperature instability - Glucose < 40

What do you assess for in a perineal assessment?

- Tears/lacerations/episiotomy - Hematomas - Hemorrhoids

What does lochia alba look like and how long does it last?

- creamy white, also contains leukocytes and decidual tissue but less fluid - 12 days to 6 weeks

What does lochia rubra look like and how long does it last?

- deep red, mixture of mucous, tissue debris and blood - Lasts 3 to 4 days post-delivery

What does lochia serosa look like and how long does it last?

- pinkish brown, contains leukocytes, decidual tissue, RBC's and serous fluid (healing process) - Last about 10 days

A. Conduction B. Convection C. Evaporation D. Radiation 1. ___ Involves the loss of heat when a liquid is converted to a vapor. Loss may be insensible (from skin and respiration) or sensible (from sweating). 2. ___Involves the transfer of heat from one object to another when the two objects are in direct contact with each other. 3. ___Involves the loss of body heat to cooler, solid surfaces that are in proximity but not in direct contact with the newborn. 4. ___Involves the flow of heat from the body surface to cooler surrounding air or to air circulating over a body surface.

1. C. Evaporation 2. A. Conduction 3. D. Radiation 4. B. Convection

What is a normal HR for a sleeping newborn?

100s

What is a normal HR for a crying newborn?

180s

What are the absolute contraindications of radiation therapy?

1st or 2nd trimester of pregnancy, multicentric tumors, and prior chest radiation

How much larger is the head of a newborn in relation to its chest?

2-3cm

What is the average amount of vaginal discharge post-delivery in mL?

240 to 270mL

A late postpartum hemorrhage happens within?

25hrs to 6wks

WBC

4,500-11,000

What is a normal period of apnea for a newborn?

5-10 secs

What is considered a moderate amount of lochia?

6-inch stain (25-50mL)

What is a normal temperature for a newborn?

97.7-100.3

What is considered a large amount of lochia?

> 6-inch stain (50-80mL)

A nurse is assessing a newborn infant following a circumcision and notes that the circumcised area is red with a small amount of bloody drainage. Which nursing action would be most appropriate? A. Document the finding B. Contact the physician C. Circle the amount of drainage and reassess in 30 minutes D. Reinforce the dressing

A Document the finding Rationale: The penis is usually red during the healing process. A yellow exudate may be noted in 24 hours, and this is a part of normal healing. The nurse would expect that the area would be red with a small amount of bloody drainage. If the bleeding is excessive, the nurse would apply gentle pressure with sterile gauze. Because the findings identified in the question are normal, the nurse would document the assessment.

What is a strawberry hemangioma?

A raised red growth on the skin

What is erythema toxicum?

A rash on an infantas body that goes away in a couple weeks

A nurse is preparing a list of self-care instructions for a postpartum client who was diagnosed with mastitis. Which of the following instructions would be included on the list? Select all that apply A. Wear a supportive bra B. Rest during the acute phase C. Maintain a fluid intake of at least 3000 ml D. Continue to breast-feed if the breasts are not too sore. E. Take the prescribed antibiotics until the soreness subsides. F. Avoid decompression of the breasts by breast-feeding or breast pump.

A, B, C, D

A nurse is completing postpartum discharge teaching to a client who had no immunity to rubella and was given a measles, mumps, and rubella (MMR) vaccine. Which of the following statements by the client indicates understanding of the teaching? A. "I will need to use contraception for 1-3 months before considering getting pregnant again." B. "I need a second vaccination during my postpartum visit." C. "I was given the vaccine because my baby is O-positive blood type." D. "I will be tested in 3 months to see if I have developed immunity."

A. "I will need to use contraception for 1-3 months before considering getting pregnant again."

When performing an assessment on a neonate, which assessment finding is most suggestive of hypothermia? A. Bradycardia B. Hyperglycemia C. Metabolic alkalosis D. Shivering

A. Bradycardia Rationale: Hypothermic neonates become bradycardic proportional to the degree of core temperature. Hypoglycemia is seen in hypothermic neonates.

