OB exam 2
When examining a newborn's eyes, the nurse would expect which assessment?
follows a light to the midline Newborns do not usually follow past the midline until 3 months of age. They do not tear.
A nurse is teaching a group of pregnant women about the signs that labor is approaching. When describing these signs, which sign would the nurse explain as being essential for effacement and dilation to occur?
Cervical ripening and softening The ripening and softening of the cervix which result from the effects of prostaglandins and pressure from Braxton Hicks contractions are essential for effacement and dilation of the cervix. Lightening occurs when the fetal presenting part begins to descend into the true pelvis. Bloody show occurs as the mucous plug is expelled as a result of cervical softening and increased pressure of the presenting part.
The nurse is preparing an educational event for pregnant women on the topic of labor pain and birth. The nurse understands the need to include the origin of labor pain for each stage of labor. What information will the nurse present for the first stage of labor?
Pain originates from the cervix and lower uterine segment. Pain sensations associated with labor originate from different places depending on the stage of labor. During the first stage of labor, the stretching required to efface and dilate the cervix stimulates pain receptors in the cervix and lower uterine segment.
A woman who is about to be discharged after a vaginal birth notices a flea-like rash on her newborn's chest that consists of tiny red lesions all across the nipple line. What is the bestresponse from the nurse when explaining this to the woman?
"It is a normal skin finding in a newborn. This most likely is erythema toxicum, also known as newborn rash and is a common finding which will gradually disappear and not need any treatment.This is often mistaken for staphylococcal pustules. This is not a sign of mistreatment by the mother, nor is it caused by a virus or group beta streptococcal infection.
The community health nurse is conducting a presentation on labor and delivery. When illustrating the birth process, the nurse should point out zero station refers to which sign?
"The presenting part is at the true pelvis and is engaged." Zero station is when the fetus is engaged in the pelvis, or has dropped. This is an encouraging sign for the client. This sign is indicative that labor may be beginning, but there is no set time frame regarding when it will start. Labor has not started yet, and the fetus has not begun to move out of the uterus.
The newborn weighing 6 lb 6 oz (2856 g), now weighs 5 lbs 14 oz (2632 g), 2 days later. Which response should the nurse prioritize to address the mother's concerns about the weight loss?
"This is a normal response." The infant has a 5% to 10% loss of birth weight during the first few days of life as the body loses excess fluid and has limited food intake. This physiologic weight loss amounts to a total loss of 6 to 10 oz. There would be no need to assess for other problems. It is also not related to feeding, nor would a breast-feeding mother need to offer supplementary formula feedings. These responses would be inappropriate.
New parents are getting ready to go home and have received information to help them learn how best to care for the new infant. Which statement indicates that they need additional teaching about how to soothe their newborn if he becomes upset?
"We'll hold off on feeding him for a while because he might be too full." The parents need more teaching that feeding or burping can be helpful in relieving air or stomach gas. Turning on a mobile above the newborn's head is helpful in calming the newborn. The movement is distracting, and the music is comforting. The newborn's back should be rubbed lightly while the parents speak softly to him. Swaddling the newborn provides security and comfort.
A client who is in the transition phase reports her pain medication last given 3 hours ago has worn off. She asks if she can have another dose of the meperidine. How should the nurse respond to her request?
"Your stage of labor makes giving another dose unsafe." Meperidine may cause CNS depression in the neonate if given too close to birth.
To indicate that the infant is making a successful transition immediately after birth, the nurse checks the heart rate. The newborn is 4 hours old. Which rate would the nurse identify as a cause for concern?
108 beats/minute The heart rate of a fetus in utero averages between 110 and 160 beats/minute. Immediately after birth, as the newborn struggles to initiate respirations, the heart rate may be as rapid as 180 beats/minute. Within 1 hour after birth, as the newborn settles down to sleep, the heart rate stabilizes to an average of 120 to 140 beats/minute. Therefore, a heart rate of 108 beats/minute would be a cause for concern.
How long is the neonatal period for a newborn?
28 days
In a local health care facility, a newborn is admitted to the transition nursery for close observation following birth, and to provide attachment time with his parents since his mother is febrile and hypertensive. Assessments will be conducted for what period of time after admission to the nursery?
6 to 12 hours The stabilization and transition time for a newborn is 6 to 12 hours when the nurse will closely observe the newborn, monitoring its blood sugar, heart rate, respiratory status and temperature and complete a full physical exam.
The nurse has been monitoring a multipara client for several hours. She cries out that her contractions are getting harder and that she cannot do this. The nurse notes the client is very irritable, nauseated, annoyed, and doesn't want to be left alone. Based on the assessment the nurse predicts the cervix to be dilated how many centimeters?
8 to 10 The reaction of the client is indicative of entering or being in the transition phase of labor, stage 1. The dilation would be 8 cm to 10 cm. Before that, when dilation is 0 to 7 cm, the client has an easier time using positive coping skills.
A student nurse is reviewing newborn physical measurements and asks the charge nurse if her client's weight of 2800 g and length of 51 cm falls within normal parameters. The charge nurse would respond to the student nurse in which manner?
A birth weight of 2800 g falls within the normal weight parameters for a full-term newborn. Average birth weight for a newborn is between 5 lb, 8 oz (2500 g) and 8 lb, 13 oz. (4000 g). Average length at birth for a newborn is between 19 and 21 inches (48 to 53 cm).
Which findings by a nurse would be considered abnormal when examining the eyes of a newborn? Select all that apply.
Absent red reflex Blue-tinged sclera The normal response is a red reflection from the retina, and absence of a red reflex is associated with congenital cataracts. The sclera should be white, not blue. All other findings are normal variants for an eye exam.
