OB exam 3

A nurse is caring for a late preterm infant. What action by the nurse is inconsistent with best practice to prevent cold stress? a. Wean the infant directly to an open crib. b. Check temperature every 3 to 4 hours. c. Encourage kangaroo care. d. Place infant on a radiant warmer.

ANS: A Weaning to an open crib takes many steps and is not done directly because of the risk of cold stress. The other actions help prevent cold stress.

The nurse is providing postpartum instructions to a client who will be breast-feeding her newborn. The nurse determines that the client has understood the instructions if she makes which statements? Select all that apply. 1. "I should wear a bra that provides support." 2. "Drinking alcohol can affect my milk supply." 3. "The use of caffeine can decrease my milk supply." 4. "I will start my estrogen birth control pills again as soon as I get home." 5. "I know if my breasts get engorged, I will limit my breast-feeding and supplement the baby." 6. "I plan on having bottled water available in the refrigerator so I can get additional fluids easily."

1. "I should wear a bra that provides support." 2. "Drinking alcohol can affect my milk supply." 3. "The use of caffeine can decrease my milk supply." 6. "I plan on having bottled water available in the refrigerator so I can get additional fluids easily."

The nurse is providing instructions to a pregnant client with human immunodeficiency virus (HIV) infection regarding care to the newborn after delivery. The client asks the nurse about the feeding options that are available. Which response should the nurse make to the client? 1. "You will need to bottle-feed your newborn." 2. "You will need to feed your newborn by nasogastric tube feeding." 3. "You will be able to breast-feed for 6 months and then will need to switch to bottle-feeding." 4. "You will be able to breast-feed for 9 months and then will need to switch to bottle-feeding."

1. "You will need to bottle-feed your newborn."

A postpartum woman with mastitis in the right breast complains that the breast is too sore for her to breast-feed her infant. The nurse should tell the client to implement which measure? 1. Pump both breasts and discard the milk. 2. Bottle-feed the infant on a temporary basis. 3. Breast-feed from the left breast and gently pump the right breast. 4. Stop breast-feeding from both breasts until this condition resolves.

3. Breast-feed from the left breast and gently pump the right breast.

The nurse is creating a plan of care for a postpartum client who was diagnosed with superficial venous thrombosis. The nurse anticipates that which intervention will be prescribed? 1. Ambulation 8 to 10 times daily 2. Administration of anticoagulants 3. Elevation of the affected extremity 4. Application of ice packs to the affected area

3. Elevation of the affected extremity

Methylergonovine has been prescribed for a woman who is at risk for postpartum bleeding in the immediate postpartum period. The nurse preparing to administer the medication ensures that which priority item is at the bedside? 1. Peripads 2. Tape measure 3. Reflex hammer 4. Blood pressure cuff

4. Blood pressure cuff

A client has just had surgery to deliver a nonviable fetus resulting from abruptio placentae. As a result of the abruptio placentae, the client develops disseminated intravascular coagulation (DIC) and is told about the complication. The client begins to cry and screams, "God, just let me die now!" Which client problem should be the priority for the client at this time? 1. Lack of power about the situation 2. Grieving because of the loss of the baby 3. Lack of knowledge regarding what occurred 4. Concern about the loss of the baby and personal health

4. Concern about the loss of the baby and personal health

The nurse is creating a plan of care for a postpartum client with a small vulvar hematoma. The nurse should include which specific action during the first 12 hours after delivery? 1. Encourage ambulation hourly. 2. Assess vital signs every 4 hours. 3. Measure fundal height every 4 hours. 4. Prepare an ice pack for application to the area.

4. Prepare an ice pack for application to the area.

The perinatal nurse caring for the postpartum woman understands that late postpartum hemorrhage is most likely caused by a. subinvolution of the uterus. b. defective vascularity of the decidua. c. cervical lacerations. d. coagulation disorders.

ANS: A The most common causes of late postpartum hemorrhage are subinvolution and retained placental fragments.

A nurse is caring for a preterm infant who has a weak cry and is irritable. What action by the nurse is best? a. Assess the infant for pain. b. Take the infant's temperature. c. Obtain a bedside glucose reading. d. Reduce stimulation in the environment.

ANS: B These are signs of inadequate thermoregulation. The nurse should assess the infant's temperature first. The other actions do not address thermoregulation.

Compared to the term infant, the preterm infant has a. few blood vessels visible though the skin. b. more subcutaneous fat. c. well-developed flexor muscles. d. greater surface area in proportion to weight.

ANS: D Preterm infants have greater surface area in proportion to their weight. They often have visible blood vessels because their skin is thin and they have less fat. More fat and well- developed flexor muscles are characteristic of a more mature infant.

The nurse is preparing a dose of naloxone for a newborn who weighs 6.9 pounds. How much naloxone does the nurse administer? ______ mg

dose is 0.1 mg/kg (6.9 x 0.1)/2.2 = 0.3 mg

The nurse is caring for four 1-day postpartum clients. Which client assessment requires the need for follow-up? 1. The client with mild afterpains 2. The client with a pulse rate of 60 beats/minute 3. The client with colostrum discharge from both breasts 4. The client with lochia that is red and has a foul-smelling odor

4. The client with lochia that is red and has a foul-smelling odor

The home care nurse's assignment is to visit a new mother at home 24 to 48 hours after discharge. What should the nurse expect to note in a healthy mother who is breast-feeding her newborn infant? 1. The mother has cracked nipples and feeds the infant with a supplemental bottle. 2. The mother complains of breast engorgement, and the infant demonstrates difficulty in latching onto the breast. 3. The mother is breast-feeding the infant with the infant's head turned toward her breast and the body flat in her arms; the mother has sore nipples, and the infant has a suck blister. 4. The mother is breast-feeding with the infant in a tummy-to-tummy position without signs of cracked nipples; the baby demonstrates bursts of sucking, followed by a pause and swallow.

4. The mother is breast-feeding with the infant in a tummy-to-tummy position without signs of cracked nipples; the baby demonstrates bursts of sucking, followed by a pause and swallow.

What risk factor for peripartum depression (PPD) is likely to have the greatest effect on the woman's condition? a. Personal history of depression b. Single-mother status c. Low socioeconomic status d. Unplanned or unwanted pregnancy

ANS: A A personal history of depression is a known risk factor for peripartum depression. Being single, from a low socioeconomic status, or having an unplanned or unwanted pregnancy may contribute to depression for some women but are not strong predictors.

The nurse provides a list of discharge instructions to a client who has delivered a healthy newborn by cesarean delivery. Which statement by the client indicates the need for further teaching? 1. "A fever on and off is expected and is nothing to worry about." 2. "Even though I am breast-feeding my baby, I still can ovulate." 3. "I can begin abdominal exercises about a month after delivery." 4. "I should contact my doctor if I am having any feelings of depression."

1. "A fever on and off is expected and is nothing to worry about."

The nurse has provided instructions for a postpartum client at risk for thrombosis regarding measures to prevent its occurrence. Which statement, if made by the client, indicates a need for further education? 1. "I should apply my antiembolism stockings after breakfast." 2. "I should avoid prolonged standing or sitting in 1 position." 3. "I should perform regularly scheduled exercise such as walking." 4. "I should avoid using pillows under my knees to prevent pressure in the back of my knee area."

1. "I should apply my antiembolism stockings after breakfast."

The nurse has provided discharge instructions to a client who delivered a healthy newborn by cesarean delivery. Which statement made by the client indicates a need for further instruction? 1. "I will begin abdominal exercises immediately." 2. "I will notify the health care provider if I develop a fever." 3. "I will turn on my side and push up with my arms to get out of bed." 4. "I will lift nothing heavier than my newborn baby for at least 2 weeks."

1. "I will begin abdominal exercises immediately."