A nurse in a newborn nursery receives a phone call to prepare for the admission of a 43-week-gestation newborn with Apgar scores of 1 and 4. In planning for the admission of this infant, the nurse's highest priority should be to: A. Connect the resuscitation bag to the oxygen outlet B. Turn on the apnea and cardiorespiratory monitors C. Set up the intravenous line with 5% dextrose in water D. Set the radiant warmer control temperature at 36.5C (97.6F)

A. Connect the resuscitation bag to the oxygen outlet Rationale: The highest priority on admission to the nursery for a newborn with low Apgar scores is airway, which would involve preparing respiratory resuscitation equipment. The other options are also important, although they are of lower priority

A client who is breast-feeding her newborn infant is experiencing nipple soreness. To relieve the soreness, the nurse suggests that the client: A. Encourage rotating breast-feeding positions with each feeding B. Stop nursing until the nipples heal C. Substitute a bottle-feeding until the nipples heal D. Wash nipples and areola with soap and warm water after each feeding

A. Encourage rotating breast-feeding position with each feeding

A nurse is caring for a client who is postpartum. Which of the following signs would be an early sign of excessive blood loss? A. Increasing pulse and decreasing blood pressure B. Dizziness and increasing respiratory rate C. Cool, clammy skin, and pale mucous membranes D. Altered mental status and level of consciousness

A. Increasing pulse and decreasing blood pressure

A nurse is caring for a postpartum client 8 hrs after delivery. Which of the following factors places the client at risk of uterine atony. Select all that apply A. Magnesium sulfate infusion B. Distended bladder C. Oxytocin infusion D. Prolonged labor E. Small for gestational age newborn

A. Magnesium sulfate infusion B. Distended bladder D. Prolonged labor

A nurse is caring for a client who is menopausal and asks the nurse about the use of herbal therapies to reduce her discomfort. Which of the following statements should the nurse make? A. Many herbal products have not undergone long-term testing for safety and efficacy B. Herbal therapies have no benefits and will not help your discomfort C. You should begin immediately as they will help you D. There are no ill effects associated with the use of herbal therapies

A. Many herbal products have not undergone long-term testing for safety and efficacy

To help limit the development of hyperbilirubinemia in the neonate, the plan of care should include: A. Monitoring for the passage of meconium each shift B. Instituting phototherapy for 30 minutes every 6 hours C. Substituting breastfeeding for formula during the 2nd day after birth D. Supplementing breastfeeding with glucose water during the first 24 hours

A. Monitoring for the passage of meconium each shift Rationale: Bilirubin is excreted via the GI tract; if meconium is retained, the bilirubin is reabsorbed

A second-day postpartum client with diabetes mellitus has scant lochia with a foul odor and a temperature of 101.6 degrees F. The physician suspects infection and writes orders to treat the client. Which of the following orders written by the physician would the nurse complete first? A. Obtain culture and sensitivity of lochia and urine B. Administer Ceftriaxone (Rocephin) C. Check the client's temperature D. Increase the intake of oral fluids.

A. Obtain culture and sensitivity of lochia and urine

A nurse is caring for a client who is 1 day postoperative following a left radical mastectomy. Which of the following behaviors should alert the nurse to the possibility that the client is having difficulty adjusting to the loss of her breast? A. Refusing to look at the dressing or surgical incision B. Asking for pain medication every 3hr C. Asking questions about the information on her postoperative care pamphlet D. Performing arm exercises once or twice a day

A. Refusing to look at the dressing or surgical incision Rationale: Clients who refuse to look at the surgical incision or surgical dressing are having difficulty adjusting to the loss of a body part or with body disfigurement. This indicates the client is not yet ready to acknowledge the results of the surgery.

A nurse is caring for a client who is 1 day postoperative following a mastectomy. Which of the following exercises should the nurse assist the client to perform on the affected side? Select all that apply A. Squeezing a rolled washcloth B. Flexing and extending her hand C. Flexing and extending her elbow D. Rotation of her shoulder E. Hand wall climbing

A. Squeezing a rolled washcloth B. Flexing and extending her hand C. Flexing and extending her elbow

A nurse is caring for a client who has a prescription for subdermal etonogestrel. The nurse should alert the provider about which of the following findings in the client's medical history? A. Takes St. John's wort B. Breastfeeds a 6-month-old infant C. Has a parent with hypertension D. Has a positive human papillomavirus (HPV) test result

A. Takes St. John's wort

A nurse is teaching a postpartum client about breast-feeding. Which of the following instructions should the nurse include? A. The diet should include additional fluids B. Prenatal vitamins should be discontinued C. Soap should be used to cleanse the breasts. D. Birth control measures are unnecessary while breast-feeding.