During an admission assessment of a client in labor, the nurse observes that there is no vaginal bleeding yet. What nursing intervention is appropriate in the absence of vaginal bleeding when the client is in the early stage of labor?
Assess amount of cervical dilation. If vaginal bleeding is absent during admission assessment, the nurse should perform vaginal examination to assess the amount of cervical dilation. Hydration status is monitored as part of the physical examination. A urine specimen is obtained for urinalysis to obtain a baseline. Vital signs are monitored frequently throughout the maternal assessment.
The practical nursing is evaluating the tracings on the fetal heart monitor. The nurse is concerned that there is a change in the tracings. What should the practical nurse do first?
Assess and reposition the woman. Due to maternal movement, the fetal heart monitor may become dislodged and not provide accurate tracings. Reposition and assess the woman to note any change with the next contraction. If concern remains, notify the registered nurse. The registered nurse will interpret the tracing and notify the health care provider.
The nurse is reviewing the medication administration record (MAR) of a client at 39 weeks' gestation and notes that she is ordered an opioid for pain relief. Which is an assessment priorityafter administering?
Assess fetal heart rate. After administering an opioid to a laboring mother, the priority is to assess the impact on the fetus. Opioid administration can cross the placental barrier with symptoms including assessing heart rate and variability. After birth, there may be a decrease in alertness. Maternal factors of a decreased blood pressure, constipation and dry month are of a lower priority.
The nurse is caring for a newborn of a mother with human immunodeficiency virus (HIV). What is the priority for the nurse to complete following delivery?
Bathe the newborn thoroughly The newborn should have a thorough bath immediately after birth to decrease the possibility of HIV transmission. It is recommended the newborn be tested for HIV at 14 to 21 days after birth, at 1-2 months and again at 4-6 months. Zidovudine should be administered within 6-12 hours post-delivery to help prevent transmission of HIV from the mother to the newborn.
Braxton Hicks contractions are termed "practice contractions" and occur throughout pregnancy. When the woman's body is getting ready to go into labor, it begins to show anticipatory signs of impending labor. Among these signs are Braxton Hicks contractions that are more frequent and stronger in intensity. What differentiates Braxton Hicks contractions from true labor?
Braxton Hicks contractions usually decrease in intensity with walking. Braxton Hicks contractions occur more frequently and are more noticeable as pregnancy approaches term. These irregular, practice contractions usually decrease in intensity with walking and position changes.
A nurse is called into the room of one of the clients where the grandparents are visiting. The grandmother is visibly upset, and says "Just look at my grandson! His head is all soft and swollen here and it shouldn't be. The doctor injured him when he was born." The nurse assesses the newborn and finds an area of swelling about the size of a half-dollar at the center of the upper scalp. The nurse determines this finding is most likely which condition?
Caput succedaneum Caput succedaneum is swelling of the soft tissue of the scalp caused by pressure of the presenting part on a partially dilated cervix or trauma from a vacuum-assisted delivery. This finding is often of concern for the families. Reassure them that the caput will decrease in a few days without treatment. Increased intracranial pressure would involve the entire scalp and not just a small portion. There would also be other neurologic signs accompanying it. Molding is an elongated head shape caused by overlapping of the cranial bones as the fetus moves through the birth canal. This will also resolve in a few days without treatment. The Harlequin sign is characterized by a clown-suit-like appearance of the newborn where the skin is dark red on one side of the body and the other side is pale. This is a harmless condition which occurs most frequently with vigorous crying or with the infant lying on his or her side.
A 30-minute-old newborn starts crying in a high-pitched manner and cannot be consoled by the mother. Which action should the nurse prioritize if jitteriness is also noted and the infant is unable to breastfeed?
Check blood glucose. One of the primary signs/symptoms of hypoglycemia in newborn infants is jitteriness and irritability. Anytime an infant is suspected of having hypoglycemia, the nurse needs to check the blood glucose level. Cold stress and pain are potential considerations to rule out if hypoglycemia is not the cause; however, jitteriness is not a recognized sign of these.
In the labor and delivery unit, which is the best way to prevent the spread of infection?
Complete hand hygiene Hand hygiene remains the number one way to prevent the spread of infection. It is appropriate to use sterile gloving for invasive procedures and limit vaginal examinations as much as possible. Providing clean gloving is also important when there is exposure to blood and body secretions.
The nurse notes persistent early decelerations on the fetal monitoring strip. Which action should the nurse prioritize in this situation?
Continue to monitor the FHR because this pattern is benign. Early decelerations are a benign finding and not indicative of fetal distress. They do not require intervention, therefore, the nurse would continue to monitor the fetal heart rate pattern. It is beyond the scope of the LPN to perform a vaginal exam, however, there is no need for a RN to perform a vaginal exam at this time either. There is no need to report the finding to the primary care provider or administer oxygen at this time.
The nurse is assessing a newborn who appears healthy and at term. Which assessment finding of the feet does the nurse predict to observe to confirm the status of at-term birth?
Creases on two-thirds of the foot As an infant matures in utero, sole creases become prominent to a greater amount. The term infant should have at least two-thirds of the foot covered by creases. These creases should be horizontal and not longitudinal, They should be in the ball of the foot before moving to the heel.
Which cardinal movement of delivery is the nurse correct to document by station?
Descent Descent is documented by station, which is the relationship of the fetal presenting part to the maternal ischial spines. Descent continues throughout labor until the fetus reaches the fetal station of +4. The other options represent fetal movements to accommodate the passage of the fetus.
Which nursing action is applied throughout all stages of labor?