The postpartum nurse is providing instructions to a client after birth of a healthy newborn. Which time frame should the nurse relay to the client regarding the return of bowel function? 1. 3 days postpartum 2. 7 days postpartum 3. On the day of birth 4. Within 2 weeks postpartum

1. 3 days postpartum

The nurse is monitoring a postpartum client who received epidural anesthesia for delivery for the presence of a vulvar hematoma. Which assessment finding would best indicate the presence of a hematoma? 1. Changes in vital signs 2. Signs of heavy bruising 3. Complaints of intense pain 4. Complaints of a tearing sensation

1. Changes in vital signs

The nurse is planning care for a postpartum client who had a vaginal delivery 2 hours ago. The client required an episiotomy and has several hemorrhoids. What is the priority nursing consideration for this client? 1. Client pain level 2. Inadequate urinary output 3. Client perception of body changes 4. Potential for imbalanced body fluid volume

1. Client pain level

The nurse is assessing a client in the postpartum period and suspects the presence of uterine atony. Which is the initial nursing action? 1. Massage the uterus until firm. 2. Take the client's blood pressure. 3. Contact the health care provider (HCP). 4. Measure the amount of drainage on the peripad.

1. Massage the uterus until firm.

The postpartum nurse is caring for a woman who just delivered a healthy newborn. The nurse should be most concerned about the presence of subinvolution if which occurs? 1. Afterpains 2. Retained placental fragments from delivery 3. An oral temperature of 99.0°F (37.2°C) following delivery 4. Increased estrogen and progesterone levels as noted on laboratory analysis

2. Retained placental fragments from delivery

The client delivered a newborn baby 3 hours ago. The assigned nurse is reviewing the electronic health record to determine if the new mother is a candidate for Rh immune globulin administration. Which criteria must be present in order to administer this medication correctly? Select all that apply. 1. The father must be Rh negative. 2. The mother must be Rh negative. 3. The newborn must be Rh positive. 4. The indirect Coombs' test must be negative. 5. The newborn must be a second or subsequent child delivered to this mother.

2. The mother must be Rh negative. 3. The newborn must be Rh positive. 4. The indirect Coombs' test must be negative.

The nurse is providing instructions to a client who has been diagnosed with mastitis. Which statement, if made by the client, indicates a need for further instruction? 1. "I need to wear a supportive bra to relieve the discomfort." 2. "I need to stop breast-feeding until this condition resolves." 3. "I can use analgesics to assist in alleviating some of the discomfort." 4. "I need to take antibiotics, and I should begin to feel better in 24 to 48 hours."

2. "I need to stop breast-feeding until this condition resolves."

The nurse is preparing to perform a fundal assessment on a postpartum client. The nurse understands that which is the initial nursing action when performing this assessment? 1. Ask the client to turn on her side. 2. Ask the client to urinate and empty her bladder. 3. Massage the fundus gently before determining the level of the fundus. 4. Ask the client to lie flat on her back, with her knees and legs flat and straight.

2. Ask the client to urinate and empty her bladder.

On the second postpartum day, a client complains of burning on urination, urgency, and frequency of urination. A urinalysis indicates the presence of a urinary tract infection. The nurse instructs the client regarding measures to take for the treatment of the infection. Which client statement indicates to the nurse the need for further instruction? 1. "I need to urinate frequently throughout the day." 2. "The prescribed medication must be taken until it is finished." 3. "My fluid intake should be increased to at least 3000 mL daily." 4. "Foods and fluids that will increase urine alkalinity should be consumed."

4. "Foods and fluids that will increase urine alkalinity should be consumed."

The postpartum nurse is taking the vital signs of a client who delivered a healthy newborn 4 hours ago. The nurse notes that the client's temperature is 100.2°F (37.8°C). What is the priority nursing action? 1. Document the findings. 2. Retake the temperature in 15 minutes. 3. Notify the health care provider (HCP). 4. Increase hydration by encouraging oral fluids.

4. Increase hydration by encouraging oral fluids.

Which instructions should the nurse provide to a client following delivery on care of the episiotomy site to prevent infection? Select all that apply. 1. Report a foul-smelling discharge. 2. Take a warm sitz baths 3 times a day. 3. Change the perineum pads 3 times a day. 4. Use warm water to rinse the perineum after elimination. 5. Wipe the perineum from front to back after voiding and defecation.

1. Report a foul-smelling discharge. 2. Take a warm sitz baths 3 times a day. 4. Use warm water to rinse the perineum after elimination. 5. Wipe the perineum from front to back after voiding and defecation.

The nurse is teaching a postpartum client about breast-feeding. Which instruction should the nurse include? 1. The diet should include additional fluids. 2. Prenatal vitamins should be discontinued. 3. Soap should be used to cleanse the breasts. 4. Birth control measures are unnecessary while breast-feeding.

1. The diet should include additional fluids.

A woman infected with the human immunodeficiency virus (HIV) has given birth to an infant who appears normal, and the nurse provides instructions about newborn infant care. Which statement by the mother indicates an understanding of the instructions? Select all that apply. 1. "I am going to need to bottle-feed my baby." 2. "I need to wash my hands before and after bathroom use." 3. "I can transmit the infection to my baby when I breast-feed." 4. "My baby won't need any medication to prevent the virus because my baby appears normal." 5. "I am going to contact some support groups to help me cope and learn ways to deal with things when I get home."

1. "I am going to need to bottle-feed my baby." 2. "I need to wash my hands before and after bathroom use." 3. "I can transmit the infection to my baby when I breast-feed." 5. "I am going to contact some support groups to help me cope and learn ways to deal with things when I get home."

The nurse in a maternity unit is providing emotional support to a client and her significant other who are preparing to be discharged from the hospital after the birth of a dead fetus. Which statement made by the client indicates a component of the normal grieving process? 1. "We want to attend a support group." 2. "We never want to try to have a baby again." 3. "We are going to try to adopt a child immediately." 4. "We are okay, and we are going to try to have another baby immediately."

1. "We want to attend a support group."

A stillborn baby was delivered in the birthing suite a few hours ago. After the delivery, the family remained together, holding and touching the baby. Which statement by the nurse would assist the family in their period of grief? 1. "What can I do for you?" 2. "Now you have an angel in heaven." 3. "Don't worry, there is nothing you could have done to prevent this from happening." 4. "We will see to it that you have an early discharge so that you don't have to be reminded of this experience."

1. "What can I do for you?"

A postpartum care unit nurse is reviewing the records of 5 new mothers admitted to the unit. The nurse determines that which mother is most likely at risk for developing a puerperal infection? Select all that apply. 1. A mother who had 10 vaginal exams during labor 2. A mother with a history of previous puerperal infections 3. A mother who gave birth vaginally to a 3200-gram infant 4. A mother who experienced prolonged rupture of the membranes 5. A mother who experienced the expected outcome with delivery of the placenta

1. A mother who had 10 vaginal exams during labor 2. A mother with a history of previous puerperal infections 4. A mother who experienced prolonged rupture of the membranes

A pregnant woman who is infected with the human immunodeficiency virus (HIV) delivers a newborn infant, and the nurse provides instructions to help the mother regarding care of the infant. Which statements by the client indicate the need for further instruction? Select all that apply. 1. "I will be sure to wash my hands thoroughly and frequently." 2. "I need to breast-feed, especially for the first 6 weeks postpartum." 3. "My baby needs to receive all of the recommended vaccines at the regular schedule." 4. "My baby has no symptoms so it is not likely that he has gotten the infection from me." 5. "My newborn infant should be on antiviral medications for the first 6 weeks after delivery."

2. "I need to breast-feed, especially for the first 6 weeks postpartum." 4. "My baby has no symptoms so it is not likely that he has gotten the infection from me."