A. The diet should include additional fluids

When providing care to postpartum patients, the nurse assesses a patient with an approximate 750 ml blood loss in the first 12 hours after a vaginal delivery of a baby with a weight of 9lbs 2oz. What does the nurse consider as the most likely cause for blood loss in the postpartum patient? A. Uterine atony B. Perineal laceration C. Retained placental fragments D. DIC

A. Uterine atony

What can you teach your postpartum patient about contractions after delivery?

Afterpains are normal and can be worse when breastfeeding and also stronger in multiparous patients. Teaching mom about fundal massage and pain medications to relieve the pain is helpful.

What helps to mature newborn lungs?

Amniotic fluid and surfactant

What is Anaphylactoid Syndrome?

Amniotic fluid embolism

What is the nursing care and management for thrombophlebitis?

Assess: - PT, PTT - platelet count - Vital signs - Signs of bleeding - leg circumference Do: - Administration of analgesics & anticoagulants - Bedrest with leg elevation - Elastic support (TEDS) or SCD - Moist warm compresses - Heparin, Coumadin, Lovenox Teach: - Brush teeth gently - Report bleeding gums - Nose or increased vaginal bleeding - Hematuria & frequent bruising

Hemocrit (Hct)

normal range: 36-45

A nursing instructor asks a nursing student to describe the procedure for administering erythromycin ointment into the eyes if a neonate. The instructor determines that the student needs to research this procedure further if the student states: A. "I will cleanse the neonate's eyes before instilling ointment." B. "I will flush the eyes after instilling the ointment." C. "I will instill the eye ointment into each of the neonate's conjunctival sacs within one hour after birth." D. "Administration of the eye ointment may be delayed until an hour or so after birth so that eye contact and parent-infant attachment and bonding can occur."

B. "I will flush the eyes after instilling the ointment Rationale: Eye prophylaxis protects the neonate against Neisseria gonorrhoeae and Chlamydia trachomatis. The eyes are not flushed after instillation of the medication because the flush will wash away the administered medication.

A nurse is caring for a client who had a vaginal delivery 24 hours ago. Which of the following findings should the nurse report to the provider? A. 2,000mL urine since delivery B. 3+ deep tendon reflexes C. Fundus at umbilicus D. Soft breasts

B. 3+ deep tendon reflexes

A nurse is caring for a client who asks to be screened for cervical cancer because a relative has been diagnosed with it. Which of the following tests should the nurse expect the provider to use? A. A serum prolactin level B. A Papanicolaou test C. A vaginal ultrasound D. An endometrial biopsy

B. A Papanicolaou test

By keeping the nursery temperature warm and wrapping the neonate in blankets, the nurse is preventing which type of heat loss? A. Conduction B. Convection C. Evaporation D. Radiation

B. Convection Rationale: Convection heat loss is the flow of heat from the body surface to the cooler air.

While assessing a 2-hour old neonate, the nurse observes the neonate to have acrocyanosis. Which of the following nursing actions should be performed initially? A. Activate the code blue or emergency system B. Do nothing because acrocyanosis is normal in the neonate C. Immediately take the newborn's temperature according to hospital policy D. Notify the physician of the need for a cardiac consult

B. Do nothing because acrocyanosis is normal in the neonate Rationale: Acrocyanosis, or bluish discoloration of the hands and feet in the neonate (also called peripheral cyanosis), is a normal finding and shouldn't last more than 24 hours after birth.

A postpartum client is diagnosed with cystitis. The nurse plans for which priority nursing intervention in the care of the client? A. Providing Sitz baths B. Encouraging fluid intake C. Placing ice on the perineum D. Monitoring hemoglobin and hematocrit levels.