Do not allow the client to lay flat on her back for long periods. Throughout the labor process, the client is not to lay flat on her back due to supine hypotension. This places weight on the great vessels and decreases blood flow. It is acceptable to place a pillow or wedge under one hip, thus distributing the client's weight to a side. The client may do the other options at different points or throughout in the labor process.
Which action would be priority for the nurse to complete immediately after the delivery of a 40-week gestation newborn?
Dry the newborn and place it skin-to-skin on mother. Thermoregulation is priority immediately following delivery and is best achieved by keeping the newborn warm and dry. This can be accomplished by drying the newborn and placing it skin-to-skin with the mother. The newborn should be dried before being swaddled and placed in the bassinet. A complete assessment needs to be done within 2 hours of delivery and glucose isn't routinely assessed.
At which time in a client's labor process would the nurse encourage effleurage?
During the early labor phase Effleurage, a form of touch therapy, is a technique that the client uses in early labor. Light touch stimulates the nerve pathways to the brain and keeps them busy, thereby blocking pain sensation. This technique does not determine true labor, is not helpful in the active stage of labor (as contractions are more intense), nor is it done when the client is ready to give birth.
The mother of a newborn observes a diaper rash on her newborn's skin. Which intervention should the nurse instruct the parent to implement to treat the diaper rash?
Expose the newborn's bottom to air several times a day. The nurse should instruct the parent to expose the newborn's bottom to air several times per day to treat and prevent diaper rashes. Use of baby wipes and products such as powder should be avoided. The parent should be instructed to place the newborn's buttocks in warm water after having had a diaper on all night but not with every diaper change.
The nursing instructor is illustrating the various positions the fetus may utilize during the passage through the vaginal canal at birth. The instructor determines the session is successful when the students correctly identify the ROA position, indicating which presentation by the fetus?
Facing the right anterior pelvic quadrant ROA (right occiput anterior) means the occiput of the fetal head points toward the mother's right anterior pelvis; the head is the presenting part.
A new mother calls her pediatrician's office concerned about her 2-week-old infant "crying all the time." When the nurse explores further, the mother reports that the infant cries at least 2 hours each day, usually in the afternoons. What recommendations would the nurse not make to this mother?
Feeding the infant more formula whenever she begins to fuss Crying by a young infant is frustrating for parents, so it is suggested that the parents first be sure that the infant's physical needs are met, then soothing measures are implemented. Feeding the infant every time he cries is not needed nor suggested. Swaddling, a soothing touch and gentle pats on the back all help calm a fussy infant.
How does a woman who feels in control of the situation during labor influence her pain?
Feelings of control are inversely related to the client's report of pain. Studies reveal that women who feel in control of their situation are apt to report less pain than those who feel they have no control.
Which consideration is a priority when caring for a mother with strong contractions 1 minute apart?
Fetal heart rate in relation to contractions The priority consideration is on the status of the fetus. Because each contraction temporarily interrupts blood flow to the placenta, there is a decrease in oxygen available. Therefore, a fetus cannot tolerate contractions lasting too long or too strong. All other options are important but not the priority.
The client in active labor overhears the nurse state the fetus is ROA. The nurse should explain this refers to which component when the client becomes concerned?
Fetal position When documenting the ROA, this is the right occiput anterior or the relationship of the fetal position to the mother using the maternal pelvis as the point of reference. Fetal station refers to the relationship of the presenting part of the fetus to the ischial spines of the pelvis. Fetal attitude refers to the relationship of the fetal parts to one another. Fetal size refers the actual size of the developing fetus.
The nurse is admitting a client who is in early labor. After determining that the birth is not imminent, which assessment should the nurse perform next?
Fetal status The woman may present to the birthing suite at any phase of the first stage of labor. Therefore, it is important to assess birth imminence, fetal status, risk factors, and maternal status immediately. If birth is not imminent and the fetal and maternal conditions are stable, perform additional data collection, including the full admission health history, a complete maternal physical assessment, the status of labor and any labor, birth, and cultural preferences the woman may have.
Which nursing action is a priority when the fetus is at the +4 station?
Have a blue bulb suction and an infant warmer ready At the station +4, the fetus is being born. The priority nursing action is to have a blue bulb or suction device for airway clearance and an infant warmer ready. During admission the nurse will place a tocometer on the maternal stomach and have a gown ready. For checking effacement and dilation, the nurse will have a lubricant and possibly an internal monitor per health care provider orders. A cesarean section is not needed as the fetus has progressed through the birth canal.
The nurse is assisting a client through labor, monitoring her closely now that she has received an epidural. Which finding should the nurse prioritize to the anesthesiologist?
Inability to push If the client is not able to push, her epidural dose may need to be adjusted to decrease the impact on the sensory system. Dry lips indicate that she may need fluids, so the nurse should give her some ice chips or a drink of water. Urinary retention and rapidly progressing labor should be directly reported to the obstetrician, not the anesthesiologist.
A multigravida client admitted in active labor has progressed well and the client ane fetus have remained in good condition. Which action should the nurse prioritize if the client suddenly shouts out, "The baby is coming!"?
Inspect the perineum. The nurse needs to determine if birth is imminent by assessing the perineum and be prepared for birth. Once the nurse assesses the coming labor, the heart sounds, contraction rate, and contacting the primary care provider can all be done, if there is time.
The nurse is caring for a newborn after the parents have spent time bonding. As the nurse performs the assessment and evidence-based care, which eye care will the nurse prioritize?
Instill 0.5% ophthalmic erythromycin. The standard eye care to prevent ophthalmia neonatorum is 0.5% erythromycin ointment or 1% tetracycline eye drops. Although 1% silver nitrate drops were once used, it has been discontinued due to its ineffectiveness. The nurse would not wait to see if the eyes show signs of irritation before administering the medication. Delaying could lead to preventable blindness.