The nurse is developing a plan of care for a client recovering from a cesarean delivery. Which action should the nurse encourage the client to do to prevent thrombophlebitis? 1. Elevate her legs. 2. Remain on bed rest. 3. Ambulate frequently. 4. Apply warm, moist packs to the legs.

3. Ambulate frequently.

The postpartum nurse is assessing a client who delivered a healthy infant by cesarean section for signs and symptoms of superficial venous thrombosis. Which sign should the nurse note if superficial venous thrombosis were present? 1. Paleness of the calf area 2. Coolness of the calf area 3. Enlarged, hardened veins 4. Palpable dorsalis pedis pulses

3. Enlarged, hardened veins

Which data should alert the nurse that the neonate is postmature? a. Cracked, peeling skin b. Short, chubby arms and legs c. Presence of vernix caseosa d. Presence of lanugo

ANS: A Loss of vernix caseosa, which protects the fetal skin in utero, may leave the skin macerated and appearing cracked and peeling. Postmature infants usually have long, thin arms and legs. Vernix caseosa decreases in the postmature infant. Absence of lanugo is common in postmature infants.

Which preterm infant should receive gavage feedings instead of a bottle? a. Sometimes gags when a feeding tube is inserted b. Is unable to coordinate sucking and swallowing c. Sucks on a pacifier during gavage feedings d. Has an axillary temperature of 98.4° F, an apical pulse of 149 beats/min, and respirations of 54 breaths/min

ANS: B An infant who cannot coordinate sucking, swallowing, and breathing should receive gavage feedings. The other infants are ready for bottle feedings.

Of all the signs seen in infants with respiratory distress syndrome, which sign is especially indicative of the syndrome? a. Pulse more than 160 beats/min b. Circumoral cyanosis c. Grunting d. Substernal retractions

ANS: C Grunting increases the pressure inside the alveoli to keep them open when surfactant is insufficient. This is a characteristic and often early sign of RDS. The other assessments are not specific to RDS.

The maternity nurse knows that which disorder can be triggered by a birth the woman views as traumatic? a. A phobia b. Panic disorder c. Posttraumatic stress disorder (PTSD) d. Obsessive-compulsive disorder (OCD)

ANS: C In PTSD, women perceive childbirth as a traumatic event. They have nightmares and flashbacks about the event, anxiety, and avoidance of reminders of the traumatic event. This will not lead to phobias, panic disorder, or OCD.

The nurse who is employed in a prenatal clinic is performing prenatal assessments on clients who are in their first trimester of pregnancy. The nurse is concerned with identifying clients who may be at risk for the development of postpartum complications. Which clients would be at most risk for development of postpartum thromboembolic disorders? Select all that apply. 1. A 39-year-old woman who reports that she smokes 2. A 24-year-old woman with a thin frame who is a vegetarian 3. A 26-year-old woman with a family history of thrombophlebitis 4. A 37-year-old woman in her fourth pregnancy who is overweight 5. A 22-year-old woman in a first pregnancy who states that oral contraceptives taken in the past have caused thrombophlebitis

1. A 39-year-old woman who reports that she smokes 4. A 37-year-old woman in her fourth pregnancy who is overweight 5. A 22-year-old woman in a first pregnancy who states that oral contraceptives taken in the past have caused thrombophlebitis

The nurse is monitoring a postpartum client who is at risk for developing postpartum endometritis. Which finding, if noted during the first 24 hours after delivery, supports a diagnosis of postpartum endometritis? 1. Abdominal tenderness and chills 2. Increased diuresis and appetite 3. Maternal oral temperature of 100.2°F (37.9°C) 4. Fundus 2 fingerbreadths below umbilicus, midline and firm

1. Abdominal tenderness and chills

The nurse is assessing the fundus in a postpartum woman and notes that the uterus is soft and spongy and not firmly contracted. The nurse should prepare to implement which interventions? Select all that apply. 1. Massaging the uterus 2. Pushing gently on the uterus 3. Assisting the woman to urinate 4. Rechecking the uterus in 1 hour 5. Checking for a distended bladder 6. Calling the delivery room to schedule an abdominal hysterectomy

1. Massaging the uterus 3. Assisting the woman to urinate 5. Checking for a distended bladder

The nurse is preparing a list of self-care instructions for a postpartum client who was diagnosed with mastitis. Which instructions should be included on the list? Select all that apply. 1. Wear a supportive bra. 2. Rest during the acute phase. 3. Maintain a fluid intake of at least 3000 mL/day. 4. Continue to breast-feed if the breasts are not too sore. 5. Take the prescribed antibiotics until the soreness subsides. 6. Avoid decompression of the breasts by breast-feeding or breast pump.

1. Wear a supportive bra. 2. Rest during the acute phase. 3. Maintain a fluid intake of at least 3000 mL/day. 4. Continue to breast-feed if the breasts are not too sore.

A new mother is seen in a health care clinic 2 weeks after giving birth to a healthy newborn infant. The mother is complaining that she feels as though she has the flu and complains of fatigue and aching muscles. On further assessment the nurse notes a localized area of redness on the left breast, and the mother is diagnosed with mastitis. The mother asks the nurse about the condition. The nurse should make which response? 1. "Mastitis usually involves both breasts." 2. "Mastitis can occur at any time during breast-feeding." 3. "Mastitis usually is caused by wearing a supportive bra." 4. "Mastitis is most common for women who have breast-fed in the past."

2. "Mastitis can occur at any time during breast-feeding."

The rubella vaccine has been prescribed for a new mother. Which statement should the postpartum nurse make when providing information about the vaccine to the client? 1. "You should avoid sexual intercourse for 2 weeks after administration of the vaccine." 2. "You should not become pregnant for 2 to 3 months after administration of the vaccine." 3. "You should avoid heat and extreme temperature changes for 1 week after administration of the vaccine." 4. "You must sign an informed consent because anaphylactic reactions can occur with the administration of this vaccine."

2. "You should not become pregnant for 2 to 3 months after administration of the vaccine."

The nurse is monitoring a client in the immediate postpartum period for signs of hemorrhage. Which sign, if noted, would be an early sign of excessive blood loss? 1. A temperature of 100.4°F (38°C) 2. An increase in the pulse rate from 88 to 102 beats/minute 3. A blood pressure change from 130/88 to 124/80 mm Hg 4. An increase in the respiratory rate from 18 to 22 breaths/minute

2. An increase in the pulse rate from 88 to 102 beats/minute

The postpartum unit nurse is performing an assessment on a client who is at risk for thrombophlebitis. Which nursing action is indicated in assessing for thrombophlebitis? 1. Palpate for pedal pulses. 2. Ask the client about pain in the calf area. 3. Assess for the presence of vaginal hematoma. 4. Ask the client to ambulate and assess for the presence of pain.

2. Ask the client about pain in the calf area.

A type 1 diabetic mother delivered a 4400-gram newborn 3 hours ago. She has already initiated breast-feeding. What should the nurse plan to do to maintain euglycemia in this client? 1. Administer her prepregnancy dose of metformin. 2. Assess her blood glucose before administering any glucose-lowering medications. 3. Administer 20 units of long-acting insulin, as sufficient time has elapsed since delivery. 4. Keep NPO (nothing by mouth) for an additional 4 hours to allow the blood glucose to normalize.

2. Assess her blood glucose before administering any glucose-lowering medications.

The postpartum client asks the nurse about the occurrence of afterpains. The nurse informs the client that afterpains will be especially noticeable during which activity? 1. Ambulating 2. Breast-feeding 3. Taking sitz baths 4. Increasing activity after arriving home

2. Breast-feeding

A client arrives at the postpartum unit after delivery of her infant. On performing an assessment, the nurse notes that the client is shaking uncontrollably. Which nursing action is appropriate? 1. Massage the fundus. 2. Cover the client with a warm blanket. 3. Contact the health care provider (HCP). 4. Place the client in Trendelenburg's position.