B. Encouraging fluid intake

A nurse is caring got a client who is experiencing menopausal symptoms and asks the nurse about menopausal hormone therapy (HT). The nurse should inform the client that HT is not recommended due to which of the following findings in the client's medical history? A. History of dermatitis B. History of breast cancer C. Multiple hospitalizations for COPD D. Concurrent treatment for GERD

B. History of breast cancer

A nurse is performing a fundal assessment for a client who is 2 days postpartum and observes the perineal pad for lochia. She notes the pad to be saturated approximately 12 cm with lochia that is bright red and contains small clots. Which of the following findings should the nurse document? A. Moderate lochia rubra B. Large lochia rubra C. Light lochia rubra D. Scant lochia serosa

B. Large lochia rubra

A nurse is caring for a client who is 2hrs postpartum. The nurse notes the client's perineal pad has a large amount of lochia rubra with several clots. Which of the following actions should the nurse perform first? A. Check for a full bladder B. Massage the fundus C. Measure vital signs D. Administer carboprost IM

B. Massage the fundus

A nursing is caring for a client who is postpartum and reports that her episiotomy incision is pulling and stinging. Which of the following actions should the nurse take? A. Encourage the client to ambulate B. Provide a sitz bath with warm water for the client C. Instruct the client to perform Kegel exercises D. Apply anesthetic cream topically each hour while the client is awake

B. Provide a sitz bath with warm water for the client

The nurse decides on a teaching plan for a new mother and her infant. The plan should include: A. Discussing the matter with her in a non-threatening manner B. Showing by example and explanation how to care for the infant C. Setting up a schedule for teaching the mother how to care for her baby D. Supplying the emotional support to the mother and encouraging her independence

B. Showing by example and explanation how to care for an infant Rationale: Teaching the mother by example is a non-threatening approach that allows her to proceed at her own pace.

A nurse is providing care to a client who is 2 hrs postpartum and is receiving an oxytocin IV. The client asks the nurse, "Why is there so little bleeding?" Which of the following responses should the nurse make? A. This could indicate a possible uterine infection B. The bleeding is minimal until I discontinue your IV medication C. You might have retained some fragments of your placenta D. You will require additional medication to increase your bleeding

B. The bleeding is minimal until I discontinue your IV medication

The nurse is teaching a client who is postpartum about the rubella vaccine. Which of the following statements should the nurse include? A. You must take this immunization if you've had the chickenpox B. You must not become pregnant for 28 days after receiving this immunization C. You must not breastfeed because the virus is passed in breastmilk D. You must not receive other vaccines at the same time as the rubella vaccine

B. You must not become pregnant for 28 days after receiving this immunization

What is milia?

Baby acne

What is a LGA at risk for?

Birth trauma, hypoglycemia, RDS

What are some lab/diagnostic tests that need to be done for an infant with respiratory distress syndrome?

Blood gases, chest x-rays

What should you monitor for in an infant with SGA?

Blood glucose, nutrition, thermal regulation

What is respiratory distress syndrome?

Breathing disorder characterized by a lack of surfactant

A nurse prepares to administer a Vitamin K injection to a newborn infant. The mother asks the nurse why her newborn infant needs the injection. The best response by the nurse would be: A. "your infant needs Vitamin K to develop immunity" B. "the Vitamin K will protect your infant from being jaundiced" C. "newborn infants are deficient in Vitamin K and this injection prevents abnormal bleeding" D. "Newborn infants have sterile bowels, and Vitamin K promotes the growth of bacteria in the bowel"

C. "Newborn infants are deficient in Vitamin K and this injection prevents abnormal bleeding" Rationale: Vitamin K is necessary for the body to synthesize coagulation factors. Vitamin K is administered to the newborn infant to prevent bleeding. Newborn infants are Vitamin K deficient because the bowel does not have the bacteria necessary for synthesizing fat-soluble Vitamin K. The infant's bowel does not support the production of Vitamin K until bacteria adequately colonizes it by food ingestion.

During ambulation to the bathroom, a postpartum client experiences a gush of dark red blood that soon stops. On assessment, a nurse finds the uterus to be firm, midline, and at the level of the umbilicus. Which of the following findings should the nurse interpret this data as being? A. Evidence of a possible vaginal hematoma B. An indication of a cervical or perineal laceration C. A normal postural discharge of lochia D. Abnormally excessive lochia rubra flow

C. A normal postural discharge of lochia

A nurse is developing a plan of care for a client 24hrs following a cesarean delivery. To prevent thrombophlebitis, the nurse plans to encourage the client to: A. Elevate her legs B. Remain on bed rest C. Ambulate frequently D. Apply warm moist packs to the legs

C. Ambulate frequently Rationale: Stasis is believed to be a predisposing factor in the development of thrombophlebitis. Only C is a preventative method.