A pregnant client is admitted to a maternity clinic for birth. The client wishes to adopt the kneeling position during labor. The nurse knows that which to be an advantage of adopting a kneeling position during labor?
It helps to rotate fetus in a posterior position. The advantage of adopting a kneeling position during labor is that it helps to rotate the fetus in a posterior position. Facilitating vaginal examinations, facilitating external belt adjustment, and helping the woman in labor to save energy are advantages of the back-lying maternal position.
The nurse is monitoring a client who is in labor and notes the client is happy, cheerful, and "ready to see the baby." The nurse interprets this to mean the client is in which stage or phase of labor?
Latent phase The woman in labor undergoes numerous psychological adaptations during labor. During the latent phase, she is often talkative and happy, and yet anxious. During transition, the client may show fear and anger. During stage two she may remain positive, but the work of labor is very intense.
A woman wearing hospital scrubs comes to the nursery and states "Mrs. Smith is ready for her baby. I will be glad to take the baby to her." What will the nursery nurse do next?
Look at the woman's hospital identification badge. Each member of the hospital staff should have an identification badge clearly displayed. The nursery nurse should look at the badge of the woman who is offering to take Mrs. Smith's baby to her as this is the only way to ensure the nurse is allowing an appropriate person to transport the baby. Education and watchful vigilance are the keys to preventing infant abductions. Each facility that cares for newborns should have specific policies and procedures in place that address this problem. The nurse should review these policies and know the protocols for the facility in which the nurse will be working.
The nurse is admitting a client in early labor and notes: FHR 120 bpm, blood pressure 126/84 mm Hg, temperature 98.8oF, contractions every 4 to 5 minutes lasting 30 seconds, and greenish-color fluid in the vaginal vault. Which finding should the nurse prioritize?
Meconium in the fluid Green tinted fluid with ROM is indicative of meconium in the amniotic sac, or the infant having a bowel movement in utero. Infection would be shown by pus or cloudy fluid and possibly an elevated temperature. The FHR is within normal range. Irregular contractions is expected at this stage of labor.
The nurse is assisting with the admission of a newborn boy to the nursery. The nurse notes what appears to be bruising on the left upper outer thigh of this dark-skinned infant. Which documentation should the nurse provide?
Mongolian spot noted on left upper outer thigh. A Mongolian spot is bluish-black areas of discoloration on the back and buttocks or extremities of dark-skinned newborns. The Harlequin sign refers to the dilation of blood vessels on only one side of the body, giving the newborn the appearance of wearing a clown suit. Mottling occurs when the lips, hands, and feet appear blue from immature peripheral circulation. Birth trauma is a possibility, however, there would be notations of an incident and the possibly other injuries would be noted.
The nurse is assessing a 3-day-old infant. The infant's sclerae have a yellow tinge as does the infant's forehead and nose. What would the nurse do next?
Obtain a transcutaneous bilirubin level. Following visual identification of jaundice, the blood level of circulating bilirubin needs to be measured either by a transcutaneous bilirubin meter or a blood draw for a bilirubin level. Until the level of bilirubin in the blood is known to be elevated, neither phototherapy nor an exchange transfusion would be implemented. A metabolic panel is not useful in determining the level of neonatal jaundice.
A group of nursing students are preparing a presentation which will illustrate various components of the birthing process. When presenting the pelvis, the students should point out that it is often referred to as which term?
Passageway The passageway is one of the 4 Ps and involves the pelvis, both bony pelvis and the soft tissues, cervix, and vagina. The passenger refers to the fetus. The primary powers are the involuntary contractions of the uterus, whereas the secondary powers come from the maternal abdominal muscles. The psyche refers to the mother's mental state.
the nurse is assessing a newborn by auscultating the heart and lungs. Which natural phenomenon will the nurse explain to the parents is happening in the cardiovascular system?
Pressure changes occur and result in closure of the ductus arteriosus. The ductus arteriosus is one of the openings through which there was fetal circulation. At birth, or within the first few days, this closes and the heart becomes the source of movement of blood to and from the lungs. The exchange of oxygen in the lungs and increasing oxygen content in the blood are respiratory functions. The removal of the fluid from the alveoli occurs mainly during the birthing process and is completed by the lungs after birth.
A 32-year-old woman presents to the labor and birth suite in active labor. She is multigravida, relaxed, and talking with her husband. When examined by the nurse, the fetus is found to be in a cephalic presentation. His occiput is facing toward the front and slightly to the right of the mother's pelvis, and he is exhibiting a flexed attitude. How does the nurse document the position of the fetus?
ROA The nurse should document the fetal position in the clinical record using abbreviations. The first letter describes the side of the maternal pelvis toward which the presenting part is facing ("R" for right and "L" for left). The second letter indicates the reference point ("O" for occiput, "Fr" for frontum, etc.). The last part of the designation specifies whether the presenting part is facing the anterior (A) or the posterior (P) portion of the pelvis, or whether it is in a transverse (T) position.
The nurse is teaching discharge instructions to the young parents of a healthy newborn boy, whose vital signs are stable and whose circumcision appears clean and intact. The nurse should encourage the parents to call the health care provider if which situation is discovered?
Redness at the base of the umbilical cord The cord should dry and fall off in the 7 to 10 days after birth. If the cord base changes color or develops drainage, the health care provider needs to be notified as these could be signs of infection. A yellowish crusty substance on the circumcision site indicates normal healing. Crying for two hours or more each day and straining at stools are normal in a newborn.
The nursery nurse notes that one of the newborn infants has white patches on his tongue that look like milk curds. What action would be appropriate for the nurse to take?