2. Cover the client with a warm blanket.

The postpartum unit nurse is creating a plan of care for a first-time mother and identifies the need for measures that will promote parent-infant bonding. Which measure should the nurse include in the plan? 1. Use a low-pitched voice to speak to the infant. 2. Encourage the mother to hold the infant when the infant cries. 3. Encourage the parents to allow the infant to sleep in the parental bed. 4. Encourage the mother to allow the nursing staff to care for the infant during her hospital stay until she is discharged.

2. Encourage the mother to hold the infant when the infant cries.

A postpartum client is diagnosed with cystitis. The nurse should plan for which priority action in the care of the client? 1. Providing sitz baths 2. Encouraging fluid intake 3. Placing ice on the perineum 4. Monitoring hemoglobin and hematocrit levels

2. Encouraging fluid intake

A postpartum unit nurse is caring for a stable client 12 hours after delivering a healthy newborn. At this time in the postpartum period, what is the recommended frequency for the nurse to assess the client's vital signs? 1. Every hour 2. Every 4 hours 3. Every 24 hours 4. Every 30 minutes

2. Every 4 hours (VS are q 15 min for an hour; q 30 min for two hours; q hour for the next 2-6 hours; then q 4 hours)

The nurse in the postpartum unit is caring for a client who has just delivered a newborn infant following a pregnancy with placenta previa. The nurse reviews the plan of care and prepares to monitor the client for which risk associated with placenta previa? 1. Infection 2. Hemorrhage 3. Chronic hypertension 4. Disseminated intravascular coagulation

2. Hemorrhage

When planning care for a postpartum client who plans to breast-feed her infant, which important piece of information should the nurse include in the teaching plan to prevent the development of mastitis? 1. Offer only 1 breast at each feeding. 2. Massage distended areas as the infant nurses. 3. Express and discard milk from the affected breast at the first signs of mastitis. 4. Cleanse the nipples with a mild antibacterial soap before and after infant feedings.

2. Massage distended areas as the infant nurses.

The nurse is preparing to assess the uterine fundus of a client in the immediate postpartum period. After locating the fundus, the nurse notes that the uterus feels soft and boggy. Which nursing intervention is appropriate? 1. Elevate the client's legs. 2. Massage the fundus until it is firm. 3. Ask the client to turn on her left side. 4. Push on the uterus to assist in expressing clots.

2. Massage the fundus until it is firm.

The nurse is caring for a client in the postpartum period immediately after delivery. The nurse performs an assessment on the client and prepares to assess uterine involution by taking which action? 1. Monitoring the vital signs 2. Palpating the uterine fundus 3. Auscultating the bowel sounds 4. Assessing the amount of drainage on the peripad

2. Palpating the uterine fundus

A rubella titer result of a 1-day postpartum client is less than 1:8, and a rubella virus vaccine is prescribed to be administered before discharge. The nurse provides which information to the client about the vaccine? Select all that apply. 1. Breast-feeding needs to be stopped for 3 months. 2. Pregnancy needs to be avoided for 1 to 3 months. 3. The vaccine is administered by the subcutaneous route. 4. Exposure to immunosuppressed individuals needs to be avoided. 5. A hypersensitivity reaction can occur if the client has an allergy to eggs. 6. The area of the injection needs to be covered with a sterile gauze for 1 week.

2. Pregnancy needs to be avoided for 1 to 3 months. 3. The vaccine is administered by the subcutaneous route. 4. Exposure to immunosuppressed individuals needs to be avoided. 5. A hypersensitivity reaction can occur if the client has an allergy to eggs.

After a precipitous delivery, the nurse notes that the new mother is passive and touches her newborn infant only briefly with her fingertips. What should the nurse do to help the woman process the delivery? 1. Encourage the mother to breast-feed soon after birth. 2. Support the mother in her reaction to the newborn infant. 3. Tell the mother that it is important to hold the newborn infant. 4. Document a complete account of the mother's reaction on the birth record.

2. Support the mother in her reaction to the newborn infant.

The nurse caring for a client with a diagnosis of subinvolution should recognize which conditions as causes of this diagnosis? Select all that apply. 1. Afterpains 2. Uterine infection 3. Increased estrogen levels 4. Increased progesterone levels 5. Retained placental fragments from delivery

2. Uterine infection 5. Retained placental fragments from delivery

The nursing student is assigned to care for a client in the postpartum unit. The coassigned registered nurse asks the student to identify the most objective method to assess the amount of lochial flow in the client. Which statement, if made by the student, indicates an understanding of this method? 1. "I can estimate the amount of blood loss by gauging the amount of staining on a perineal pad." 2. "I should ask the client to keep a record and document every time the perineal pad is changed." 3. "I should weigh the perineal pad before and after use and note the amount of time between each pad change." 4. "I can look at the perineal pad and gauge the amount of staining and relate it to the amount of time between pad changes."

3. "I should weigh the perineal pad before and after use and note the amount of time between each pad change."

The discharge nurse is discussing mastitis with a postpartum client. Which statement made by the client indicates a need for further instruction? 1. "If I develop a hot, reddened, triangle-shaped area on my breast, I should contact my health care provider." 2. "Antibiotics, rest, warm compresses, and adequate fluid intake are all important for the treatment of mastitis." 3. "If I develop a fever, chills, or body aches at any time after discharge, I should stop breast-feeding immediately." 4. "I may develop mastitis if I wear underwire bras, experience excessive fatigue, or suddenly decrease the number of feedings."

3. "If I develop a fever, chills, or body aches at any time after discharge, I should stop breast-feeding immediately."

The nurse is preparing to care for four assigned clients. Which client is at most risk for hemorrhage? 1. A primiparous client who delivered 4 hours ago 2. A multiparous client who delivered 6 hours ago 3. A multiparous client who delivered a large baby after oxytocin induction 4. A primiparous client who delivered 6 hours ago and had epidural anesthesia

3. A multiparous client who delivered a large baby after oxytocin induction

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. Which is the nurse's initial action? 1. Assess the client's vital signs. 2. Call the health care provider (HCP). 3. Gently massage the uterine fundus. 4. Administer a 300-mL bolus of a 20 units/L oxytocin solution.

3. Gently massage the uterine fundus.

The nurse is assessing a client who is 6 hours postpartum after delivering a full-term healthy newborn. The client complains to the nurse of feelings of faintness and dizziness. Which nursing action is most appropriate? 1. Raise the head of the client's bed. 2. Obtain hemoglobin and hematocrit levels. 3. Instruct the client to request help when getting out of bed. 4. Inform the nursery room nurse to avoid bringing the newborn to the client until the client's symptoms have subsided.

3. Instruct the client to request help when getting out of bed.

On assessment of a postpartum client, the nurse notes that the uterus feels soft and boggy. The nurse should take which initial action? 1. Document the findings. 2. Elevate the client's legs. 3. Massage the fundus until it is firm. 4. Push on the uterus to assist in expressing clots.

3. Massage the fundus until it is firm.

A client with known cardiac disease has been admitted to the postpartum care unit after an uneventful delivery. The nurse instructs the client to use the call button for assistance whenever she needs to get out of bed or wishes to care for her infant. Which postpartum complication is the nurse most concerned about for this client? 1. Postpartum infection 2. Maternal attachment 3. Maternal overexertion 4. Postpartum newborn-mother bonding

3. Maternal overexertion

When performing a postpartum assessment on a client, the nurse notes the presence of clots in the lochia. The nurse examines the clots and notes that they are larger than 1 cm. Which nursing action is most appropriate? 1. Document the findings. 2. Reassess the client in 2 hours. 3. Notify the health care provider (HCP). 4. Encourage increased oral intake of fluids.