A postpartum nurse is caring for a client who is 4 hours postpartum and has a painful third-degree perineal laceration. Which of the following interventions should the nurse take? A. Prepare to initiate a warm water sitz bath for the client's perineum B. Encourage the client to sit on a soft pillow C. Apply cold ice packs to the client's perineum D. Administer an acetaminophen suppository rectally

C. Apply cold ice packs to the client's perineum

A female middle adult client tells a nurse that she tested positive for a mutant BRCA1 gene. The nurse should recognize that the client is at an increased risk for which of the following situations? A. Delivering a child who had Down Syndrome B. Developing Alzheimer's disease C. Developing breast cancer D. Developing thyroid cancer

C. Developing breast cancer

A nurse is caring for a middle adult female client who reports that her menstrual periods have become irregular, and she has been having hot flashes. The nurse should expect the client to have which of the following manifestations associated with early menopause? A. Urinary retention B. Decreased blood pressure C. Dryness with intercourse D. Elevation in body temperature above (100F)

C. Dryness with intercourse Rationale: Menopause, the cessation of a woman's menstrual periods, occurs when the ovaries stop making estrogen. Because of the changes in the vagina, some women can have dryness, discomfort, or pain during sexual intercourse.

On assessment of a client who is 30 minutes into the fourth stage of labor, the nurse finds the client's perineal pad saturated with blood and blood soaked into the bed linen under the client's buttocks. The nurse's initial action is which of the following. A. Call the physician B. Assess the client's vital signs C. Gently massage the uterine fundus D. Administer a 300ml bolus of a 20 units/L Oxytocin (Pitocin) solution

C. Gently massage the uterine fundus

A nurse is providing postpartum discharge teaching about proper storage of breast milk for a client who is breastfeeding. Which of the following client statements indicates an understanding of the teaching? A. I can store my pumped milk in the door of the refrigerator B. I can use the microwave to thaw my frozen breast milk C. I will discard any unused breastmilk that is left in the bottle D. I can refreeze any breastmilk after it has been thawed

C. I will discard any unused breastmilk that is left in the bottle

Which of the following most characterizes endometrial cancer? A. Dyspareunia B. Thickened endometrial lining C. Irregular menstrual bleeding D. Low blood pressure

C. Irregular menstrual bleeding Rationale: Endometrial cancer arises from the lining of the uterus. The first sign is abnormal bleeding. Painful intercourse is a symptom along with painful urination. It typically occurs after menopause.

A nurse is providing teaching for a postpartum client who is breastfeeding. Which of the following pieces of information should the nurse include in the teaching? A. You should supplement your baby with formula until you notice that your breasts become firm and full B. You should adhere to a schedule when feeding your baby to ensure she is getting enough to eat C. Your milk supply will noticeably increase in volume around the third or fourth day after delivery D. It is typical for your nipples to hurt for the first few weeks while you are breastfeeding

C. Your milk supply will noticeably increase in volume around the third or fourth day after delivery

What is the Homan's sign?

Calf pain upon dorsiflexion or redness, heat, swelling in extremities

Papanicolaou smear (Pap smear) is usually done to determine cancer of what?

Cervical cancer

Congenital fissure or longitudinal opening of the lip_______________________.

Cleft lip

Atelectasis

Collapsed lung

Management for hypovolemic shock

Control bleeding, uterine packing, ligation or hysterectomy, IV

A nurse is providing instructions to a mother who has been diagnosed with mastitis. Which of the following statements if made by the mother indicates a need for further teaching? A. "I need to take antibiotics, and I should begin to feel better in 24-48 hours." B. "I can use analgesics to assist in alleviating some of the discomfort." C. "I need to wear a supportive bra to relieve the discomfort." D. "I need to stop breastfeeding until this condition resolves."

D. "I need to stop breastfeeding until this condition resolves." Rationale: Keep breast pads clean and dry by changing often; continue to feed from both breasts.