Report the finding to the pediatrician. Although the finding looks like a milk curd, if the white patch remains after feeding, the pediatrician needs to be notified. The likely cause of the white patch on the tongue is a fungal infection called Candida albicans, which the newborn probably contracted while passing through the birth canal. The nurse should not try to remove the patches.
A nurse is teaching a new mother about what to expect for bowel elimination in her newborn. Because the mother is breastfeeding, what should the nurse tell her about the newborn's stools?
Stools should be yellow-gold, loose, and stringy to pasty. The stools of a breast-fed newborn are yellow-gold, loose, and stringy to pasty in consistency. The stools of the formula-fed newborn vary depending on the type of formula ingested. They may be yellow, yellow-green, or greenish and loose, pasty, or formed in consistency, and they have an unpleasant odor.
A woman has just given birth vaginally to a newborn. Which action will the nurse do first?
Suction the mouth and nose. The first priority is to ensure a patent airway by suctioning the newborn's mouth and nose. Before leaving the birthing area, newborn identification procedures are completed, including applying the identification bracelet and possibly footprinting, depending on the agency's policy. An apical heart rate and temperature are checked soon after birth, but do not take priority over ensuring a patent airway.
A nurse is concerned that a 1-day-old newborn is becoming ill and may be septic. What signs of distress would validate the nurse's concerns?
Temperature instability Temperature instability is one of several signs of possible sepsis in a newborn. Other signs include poor feeding, lethargy, irritability and hypoglycemia. Late signs of sepsis include apnea and jaundice. A heart rate of 152, a respiratory rate of 40 and erythema toxicum are all normal findings.
A primigravidia client at 38 weeks' gestation calls the clinic and reports, "My baby is lower and it is more difficult to walk." Which response should the nurse prioritize?
The baby has dropped into the pelvis; your body and baby are getting ready for labor in the next few weeks." The baby can drop into the pelvis, an event termed lightening, and can happen for up to 2 weeks before the woman goes into labor. This is normal and does not require intervention.
The nurse is caring for a client who is late in her pregnancy. What assessment finding should the nurse attribute to the role of prostaglandins?
The cervix is softening The prostaglandin theory is another theory of labor initiation. Prostaglandins influence labor in several ways, which include softening the cervix and stimulating the uterus to contract. However, evidence supporting the theory that prostaglandins are the agents that trigger labor to begin is inconclusive.
Which client outcome during active and transitional labor is best?
The client will practice breathing techniques during contractions. The nurse identifies a priority during the active and transitional stage of labor as working with the contractions to give birth. Being tense works against cervical dilation and fetal descent. For that reason, the client is encouraged to practice breathing techniques. It may be unrealistic to state that the pain level is under 7 in the active and transitional phase. Walking in the hall and tolerating liquids also depends on the client.
What assessment finding would suggest to the care team that the pregnant client has completed the first stage of labor?
The client's cervix is fully dilated. The first stage of labor ends with the client's cervix being fully dilated at 10 cm. The onset of contractions signals the beginning of the first stage and birth occurs at the end of the second stage.
A client gives birth to a baby at a local health care facility. The nurse observes that the infant is fussy and begins to move her hands to her mouth and suck on her hand and fingers. How should the nurse interpret these findings?
The infant is attempting self-consoling maneuvers. The hand-to-mouth movement of the baby indicates the self-quieting and consoling ability of a newborn. The other options are states of behavior of a newborn but are not applicable to this situation.
A woman's husband expresses concern about risk of paralysis from an epidural block being given to his wife. Which would be the most appropriate response by the nurse?
The injection is given in the space outside the spinal cord." An epidural block, as the name implies, does not enter the spinal cord but only the epidural space outside the cord.
Which statement is true regarding fetal and newborn senses?
The rooting reflex is an example that the newborn has a sense of touch. Newborns experience pain, have vision, and can discriminate between tastes. The rooting reflex is an example of a newborn's sense of touch. The fetus can hear in utero.
Which change in client status suggests that labor is anticipated?
The woman can breathe easier throughout the day. Symptoms that the woman is able to breathe easier strongly suggest lightening. Lightening means that the fetus has dropped into the pelvis or is engaged. Typically when the fetus is in the pelvis, it impinges on the bladder causing the need for more frequent urination. Braxton Hicks contractions are the first contractions which may be present for some time. These contractions occur but can diminish when walking or when position changes. Anxiety and anticipation is commonly felt throughout pregnancy.
A client experiencing contractions presents at a health care facility. Assessment conducted by the nurse reveals that the client has been experiencing Braxton Hicks contractions. The nurse has to educate the client on the usefulness of Braxton Hicks contractions. Which role do Braxton Hicks contractions play in aiding labor?
These contractions help in softening and ripening the cervix. Braxton Hicks contractions assist in labor by ripening and softening the cervix and moving the cervix from a posterior position to an anterior position. Prostaglandin levels increase late in pregnancy secondary to elevated estrogen levels; this is not due to the occurrence of Braxton Hicks contractions. Braxton Hicks contractions do not help in bringing about oxytocin sensitivity. Occurrence of lightening, not Braxton Hicks contractions, makes maternal breathing easier.
he nurse is correct to instruct the active labor client on which type of patterned breathing?
Transitioning breaths from "slow, deep breaths to quicker short breaths" at the contraction peak. A client who is in active labor varies her breathing technique to the modified-paced breathing which alters between slow, deep breaths to shorter and quicker breaths at the contraction peak. Slow paced breathing is for early labor and focuses on relaxation. Short quick breaths are used with more intense and frequent contractions. The client should not hold her breath until pushing begins.