3. Notify the health care provider (HCP).

The rubella vaccine is prescribed to be administered to a client 2 days after delivery of her child. The nurse preparing to administer the vaccine develops a list of the potential risks associated with this vaccine. The nurse reviews the list with the client and cautions the client to avoid which situation? 1. Sunlight for 3 days 2. Scratching the injection site 3. Pregnancy for 2 to 3 months after the vaccination 4. Sexual intercourse for 2 to 3 months after the vaccination

3. Pregnancy for 2 to 3 months after the vaccination

The nurse is checking lochia discharge in a woman in the immediate postpartum period. The nurse notes that the lochia is bright red and contains some small clots. Based on these data, the nurse should make which interpretation? 1. The client is hemorrhaging. 2. The client needs to increase oral fluids. 3. The client is experiencing normal lochia discharge. 4. The client's health care provider (HCP) needs to be notified of the finding.

3. The client is experiencing normal lochia discharge.

The nurse is assessing a client for signs of postpartum depression. Which observation, if noted in the new mother, indicates a need for follow-up or further assessment related to this form of depression? 1. The mother is caring for the infant in a loving manner. 2. The mother demonstrates an interest in the surroundings. 3. The mother constantly complains of tiredness and fatigue. 4. The mother looks forward to visits from the father of the newborn.

3. The mother constantly complains of tiredness and fatigue.

The nurse is monitoring a postpartum client in the fourth stage of labor. Which finding, if noted by the nurse, indicates a complication related to a laceration of the birth canal? 1. Presence of dark red lochia 2. Palpation of the uterus as a firm, contracted ball 3. The saturation of more than 1 peripad per hour 4. Palpation of the fundus at the level of the umbilicus

3. The saturation of more than 1 peripad per hour

The nurse is assigned to care for a client who has chosen to formula-feed her infant. The nurse should plan to provide which instruction to the client? 1. Apply a heating pad to breasts for comfort. 2. Wear a breast shield to correct nipple inversion. 3. Wear a supportive brassiere continuously for 72 hours. 4. Use the manual breast pump provided to express milk.

3. Wear a supportive brassiere continuously for 72 hours.

The home care nurse visits a client who has delivered a healthy newborn infant via vaginal delivery. An episiotomy was performed, and the woman has developed a wound infection at the episiotomy site. The nurse provides instructions to the client regarding care related to the infection. Which statement, if made by the mother, indicates a need for further instruction? 1. "I need to take the antibiotics as prescribed." 2. "I need to take warm sitz baths to promote healing." 3. "I need to apply warm compresses to provide comfort." 4. "I need to isolate the infant for 48 hours after beginning the antibiotics."

4. "I need to isolate the infant for 48 hours after beginning the antibiotics."

The nurse is providing instructions about measures to prevent postpartum mastitis to a client who is breast-feeding her newborn. Which client statement would indicate a need for further instruction? 1. "I should breast-feed every 2 to 3 hours." 2. "I should change the breast pads frequently." 3. "I should wash my hands well before breast-feeding." 4. "I should wash my nipples daily with soap and water."

4. "I should wash my nipples daily with soap and water."

The postpartum unit nurse has provided discharge instructions to a client planning to breast-feed her normal, healthy infant. Which statement by the client indicates an understanding of the instructions? 1. "If I experience any sweating during the night, I should call the health care provider." 2. "If I have uterine cramping while breast-feeding, I should contact the health care provider." 3. "If I'm still having vaginal drainage in a week, I should contact the health care provider." 4. "If I notice any pain, redness, or swelling in my breasts, I should contact the health care provider."

4. "If I notice any pain, redness, or swelling in my breasts, I should contact the health care provider."

The nursing instructor is reviewing the plan of care for a postpartum client with a student. The instructor asks the nursing student about the taking-in phase according to Rubin's phases of regeneration and the client behaviors that are most likely to occur during this phase. Which responses made by the student indicate an understanding of this phase? Select all that apply. 1. "The client would be independent." 2. "The client initiates activities on her own." 3. "The client participates in mothering tasks." 4. "The client may complain of lack of sleep and fatigue." 5. "The client is self-focused and talks to others about labor."

4. "The client may complain of lack of sleep and fatigue." 5. "The client is self-focused and talks to others about labor."

After surgical evacuation and repair of a paravaginal hematoma, a client is discharged 3 days postpartum. The nurse determines that the client needs further discharge instructions when the client makes which statement? 1. "I will probably need my mother to help me with housekeeping." 2. "Because I am so sore, I will nurse the baby while lying on my side." 3. "My husband and I will not have intercourse until the stitches are healed." 4. "The only medications I will take are prenatal vitamins and stool softeners."

4. "The only medications I will take are prenatal vitamins and stool softeners."

The nurse is preparing to care for a client in the immediate postpartum period who has just delivered a healthy newborn. How often should the nurse plan to take the client's vital signs? 1. Hourly for the first 2 hours and then every 4 hours 2. 30 minutes during the first hour and then every hour for the next 2 hours 3. 5 minutes for the first 30 minutes and then every hour for the next 4 hours 4. 15 minutes during the first hour and then every 30 minutes for the next 2 hours

4. 15 minutes during the first hour and then every 30 minutes for the next 2 hours

The nurse performs an assessment on a client who is 4 hours postpartum. The nurse notes that the client has cool, clammy skin and is restless and excessively thirsty. What immediate action should the nurse take? 1. Provide oral fluids and begin fundal massage. 2. Begin hourly pad counts and reassure the client. 3. Elevate the head of the bed and assess vital signs. 4. Assess for hypovolemia and notify the health care provider (HCP).

4. Assess for hypovolemia and notify the health care provider (HCP).

The postpartum unit nurse has provided information on performing a sitz bath to a new mother after a vaginal delivery. The client demonstrates understanding of the purpose of the sitz bath by stating that it will promote which action? 1. Numb the tissue. 2. Stimulate a bowel movement. 3. Reduce the edema and swelling. 4. Assist in healing and provide comfort.

4. Assist in healing and provide comfort.

Which nursing intervention is appropriate for a postpartum client with a diagnosis of endometritis to facilitate participation in newborn care? 1. Limit fluid intake. 2. Maintain the client in a supine position. 3. Ask family members to care for the newborn. 4. Encourage the client to take pain medication as prescribed.

4. Encourage the client to take pain medication as prescribed.

A pregnant client is admitted in labor. The nursing assessment reveals that the client's hemoglobin and hematocrit levels are low, indicating anemia. What should the nurse observe for following the client's labor? 1. Anxiety 2. Hot flashes 3. Low self-esteem 4. Postpartum infection

4. Postpartum infection

A new mother received epidural anesthesia during labor and had a forceps delivery after pushing for 2 hours. At 6 hours postpartum her systolic blood pressure has dropped 20 points, her diastolic blood pressure has dropped 10 points, and her pulse is 120 beats/minute. The client is anxious and restless. On further assessment, a vulvar hematoma is verified. After notifying the health care provider (HCP), what is the nurse's next action? 1. Reassure the client. 2. Monitor fundal height. 3. Apply perineal pressure. 4. Prepare the client for surgery.

4. Prepare the client for surgery.

The nurse in the postpartum unit is observing the mother-infant bonding process in a client. Which observation, if made by the nurse, indicates the potential for a maladaptive interaction? 1. The mother is observed talking to the newborn. 2. The mother performs cord care for the newborn. 3. The mother verbalizes discomfort with the new role of motherhood. 4. The mother requests that the nurse feed the newborn because she is feeling fatigued.

4. The mother requests that the nurse feed the newborn because she is feeling fatigued.

The nurse evaluates the ability of a hepatitis B-positive mother to provide safe bottle-feeding to her newborn during postpartum hospitalization. Which maternal action best exemplifies the mother's knowledge of potential disease transmission to the newborn? 1. The mother requests that the window be closed before feeding. 2. The mother holds the newborn properly during feeding and burping. 3. The mother tests the temperature of the formula before initiating feeding. 4. The mother washes and dries her hands before and after self-care of the perineum and asks for a pair of gloves before feeding.