The nurse is collecting information for assessing a woman at her 6 week postpartum appointment. Which of the following does the nurse anticipate the patient reporting for current lochia? A. Lochia rubra B. Lochia serosa C. Lochia alba D. Absence of lochia

D. Absence of lochia

A nurse is caring for a client whose Papanicolaou (Pap) test cytology results are abnormal. Which of the following procedures should the nurse anticipate for this client? A. Rectovaginal palpation by the provider B. Dilation and curettage C. Human chorionic gonadotropin (hCG) test D. Colposcopy

D. Colposcopy

The nurse is working with a postpartum mom after deliver. Which behavior would the nurse expect to assess during the taking in phase of the couplet? A. Frequent infant care questions B. Adapting to parent role C. Encouraging own self-care D. Contemplating thoughts on labor

D. Contemplating thoughts of labor

A postpartum nurse is providing instructions to the mother of a newborn infant with hyperbilirubinemia who is being breastfed. The nurse provides which most appropriate instructions to the mother? A. Switch to bottle feeding the baby for 2 weeks B. Stop the breast feedings and switch to bottle feeding permanently C. Feed the newborn infant less frequently D. Continue to breastfeed every 2-4 hours

D. Continue to breastfeed every 2-4hours Rationale: Breastfeeding should be initiated within 2 hours after birth and every 2-4 hours thereafter. The other options are not necessary.

A nurse is providing teaching to a client about the manifestations of uterine prolapse. Which of the following statements by the client should indicate to the nurse a need for further teaching? A. The symptoms can get worse with penile penetration during intercourse. B. A sensation of pressure in the pelvis can occur C. Low back pain can occur frequently D. Feces can be present in the vagina

D. Feces can be present in the vagina Rationale: The presence of feces in the vagina is a manifestation of a genital fistula. This statement indicates a need for further teaching.

A nurse is teaching for a client who is to begin taking tamoxifen to treat breast cancer. The nurse should instruct the client to expect which of the following findings as an adverse effect of the medication? A. Tinnitus B. Constipation C. Urinary retention D. Hot flashes

D. Hot flashes Rationale: The nurse should instruct the client to expect hot flashes as an adverse effect of tamoxifen, because it is an antiestrogen medication that blocks estrogen receptors.

A nurse is caring got a client who is 3 days postpartum and has chosen to formula-feed her newborn. During the examination of the client's breasts, the nurse notes that they are warm and firm. Which of the following actions should the nurse plan to take? A. Encourage the client to pump the breasts B. Instruct the client to take a warm shower twice per day C. Tell the client to massage the breasts D. Instruct the client to apply cold compresses

D. Instruct the client to apply cold compresses

A neonate has been diagnosed with caput succedaneum. Which statement is correct about this condition? A. It usually resolves in 3-6 weeks B. It doesn't cross the cranial suture line C. It's a collection of blood between the skull and the periosteum D. It involves swelling of tissue over the presenting part of the presenting head

D. It involves swelling of tissue over the presenting part of the presenting head Rationale: Caput succedaneum is the swelling of tissue over the presenting part of the fetal scalp due to sustained pressure; it resolves in 3-4 days.

Neonates of mothers with diabetes are at risk for which complication following birth? A. Atelectasis B. Microcephaly C. Pneumothorax D. Macrosomia

D. Macrosomia Rationale: Neonates of mothers with diabetes are at increased risk for macrosomia (excessive fetal growth) as a result of the combination of the increased supply of maternal glucose and an increase in fetal insulin.

A healthy term neonate born by C-section was admitted to the transitional nursery 30 minutes ago and placed under a radiant warmer. The neonate has an axillary temperature of 99.5F, a respiratory rate of 80 breaths/minute, and a heel stick glucose value of 60 mg/dl. Which action should the nurse take? A. Wrap the neonate warmly and place her in an open crib B. Administer an oral glucose feeding of 10% dextrose in water C. Increase the temperature setting on the radiant warmer D. Obtain an order for IV fluid administration

D. Obtain an order for IV fluid administration Rationale: Assessment findings indicate that the neonate is in respiratory distress—most likely from transient tachypnea, which is common after cesarean delivery. A neonate with a rate of 80 breaths a minute shouldn't be fed but should receive IV fluids until the respiratory rate returns to normal. To allow for close observation for worsening respiratory distress, the neonate should be kept unclothed in the radiant warmer.