A first-time mother informs the nurse that she is unable to breastfeed her newborn through the day as she is usually away at work. She adds that she wants to express her breast milk and store it for her newborn to have later. What instruction would be correct to offer the mother to ensure the safety of the stored expressed breast milk?
Use the sealed and chilled milk within 24 hours. The nurse should instruct the woman to use the sealed and chilled milk within 24 hours. The nurse should not instruct the woman to use frozen milk within 6 months of obtaining it, to use microwave ovens to warm chilled milk, or to refreeze the used milk and reuse it. Instead, the nurse should instruct the woman to use frozen milk within 3 months of obtaining it, to avoid using microwave ovens to warm chilled milk, and to discard any used milk and never refreeze it.
The parents of a 1-day-old newborn are concerned the infant is cold and shivering. Which action should the nurse prioritize to best prevent heat loss?
Warm all surfaces and objects that come in contact with the newborn. The 1-day-old infant will have regulated body temperature at this point in life and the radiant heater is no longer used. Interventions are the best way to prevent heat loss for this newborn; these would include making sure surfaces such as scales, examination tables and instruments are warm. Keeping the newborn under a radiant heater and covering the newborn with several blankets while under the warmer could lead to hyperthermia, which can be just as detrimental to the newborn as hypothermia. Infants are bathed when their temperatures are stable.
A nurse is teaching a newborn's caregivers how to change a diaper correctly. Which statement, by the caregiver best indicates the nurse's teaching was effective?
We will fold down the front of her diaper under the umbilical cord until it falls off." In order to prevent the cord from becoming irritated and help dry it out, the diaper is rolled down in the front. A newborn's diaper needs to be changed frequently; however, the baby do not need to be awoken during the night. Warm water or wipes are sufficient to clean the perineal area at diaper changes. Barrier creams may be used as needed, but should not be applied after every diaper change.
The nurse is preparing to assess the pulse on a newborn who has just arrived to the nursery after being cleaned in the labor and birth suite and swaddled in a blanket. Which action should the nurse prioritize?
Wear clean gloves. Infection control is a priority nursing intervention. Gloves need to be worn when in contact with the infant who has not been bathed after birth. All options are valid options; however, a three-minute surgical scrub is generally only required at the beginning of a shift. The nurse should always wash the hands before putting on gloves to care for an infant and after taking gloves off. Standard precautions are used with every client.
The nurse is explaining the care the newborn will be receiving right after birth to the parents. The nurse should point out the infant will receive an ophthalmic antibiotic ointment by approximately which time?
Within one hour Within the first hour after birth, an antibiotic ointment must be placed in the newborn's eyes to prevent opthalmia neonatorum, a severe eye infection contracted in the birth canal of a woman with gonorrhea or chlamydia.
On examination, the hands and feet of a 12-hour-old infant are cyanotic without other signs of distress. The nurse should document this as:
acrocyanosis. Acrocyanosis is a blue tint to the hands and feet of newborns during the first few days of life. Acrocyanosis is a normal finding and is not indicative of a potential for respiratory distress, poor oxygenation, or cold stress.
A nurse is conducting an in-service program for staff nurses working in the labor and birth unit. The nurse is discussing ways to promote a positive birth outcome for the woman in labor. The nurse determines that additional teaching is necessary when the group identifies which measure?
allowing the woman time to be alone Positive support, not being alone, promotes a positive birth experience. Being alone can increase anxiety and fear, decreasing the woman's ability to cope. Feelings of control promote self-confidence and self-esteem, which in turn help the woman to cope with the challenges of labor. Information about procedures reduces anxiety about the unknown and fosters cooperation and self-confidence in her abilities to deal with labor. Catecholamines are secreted in response to anxiety and fear and can inhibit uterine blood flow and placental perfusion. Relaxation techniques can help to reduce anxiety and fear, in turn decreasing the secretion of catecholamines and ultimately improving the woman's ability to cope with labor.
The nurse determines that the fetal heart rate averages approximately 140 beats per minute over a 10-minute period. The nurse identifies this as:
baseline FHR. The baseline FHR averages 110 to 160 beats per minute over a 10-minute period. Fetal bradycardia occurs when the FHR is less than 110 beats per minute for 10 minutes or longer. Short-term variability is the beat-to-beat change in FHR. Baseline variability refers to the normal physiologic variations in the time intervals that elapse between each fetal heartbeat observed along the baseline in the absence of contractions, decelerations, and accelerations.
Which feature would alert the nurse that the client is in the transition phase of labor?
beginning urge to bear down Starting of the urge to bear down is a feature associated with the transition phase of labor. The transition phase is the last phase of the first stage of labor. In this phase the process of cervical dilatation is completed. During this phase the client experiences an increase in rectal pressure, an increase in the bloody show, and an urge to bear down. The contractions are stronger and hence the client feels irritable, restless, and nauseous. The client feels enthusiastic during the latent phase and not the transition phase.
The nurse is admitting a 10-pound (4.5-kg) newborn to the nursery. What is important for the nurse to monitor during the transition period?
blood sugar Most facilities have protocols to guide nursing care in the treatment of hypoglycemia. Many pediatricians have preprinted orders that can be initiated if the glucose level falls below a predetermined level (usually 40-50 mg/dL).
As a part of the newborn assessment, the nurse examines the infant's skin. Which nursing observation would warrant further investigation?
bright red, raised bumpy area noted above the right eye A red bumpy area noted above the right eye is a hemangioma and needs further investigation to determine whether the hemangioma could interfere with the infant's vision. They may grow larger during the first year then fade and usually disappear by age 9. Stork bites or salmon patches and blue or purple splotches on buttocks (Mongolian spots) are common skin variations and are not concerning. Erythema toxicum, seen as a fine red rash over the chest and back, is also a normal skin variant that will disappear withn a few days.