4. The mother washes and dries her hands before and after self-care of the perineum and asks for a pair of gloves before feeding.

Which measure may prevent mastitis in the breastfeeding mother? a. Initiating early and frequent feedings b. Nursing the infant for 5 minutes on each breast c. Wearing a tight-fitting bra d. Applying ice packs before feeding

ANS: A Early and frequent feedings prevent stasis of milk, which contributes to engorgement and mastitis. Five minutes does not adequately empty the breast. This will produce stasis of the milk. A firm-fitting bra will support the breast but not prevent mastitis. The breast should not be bound. Warm packs before feeding will increase the flow of milk.

An infant with severe meconium aspiration syndrome (MAS) is not responding to conventional treatment. Which treatment may be necessary for this infant? a. Extracorporeal membrane oxygenation b. Respiratory support with ventilator c. Insertion of laryngoscope and suctioning of the trachea d. Insertion of an endotracheal tube

ANS: A Extracorporeal membrane oxygenation is a highly technical method that oxygenates the blood while bypassing the lungs, allowing the infant's lungs to rest and recover. The infant is most likely intubated and on a ventilator already. Laryngoscope insertion and tracheal suctioning are performed after birth before the infant takes the first breath.

The nurse is teaching the parents of a newborn who is going to receive phototherapy. What other measure does the nurse teach to help reduce the bilirubin? a. Increase the frequency of feedings. b. Increase oral intake of water between feedings. c. How to prepare the newborn for an exchange transfusion d. Wrap the infant in triple blankets to prevent cold stress during phototherapy.

ANS: A Frequent feedings prevent hypoglycemia, provide protein to maintain albumin levels in the blood and promote gastrointestinal motility and removal of bilirubin in the stools. More frequent breastfeeding should be encouraged. Avoid offering water between feedings, because the infant may decrease his or her milk intake. Breast milk or formula is more effective at removing bilirubin from the intestines. Exchange transfusions are seldom necessary but may be performed when phototherapy cannot reduce high bilirubin levels quickly enough. Wrapping the infant in blankets will prevent the phototherapy from getting to the skin and being effective. The infant should be uncovered and unclothed.

The nurse should expect medical intervention for subinvolution to include a. oral methylergonovine maleate (Methergine) for 48 hours. b. oxytocin intravenous infusion for 8 hours. c. oral fluids to 3000 mL/day. d. intravenous fluid and blood replacement.

ANS: A Methergine provides long-sustained contraction of the uterus and is the usual treatment. Oxytocin and oral fluids are not used for this condition. There is no indication that blood loss has occurred in this situation; if it does blood replacement may be necessary.

Nursing care of the infant with neonatal abstinence syndrome should include a. Positioning the infant's crib in a quiet corner of the nursery b. Feeding the infant on a 2-hour schedule c. Placing stuffed animals and mobiles in the crib to provide visual stimulation d. Spending extra time holding and rocking the infant

ANS: A Placing the crib in a quiet corner helps avoid excessive stimulation of the infant. These infants have an increase calorie needs but poor suck and swallow coordination. Feeding should occur to meet these needs. Stimulation should be kept to a minimum.

The nurse is caring for a neonate undergoing phototherapy. What action does the nurse include on the infant's care plan? a. Keep the infant's eyes covered under the light. b. Keep the infant supine at all times. c. Restrict parenteral and oral fluids. d. Dress the infant in only a T-shirt and diaper.

ANS: A Retinal damage from phototherapy should be prevented by using eye shields on the infant under the light. To ensure total skin exposure, the infant's position is changed frequently. Special attention to increasing fluid intake ensures that the infant is well hydrated. To ensure total skin exposure, the infant is not dressed.

Early postpartum hemorrhage is defined as signs and symptoms of hypovolemia with which of the following descriptions of blood loss? a. Cumulative blood loss >1000 mL in the first 24 hours after the birth process. b. 750 mL in the first 24 hours after vaginal delivery c. Cumulative blood loss >1000 mL in the first 48 hours after the birth process d. 1500 mL in the first 48 hours after cesarean delivery

ANS: A The newest definition of early postpoartum hemorrhage is cumulative blood loss >1000 mL with signs of hypovolemia within the first 24 hours after the birth process. Hemorrhage after 24 hours is considered late postpartum hemorrhage.

A newborn has meconium aspiration at birth. The nurse notes increasing respiratory distress. What action takes priority? a. Obtain an oxygen saturation. b. Notify the provider at once. c. Stimulate the baby to increase respirations. d. Prepare to initiate ECMO.

ANS: A This baby has a risk for, and signs of, persistent pulmonary hypertension. The nurse first checks an oxygen saturation then notifies the provider, or alternatively, gets the reading (and other assessments) while another nurse does the notification. This baby most likely has tachypnea so stimulation to increase respirations is not needed. ECMO may or may not be needed depending on whether or not other treatments work.

A nurse is caring for a preterm baby who weighs 4.8 pounds. What assessment finding indicates the baby is dehydrated? a. Urine output of 3.3 mL/hour b. Urine specific gravity of 1.001 c. Low serum sodium d. Weight gain of 43 g in one day

ANS: A This baby weighs 2.18 kg. Dehydration is noted with a urine output of <2 mL/kg/hour. A urine output of 3.3 mL is 1.5 mL/kg/hour and so indicates dehydration. The dilute urine specific gravity indicates overhydration as does the low serum sodium. The weight gain is normal (15 to 20 g/kg/day).

The perinatal nurse is caring for a woman in the immediate postbirth period. Assessment reveals that the woman is experiencing profuse bleeding. The most likely etiology for the bleeding is a. uterine atony. b. uterine inversion. c. vaginal hematoma. d. vaginal laceration.

ANS: A Uterine atony is marked hypotonia of the uterus. It is the leading cause of postpartum hemorrhage. The other situations can cause bleeding but are not the most common cause.

What action by the nurse is the most important action in preventing neonatal infection? a. Good hand hygiene b. Isolation of infected infants c. Separate gown technique d. Standard Precautions

ANS: A Virtually all controlled clinical trials have demonstrated that effective handwashing is responsible for the prevention of nosocomial infection in nursery units. The other actions do reduce risk but not nearly to the degree that good hand hygiene does.

While caring for the postterm infant, the nurse recognizes that the fetus may have passed meconium prior to birth as a result of a. hypoxia in utero. b. NEC. c. placental insufficiency. d. rapid use of glycogen stores.

ANS: A When labor begins, poor oxygen reserves may cause fetal compromise. The fetus may pass meconium as a result of hypoxia before or during labor, increasing the risk of meconium aspiration. Meconium is not passed as a result of NEC, placental insufficiency, or rapid use of glycogen stores.

A woman who has had no prenatal care enters the labor and delivery unit in advanced labor. She has chickenpox. What action by the nurse is best? a. Place the woman in isolation. b. Give the woman immune globulin before delivery. c. Treat the woman with acyclovir. d. Administer antibiotics to the infant after birth.

ANS: A Women with varicella infections (chickenpox or shingles) need to be in isolation (airborne and contact per the CDC). There might not be enough time to administer immune globulin to the mother before delivery, but it could be given to the baby. Acyclovir is the drug of choice for treatment, but the staff needs to be protected from this infection through isolation precautions. Antibiotics are not used for this disease.

A home health care nurse is checking on a new mother with signs of obsessive-compulsive disorder. What assessment findings correlate with this condition? (Select all that apply.) a. Frequently checking on the baby b. Fear of being alone with the baby c. Woman states she feels worthless d. Woman has bought $5,000 worth of toys e. Mother states birth was very traumatic

ANS: A, B Postpartum OCD often manifests with women performing obsessive behaviors and voicing fear of being left alone with their baby. Feeling worthless is a sign of depression. A spending spree might be a sign of the manic phase of bipolar disease. Viewing the birth as traumatic may lead to PTSD.