A nurse is caring for a middle adult client who has just received the diagnosis of endometrial cancer. In taking a nursing history, which of the following manifestations is likely to be reported by this client? A. Unilateral swelling on the posterior of the vulva B. Extreme abdominal pain with intercourse C. Green, malodorous vaginal discharge D. Postmenopausal bleeding

D. Postmenopausal bleeding

A nurse is presenting educational materials for a group of middle-aged clients about menopausal hormone therapy following total hysterectomy. Which of the following information should the nurse include in the information? A. Take at different times of the day B. Take an extra dose if missed a day C. Prevents from having cerebral hemorrhage D. Prevents osteoporotic fractures

D. Prevents osteoporotic fractures Rationale: Menopausal hormone therapy may decrease and protect the client from osteoporotic fracture due to the preservation of bone mineral density.

A nurse at a clinic is preparing to teach the process of involution to a group of antenatal clients. Which of the following information should the nurse provide? A. The fundus is approximately 2cm above the level of the umbilicus at the end of the third stage of labor B. The fundus is approximately 3cm above the umbilicus within 12 hrs after delivery C. The fundus is located halfway between the umbilicus and mons pubis on the sixth day postpartum D. The fundus is no palpable abdominally at 2 weeks postpartum

D. The fundus is no palpable abdominally at 2 weeks postpartum

A nurse is assessing a postpartum client who reports strong contractions whenever she breastfeeds her newborn. The nurse should respond with which of the following statements? A. Prolactin is increasing the blood supply to your uterus, and you are feeling blood vessel engorgement B. You probably have a small blood clot in your uterus, which is causing the uterus to contract in order to expel it C. Your breasts are secreting a hormone that enters the bloodstream and causes your abdominal muscles to contract D. The same hormone that is released in response to the baby's sucking and causes milk to flow also makes the uterus contract

D. The same hormone that is released in response to the baby's sucking and causes milk to flow also makes the uterus contract

A mother of a term neonate asks what the thick, white, cheesy coating is on his skin. Which correctly describes this finding? A. Lanugo B. Milia C. Nevus flammeus D. Vernix

D. Vernix

Severe anomaly of failure in the development of the diaphragm that results in an abnormal insertion onto the inner chest wall ______________________.

Diaphragmatic Hernia

What is the side effect of hemabate?

Diarrhea

Nursing measures to maintain newborns' body temperature include:

Drying them immediately after birth to prevent heat loss through evaporation, wrapping them in prewarmed blankets, putting a hat on their head, and placing them under a temperature-controlled radiant warmer. Skin to skin is also helpful as long as the person providing the skin to skin is preventing any drafts to the baby.

What is the most common symptom of ovarian cancer?

Pelvic bloating and pressure

What is lanugo?

Fine, soft hair that covers the body of an infant. It will fall out in the coming weeks.

Sucking reflex

STIMULATION: Mouth touched by object RESPONSE: Sucks on object DURATION: Disappears at three to four months

Grasping reflex

STIMULATION: Palms touched RESPONSE: Grasps tightly DURATION: Weakens at three months; disappears at a year

Tonic neck reflex

STIMULATION: Placed on back RESPONSE: Makes fists and turns head to the right DURATION: Disappears at two months

Anomaly of the anterior abdominal wall __________________________.

Gastroschisis

Babinski reflex

STIMULATION: Sole of foot stroked RESPONSE: Fans out toes and twists foot in DURATION: Disappears at nine months to a year

Moro reflex

STIMULATION: Sudden move; loud noise RESPONSE: Startles; throws out arms and legs and then pulls them toward body DURATION: Disappears at three to four months

If the postpartum patients uterus is boggy and deviated to the right, what would the nurse do next after massaging the uterus?

Have the patient get up and void then when she returns to bed, reassess the fundus for location and firmness. If the uterus is still boggy, massage.

Methergine has been ordered for a postpartum patient with excessive bleeding. What condition would alert the nurse to hold this medication?

High blood pressure: PIH (pregnancy induced hypertension and/or preeclampsia

Increase in CSF in the ventricles of the brain due to overproduction or impaired circulation and absorption_______________________.