A client in labor is agitated and nervous about the birth of her child. The nurse explains to the client that fear and anxiety cause the release of certain compounds which can prolong labor. Which compounds is the nurse referring to in the explanation?
catecholamines Fear and anxiety cause the release of catecholamines, such as norepinephrine and epinephrine, which stimulate the adrenergic receptors of the myometrium. This in turn interferes with effective uterine contractions and results in prolonged labor. Estrogen promotes the release of prostaglandins and oxytocin. Relaxin is a hormone that is involved in producing backache by acting on the pelvic joints. Prostaglandins, oxytocin, and relaxin are not produced due to fear or anxiety in clients during labor.
While assessing a newborn, the nurse notes that half the body appears red while the other half appears pale. The nurse interprets this finding as:
harlequin sign. Harlequin sign refers to the dilation of blood vessels on only one side of the body. It gives a distinct midline demarcation, which is pale on one side and red on the opposite. Stork bites are superficial vascular areas found on the nape of the neck, eyelids, between the eyes and upper lip. Mongolian spots are blue or purple splotches that appear on the lower back and buttocks. Erythema toxicum is a benign, idiopathic, generalized, transient rash that resembles flea bites.
To give birth to her infant, a woman is asked to push with contractions. Which pushing technique is the most effective and safest?
head elevated, grasping knees, breathing out An important point is to be certain the woman does not hold her breath, as this puts pressure on the vena cava, reducing blood return.
The AGPAR score is based on which 5 parameters?
heart rate, muscle tone, reflex irritability, respiratory effort, and color A newborn can receive an APGAR score ranging from 0 to 10. The score is based on 5 factors, each of which is assigned a 0, 1, or 2. Heart rate (should be above 100), muscle tone (should be able to maintain a flexion position), reflex irritability (newborn should cry or sneeze when stimulated), and respiratory effort are evaluted by the presence of a strong cry and by color. Color is evaluated by noting the color of the body and hands and feet.
A nursing student will pick which value as a correct laboratory value for a newborn?
hemoglobin (HBG) 17 to 20 g/dL The normal laboratory values for a newborn include HGB 17 to 20g/dL, HCT 52% to 63%, platelets 100,000 to 300,000µL , RBCs 5.1 to 5.8, and WBCs 10 to 30,000/mm³3.
The nurse is explaining to new parents that a potential complication of a cesarean birth is transient tachypnea. The nurse explains that this is due to which occurrence?
lack of thoracic compressions during birth A baby born by cesarean birth does not have the same benefit of the birth canal squeeze as does the newborn born by vaginal birth. This may result in the fluid in the lungs being removed too slowly or incompletely. Research findings support the need for thoracic compression to assist with the removal of the fluid and facilitate adequate breathing in the newborn.
The nurse assesses a client in labor and finds that the fetal long axis is longitudinal to the maternal long axis. How should the nurse document this finding?
lie The nurse is assessing fetal lie, the relationship of the fetal long axis to the maternal long axis. When the fetal long axis is longitudinal to the maternal long axis, the lie is said to be longitudinal. Presentation is the portion of the fetus that overlies the maternal pelvic inlet. Attitude is the relationship of the different fetal parts to one another. Position is the relationship of the fetal denominator to the different sides of the maternal pelvis.
A nurse is meeting with a group of pregnant clients who are in their last trimester to teach them the signs that may indicate they are going into labor. The nurse determines the session is successful after the clients correctly choose which signs as an indication of starting labor? Select all that apply.
lightening bloody show backache The signs of approaching labor include lightening, bloody show, and backache. Lightening is the falling forward of the pregnant uterus due to settlement of the fetal head into the maternal pelvis. Backache associated with pelvic cramping pain, which is regular and increases in intensity, is suggestive of impending labor. Bloody show is the expulsion of the cervical mucous plug tinged with blood, and occurs due to cervical effacement and dilatation. Weight loss and diarrhea are other signs of impending labor. Weight gain and constipation are not signs of impending labor.
The nurse is preparing a teaching plan for new parents about why newborns experience heat loss. Which information about newborns would the nurse include?
limited voluntary muscle activity Newborns have limited voluntary muscle activity or movement to produce heat. They have thin skin with blood vessels close to the surface. They cannot shiver to generate heat. They have limited stores of metabolic substances such as glucose and glycogen.
The nurse is assessing a client in labor for pain and notes she is currently not doing well handling the increased pain. Which opioid can the nurse offer to the client to assist with pain control?
meperidine Meperidine is an opioid that is commonly used during labor and birth. Secobarbital and thiopental are barbiturates. Hydroxyzine hydrochloride is a tranquilizer which can be used to supplement the narcotic or reduce anxiety.
The nurse is teaching the parents of a newborn baby girl the basic discharge instructions. The nurse determines the session is successful after the couple articulate they will contact the primary care provider if their infant shows which sign of diarrhea?
more than two episodes of diarrhea in one day Diarrhea is defined as frequent stools with high water content. Because newborns dehydrate quickly, it is important for parents to notify the care provider if the newborn has more than two episodes of diarrhea in one day.
Assessment reveals that the fetus of a client in labor is in the vertex presentation. The nurse determines that which part is presenting?
occiput With a vertex presentation, a type of cephalic presentation, the fetal presenting part is the occiput. The shoulders are the presenting part when the fetus is in a shoulder presentation. The brow or sinciput is the presenting part when a fetus is in a brow presentation. The buttocks are the presenting part when a fetus is in a breech presentation.