What actions can the labor and delivery nurse take to decrease a woman's chance of contracting a puerperal infection? (Select all that apply.) a. Avoid straight catheterizing the woman unless she cannot void. b. Keep vaginal examinations to a minimum. c. Change wet peripads and linens frequently. d. Maintain the woman on bedrest while laboring. e. Use good hand hygiene before and after contact with the woman.

ANS: A, B, C, E Risk for infection increases with catheterization, vaginal examinations, exposure to wet linens and pads, and poor hand hygiene. Remaining on bedrest does not reduce the chance for infection.

Medications used to manage postpartum hemorrhage include which of the following? (Select all that apply.) a. Oxytocin b. Methergine c. Terbutaline d. Hemabate e. Magnesium sulfate

ANS: A, B, D Pitocin, Methergine, and Hemabate are all used to manage PPH. Terbutaline and magnesium sulfate are tocolytics; relaxation of the uterus causes or worsens PPH.

The nurse explain to the student that which of the following factors increase a woman's risk for thrombosis? (Select all that apply.) a. Use of stirrups for a prolonged period of time b. Prolonged bedrest during or after labor and delivery c. Adherence to a strict vegetarian diet d. Excessive sweating during labor e. Maternal age greater than 30 years of age

ANS: A, B, D, E Use of stirrups for a prolonged period of time, bedrest, excessive sweating (leading to dehydration) all increase the risk of thrombosis. Vegetarian diets are not related. Maternal age >35 increases the risk.

The nurse tells the nursing student that late preterm infants are at increased risk for which of the following problems? (Select all that apply.) a. Problems with thermoregulation b. Cardiac distress c. Hyperbilirubinemia d. Sepsis e. Hyperglycemia

ANS: A, C, D Problems with thermoregulation, hyperbilirubinemia, and sepsis are common with late preterm infants. They typically have respiratory distress and hypoglycemia.

A postpartum patient is at increased risk for postpartum hemorrhage if she delivers a(n) a. 5-lb, 2-oz infant with outlet forceps. b. 6.5-lb infant after a 2-hour labor. c. 7-lb infant after an 8-hour labor. d. 8-lb infant after a 12-hour labor.

ANS: B A rapid (precipitous) labor and delivery may cause exhaustion of the uterine muscle and prevent contraction. The use of forceps may cause lacerations that could lead to bleeding, but that is not as common as hemorrhage after a precipitous labor when they are used only in the outlet. Eight-hour and 12-hour labors are normal in length.

A multiparous woman is admitted to the postpartum unit after a rapid labor and birth of a 4000-g infant. Her fundus is boggy, lochia is heavy, and vital signs are unchanged. The nurse has the woman void and massages her fundus, but her fundus remains difficult to find, and the rubra lochia remains heavy. What action should the nurse take next? a. Continue to massage the fundus. b. Notify the provider. c. Recheck vital signs. d. Insert an indwelling urinary catheter.

ANS: B After taking these corrective actions, the nurse should contact the provider and anticipate collaborative care measures. Another nurse can assess vital signs. Since the woman just voided, an indwelling catheter is not needed.

To maintain optimal thermoregulation for the premature infant, what action by the nurse is most appropriate? a. Bathe the infant once a day. b. Put an undershirt on the infant in the incubator. c. Assess the infant's hydration status. d. Lightly clothe the infant under the radiant warmer.

ANS: B Air currents around an unclothed infant will result in heat loss. Bathing causes evaporative heat loss. Assessing hydration will not maintain thermoregulation. Clothing is not worn when the infant is under a radiant warmer.

If the nurse suspects a uterine infection in the postpartum patient, she should assess the a. pulse and blood pressure. b. odor of the lochia. c. episiotomy site. d. abdomen for distention.

ANS: B An abnormal odor of the lochia indicates infection in the uterus. The pulse may be altered with an infection, but the odor of the lochia will be an earlier sign and more specific. The infection may move to the episiotomy site if proper hygiene is not followed, but this does not demonstrate a uterine infection. The abdomen becomes distended usually because of a decrease of peristalsis, such as after cesarean section.

What instructions should be included in the discharge teaching plan to assist the patient in recognizing early signs of complications? a. Palpate the fundus daily to ensure that it is soft. b. Notify the physician of a return to bright red bleeding. c. Report any decrease in the amount of brownish red lochia. d. The passage of clots as large as an orange can be expected.

ANS: B An increase in lochia or a return to bright red bleeding after the lochia has become pink indicates a complication. The fundus should stay firm. Large clots after discharge are a sign of complications and should be reported.

The goal of treatment of the infant with phenylketonuria (PKU) is to a. cure cognitive delays. b. prevent central nervous system (CNS) damage. c. prevent gastrointestinal symptoms. d. prevent the renal system damage.

ANS: B CNS damage can occur as a result of toxic levels of phenylalanine. No cure exists for cognitive delays should they occur. Digestive problems are a clinical manifestation of PKU, but it is more important to prevent the CNS damage. PKU does not involve renal dysfunction.

A woman delivered a 9-lb, 10-oz baby 1 hour ago. When you arrive to perform her 15-minute assessment, she tells you that she "feels all wet underneath." You discover that both pads are completely saturated and that she is lying in a 6-inch-diameter puddle of blood. What is your first action? a. Call for help. b. Assess the fundus for firmness. c. Take her blood pressure. d. Check the perineum for lacerations.

ANS: B Firmness of the uterus is necessary to control bleeding from the placental site. The nurse should first assess for firmness and massage the fundus as indicated. Calling for help is not needed unless corrective action does not improve the situation. Another nurse can take the blood pressure or the original nurse can do so after assessing the fundus and massaging it if needed. Checking the perineum for lacerations would be appropriate if the fundus was firm.

The nurse learns that the most common cause of pathologic hyperbilirubinemia is which of the following? a. Hepatic disease b. Hemolytic disorders in the newborn c. Postmaturity d. Congenital heart defect

ANS: B Hemolytic disorders in the newborn are the most common cause of pathologic jaundice. Hepatic damage and prematurity may be causes of pathologic hyperbilirubinemia, but they are not the most common cause. Congenital heart defect is not a common cause of pathologic hyperbilirubinemia in neonates.

An infant with hypocalcemia is receiving an intravenous bolus of calcium. The infant's heart rate changes from 144 beats/minute to 62 beats/minute. What action by the nurse is best? a. Call for a stat EGG. b. Stop the infusion. c. Stimulate the infant. d. Administer magnesium.

ANS: B IV calcium can lead to bradycardia. When this infant's heart rate drops to 60 beats/minute, the nurse stops the infusion. A stat ECG is not necessary unless policy requires it or the bradycardia does not resolve. Stimulating the infant will not increase the heart rate. Magnesium infusion will also not increase the heart rate.

The nurse knows that a measure for preventing late postpartum hemorrhage is to a. administer broad-spectrum antibiotics. b. inspect the placenta after delivery. c. manually remove the placenta. d. pull on the umbilical cord to hasten the delivery of the placenta.

ANS: B If a portion of the placenta is missing, the clinician can explore the uterus, locate the missing fragments, and remove the potential cause of late postpartum hemorrhage. Broad-spectrum antibiotics will be given if postpartum infection is suspected. Manual removal of the placenta increases the risk of postpartum hemorrhage. The placenta is usually delivered 5 to 30 minutes after birth of the baby without pulling on the cord. That can cause uterine inversion.

The patient who is being treated for endometritis is placed in Fowler's position because it a. promotes comfort and rest. b. facilitates drainage of lochia. c. prevents spread of infection to the urinary tract. d. decreases tension on the reproductive organs.