Hydrocephalus Hydro: think fluid

What should you monitor for an infant with LGA?

Hypoglycemia, hyperglycemia, hyperbilirubinemia, RDS

Malformation of the male genitalia ____________________.

Hypospadias

Cold stress ______ oxygen demand in an infant

Increases

What is mastitis?

Infection of the breast that occurs in breast-feeding mothers

What does a cephalohematoma frequently cause?

Jaundice

What are the complications of an early postpartum hemorrhage?

L - Lacerations A - Atony R - Retained placental tissue/fragments R - Ruptured uterus Y - You pulled too hard on cord (uterus inversion)

What is a very common complication of breast cancer and lymph node removal?

Lymphedema

Define menopause. What signs and/or symptoms would we assess in a menopausal patient? What nursing interventions would we implement?

Menopause is complete cessation of menstruation for one year. A patient may experience hot flashes, palpitations, diaphoresis, and/or osteoporosis. Nursing interventions include: assessing psychosocial response, discussing estrogen therapy including preventing osteoporosis and heart disease, and discussing alternate therapies to try (diet, exercise, calcium supplements).

A condition in which a small brain is located within a normal-sized cranium________________________________.

Microcephaly Micro: think small

The nurse is assessing the lochia on a 1 day postpartum patient. The nurse notes that the lochia is red and has a foul smelling odor. What should the nurse be suspicious of with this patients assessment?

Most likely is infection

What is meconium aspiration?

Newborn inhales meconium into the lungs in utero or on taking the first breath after birth

What medication is given first if patient is bleeding and massaging the uterus is not working?

Oxytocin

What are the signs/symptoms of lymphedema?

Pain, paresthesia, impaired motor function, and heaviness in arm

What is the most common symptom of vulvar cancer?

Persistent vulvar itching

What are the causes/risk factors of meconium aspiration?

Post term infant, breech, forceps, or vacuum extraction, nulliparity

What does REEDA stand for?

Redness Edema Ecchymosis (bruising) Drainage Approximation

What is thrombophlebitis?

Refers to a thrombus that is associated with inflammation

What are the complications of a late postpartum hemorrhage?

S - Subinvolution I - Infection R - Retained placental fragments

Rooting reflex

STIMULATION: Cheek stroked, or side of mouth touched RESPONSE: Turns towards source, opens mouth and sucks DURATION: Disappears at three to four months

Blinking reflex

STIMULATION: Flash of light or puff of air RESPONSE: Closes eyes DURATION: Permanent

Stepping reflex

STIMULATION: Infant held upright with feet touching ground RESPONSE: Moves feet as if to walk DURATION: Disappears at three to four months

What are the treatments for meconium aspiration?

Suctioning, provide oxygen, IV fluids

Atrophic vaginitis

Thinning of the vagina and loss of moisture because of depletion of estrogen, which causes inflammation of tissue

A early postpartum hemorrhage happens within?

The first 24hrs

Elevation of pulse, stroke volume, and cardiac output for the first hour postpartum occurs then gradually decreases to a prepregnant state baseline by 2-3 months

This is normal

What is the proper way to check the position of a postpartum patient's fundus?

To palpate the uterine fundus, support the lower segment of the uterus with a hand placed just above the symphysis pubis (this steadies the uterus and prevents downward displacement) then gently palpate the fundus (top of the uterus) with your other hand to evaluate firmness and location.

What are the 5 T's of postpartum hemorrhage?

Tone: Uterine atony/distended bladder Tissue: Retained placenta/large clots Trauma: Lacerations of lower genital track Thrombin: Coagulopathy Traction: Uterine inversion

What is a targeted immunotherapy medication used for breast cancer?

Trastuzumab (Hereceptin)

What is the REEDA scale used for?

Used for perineal assessment: episiotomy/lacerations

Methergine is used for:

Uterine atony (boggy uterus) - DO NOT GIVE PTs WITH HIGH BP OR PRECLAMPSIA

How soon after birth do you want a newborn to void and produce stool?

Within 24hrs

When should we educate women to do a self-breast exam?

Women should perform a self-breast exam monthly preferably one week after their menses.

Hemoglobin

normal range: 12-16