A nurse is observing the interaction between a new mother and her neonate. The nurse notes that the neonate moves his head and eyes to focus on the mother's voice and smile. The nurse interprets this as which behavioral response?
orientation The neonate is demonstrating orientation, the neonate's ability to respond to auditory and visual stimuli, as demonstrated by the movement of head and eyes to focus on that stimuli. Habituation is the newborn's ability to process and respond to visual and auditory stimuli. Habituation is the ability to block out external stimuli after the newborn has become accustomed to the activity. Motor maturity depends on gestational age and involves evaluation of posture, tone, coordination, and movements. These activities enable newborns to control and coordinate movement. When stimulated, newborns with good motor organization demonstrate movements that are rhythmic and spontaneous. Self-quieting ability (also called self-soothing) refers to newborns' ability to quiet and comfort themselves.
When the nurse is applying a skin temperature probe to a newborn who is lying on his side, which location would be most appropriate?
over the liver To obtain accurate assessment of whole body temperature, a skin temperature probe should be placed over the liver if the newborn is supine or in the side-lying position. Bony areas such as the hip or areas with brown fat such the mediastinum or between the scapulae should be avoided because these areas do not give accurate readings.
A maternity nurse is aware that the fetal head is the presenting part in complete extension position. Which type of birth should the maternity nurse anticipate?
prolonged labor and possible cesarean birth The attitude of the fetal head is moderate flexion. If there are changes in the fetal attitude (the head), the presenting part is then a larger diameter to the maternal pelvis. This presentation could cause a long labor and possible cesarean birth.
A nurse is teaching newborn care to students. The nurse correctly identifies which mechanism as the predominant form of heat loss in the newborn?
radiation, convection, and conduction Heat loss in the newborn occurs primarily through radiation, convection, and conduction because of the newborn's large ratio of body surface to weight and because of the marked difference between core and skin temperatures. Nonshivering thermogenesis is a mechanism of heat production in the newborn. Lack of brown adipose tissue contributes to heat loss, particularly in premature infants, but it is not the predominant form of heat loss. Peripheral vasoconstriction is a method to increase heat production.
A nurse is caring for a client who has been administered an epidural block. Which should the nurse assess next?
respiratory rate The nurse must monitor for respiratory depression. Monitoring the client's respiratory rate will be the best indicator of respiratory depression.
The nurse is preparing to apply a thermistor probe to a newborn to monitor the newborn's temperature. At which location would the nurse apply the probe?
right upper abdominal quadrant A thermistor probe is taped to the newborn's abdomen, usually in the right upper quadrant. This allows for position changes without having to readjust the probe.
The nurse is documenting assessment of infant reflexes. She strokes the side of the infant's face, and the baby turns toward the stroke. What reflex has the nurse elicited?
rooting This is the rooting reflex and is used to encourage the infant to feed. This reflex and the sucking reflex work together to assist the infant with cues for feeding at the breast. The tonic neck (or fencing) reflex and the Moro (or startle reflex) are total body reflexes and assess neurologic function in the newborn.
During the second stage of labor, a woman is generally:
turning inward to concentrate on body sensations. Second-stage contractions are so unusual that most women are unable to think of things other than what is happening inside their body.
When assessing the newborn's umbilical cord, what should the nurse expect to find?
two smaller arteries and one larger vein When inspecting the vessels in the umbilical cord, the nurse should expect to encounter one larger vein and two smaller arteries. In 0.5% of births (3.5% of twin births), there is only one umbilical artery, which can be linked to cardiac or chromosomal abnormalities.
A 19-year-old woman presents to the emergency department in the late stages of active labor. Assessment reveals she received no prenatal care. As part of her examination, a rapid HIV screen indicates she is HIV positive. To reduce the perinatal transmission to her infant, which intravenous medication would the nurse anticipate adminstering?
zidovudine Zidovudine (ZDV) is recommended to reduce perinatal transmission of HIV (2mg/kg IV over an hour, and then a maintenance infusion of 1 mg/kg per hour until birth) or a single 200-mg oral dose of nevirapine at the onset of labor. Since this client presented in the late stages, zidovudine would be the better choice. Tenofovir and maraviroc are also HIV medications, but they are not the better choices for this scenario.
As a woman enters the second stage of labor, her membranes spontaneously rupture. When this occurs, what would the nurse do next?
Assess fetal heart rate for fetal safety. Rupture of the membranes may lead to a prolapsed cord. Assessment of FHR detects this.
The nurse is assessng a newborn male in the presence of the parents and notes that he has a hypospadias. How should the nurse respond when questioned by the parents as to what this means?
His urinary meatus in located on the under surface of the glans." The term "hypospadias" refers to the urinary meatus being abnormally located on the ventral (under) surface of the glans. There are no special terms to indicate normal genitalia. Cryptorchidism refers to undescended testes. Hydrocele refers to the collection of fluid in the scrotal sac.
A nurse is preparing to administer phytonadione to a newborn. After confirming the order, what will the nurse do next?
Identify the newborn. The nurse will identify the correct newborn before administering phytonadione (vitamin K). The newborn's weight is not needed to calculate the dosage as all newborns receive 0.5 mg IM within one hour of birth. Phytonadione is given to decrease the risk of hemorrhage.
A nurse is caring for a pregnant client in labor in a health care facility. The nurse knows that which sign marks the termination of the first stage of labor in the client?
dilation of cervix diameter to 10 cm The first stage of labor terminates with the dilation of the cervix diameter to 10 cm. Diffused abdominal cramping and rupturing of the fetal membrane occurs during the first stage of labor. Regular contractions occur at the beginning of the latent phase of the first stage; they do not mark the end of the first stage of labor.