ANS: B Lochia and infectious material are eliminated by gravity drainage when the woman is placed in the Fowler's position.

Which woman is at greatest risk for early postpartum hemorrhage? a. A primiparous woman being prepared for an emergency cesarean birth for fetal distress b. A woman with severe preeclampsia on magnesium sulfate whose labor is being induced c. A multiparous woman with an 8-hour labor d. A primigravida in spontaneous labor with preterm twins

ANS: B Magnesium sulfate administration during labor poses a risk for PPH. Magnesium acts as a smooth muscle relaxant, thereby contributing to uterine relaxation and atony. The other situations do not post risk factors or causes of early PPH.

A provider left an order for a woman to have Methylergonovine 0.2 mg IM. The nurse assesses the woman and finds her vital signs to be: temperature 37.9° C (100.2° F), pulse 90 beats/minute, respirations 18 breaths/minute, and blood pressure 152/90 mm Hg. What action by the nurse is most appropriate? a. Administer acetaminophen first. b. Check policy for administration. c. Give the medication as prescribed. d. Consult with the provider.

ANS: B Methylergonovine is contraindicated in women with hypertension. The nurse should check the agency's policy to see at what blood pressure reading this medication should be held. After checking the policy, the nurse can consult the provider if it can't be given. Acetaminophen is not related to this situation.

The difference between physiologic and nonphysiologic jaundice is that nonphysiologic jaundice a. usually results in kernicterus. b. appears during the first 24 hours of life. c. results from breakdown of excessive erythrocytes not needed after birth. d. begins on the head and progresses down the body.

ANS: B Nonphysiologic jaundice appears during the first 24 hours of life, whereas physiologic jaundice appears after the first 24 hours of life. Pathologic jaundice may lead to kernicterus, but it needs to be stopped before that occurs. Both jaundices are the result of the breakdown of erythrocytes. Pathologic jaundice is due to a pathologic condition, such as Rh incompatibility.

Parents of a newborn with phenylketonuria are anxious to learn about the appropriate treatment for their infant. What topic does the nurse include in the teaching plan? a. Fluid and sodium restrictions b. A phenylalanine-free diet c. Progressive mobility and splinting d. A protein-rich diet

ANS: B Phenylketonuria is treated with a special diet that restricts phenylalanine intake. Fluid and sodium restrictions are not included in this plan. Mobility and splinting are not included in the plan. A protein-rich diet is not in the plan.

What is most helpful in preventing premature birth? a. High socioeconomic status b. Adequate prenatal care c. Transitional Assistance to Needy Families d. Women, Infants, and Children nutritional program

ANS: B Prenatal care is vital in identifying possible problems. Women from higher economic status are more likely to seek adequate prenatal care, but it is the care that is most helpful. Government programs help with specific needs of the pregnant woman, but adequate care is more important.

In caring for the preterm infant, what complication is thought to be a result of high arterial blood oxygen level? a. Necrotizing enterocolitis (NEC) b. Retinopathy of prematurity (ROP) c. Bronchopulmonary dysplasia (BPD) d. Intraventricular hemorrhage (IVH)

ANS: B ROP is thought to occur as a result of high levels of oxygen in the blood. NEC is due to the interference of blood supply to the intestinal mucosa. Necrotic lesions occur at that site. BPD is caused by the use of positive pressure ventilation against the immature lung tissue. IVH is due to rupture of the fragile blood vessels in the ventricles of the brain. It is most often associated with hypoxic injury, increased blood pressure, and fluctuating cerebral blood flow.

A neonate has white patches in her mouth that bled when the mother tried wiping them away. What action by the nurse is best? a. Tell the mother to leave the patches alone. b. Assess the mother for a perineal rash. c. Give the infant medicated pacifiers. d. Test the infant for toxoplasmosis.

ANS: B These patches are characteristic of maternal infection with candidiasis or yeast. The nurse assesses the mother's perineal area for a rash. Telling the mother to leave the rash alone may be appropriate information but does not get to the bottom of the issue. The nurse should not provide medication without knowing what is being treated. The baby does not have toxoplasmosis.

A premature infant never seems to sleep longer than an hour at a time. Each time a light is turned on, an incubator closes, or people talk near her crib, she wakes up and cries inconsolably until held. The correct nursing diagnosis is ineffective coping related to a. severe immaturity. b. environmental stress. c. physiologic distress. d. behavioral responses.

ANS: B This nursing diagnosis is the most appropriate for this infant. Light and sound are known adverse stimuli that add to an already stressed premature infant. The nurse must monitor the environment closely for sources of overstimulation. The other diagnoses do not recognize that fact.

A steady trickle of bright red blood from the vagina in the presence of a firm fundus suggests a. uterine atony. b. lacerations of the genital tract. c. perineal hematoma. d. infection of the uterus.

ANS: B Undetected lacerations will bleed slowly and continuously. Bleeding from lacerations is uncontrolled by uterine contraction. The fundus is not firm with uterine atony. A hematoma would be internal. Swelling and discoloration would be noticed, but bright bleeding would not be. With an infection of the uterus there would be an odor to the lochia and systemic symptoms such as fever and malaise.

A woman who has a history of frequent substance abuse is close to delivering. What action by the nurse is best? a. Notify social services of the situation prior to the birth. b. Draw up and label a syringe of naloxone. c. Administer naloxone if the baby shows signs of withdrawal. d. Prepare to administer naloxone to the mother.

ANS: B When anticipating the delivery of a baby whose mother is addicted to opioids, the nurse prepares to give the newborn naloxone for respiratory depression. To administer the drug in the fastest way possible, the nurse prepares a syringe with the medication. Then when the baby's weight is known, the nurse discards the excess drug and administers the correct dose to the baby. Social services will need to be involved but not at this point; the medication is the priority. The naloxone may cause signs of withdrawal in the infant. The baby gets the naloxone, not the mother.

Newborns whose mothers are substance abusers frequently have what behaviors? (Select all that apply.) a. Circumoral cyanosis b. Decreased amounts of sleep c. Hyperactive Moro (startle) reflex d. Difficulty feeding e. Weak cry

ANS: B, C, D The infant exposed to drugs in utero often has poor sleeping patterns, hyperactive reflexes, and uncoordinated sucking and swallowing behavior. They do not have circumoral cyanosis and will have a high-pitched cry.

Some infants develop hypoxic-ischemic encephalopathy after asphyxia. Therapeutic hypothermia has been used to improve neurologic outcomes for these infants. Criteria for the use of this modality include (Select all that apply.) a. The infant must be 28 weeks gestation or greater. b. Have evidence of an acute hypoxic event. c. Be in a facility they can initiate treatment within 6 hours. d. The infant must be 36 or more weeks' gestation. e. The treatment must be initiated within the first 12 hours of life.

ANS: B, C, D The infant must be at least 36 weeks of gestation to meet the criteria for therapeutic hypothermia. Treatment should be initiated within the first 6 hours of life, ideally at a tertiary care center. The infant must have evidence of perinatal hypoxic-ischemic episodes.

An important nursing factor during the care of the infant in the NICU is assessment for signs of adequate parental attachment. The nurse must observe for signs that bonding is not occurring as expected. These include (Select all that apply.) a. using positive terms to describe the infant. b. showing interest in other infants equal to that of their own. c. naming the infant. d. decreasing the number and length of visits. e. refusing offers to hold and care for the infant.

ANS: B, D, E Bonding is not progressing as expected when parents show interest in other babies equal to that of their own, decreasing the number and length of visits, and refusing to hold and help care for the infant. Using positive terms to describe the baby and naming the infant are signs that bonding is occurring.

A woman just received an injection of carboprost, 2500 mcg IM. What actions by the nurse take priority? (Select all that apply.) a. Assess for nausea and vomiting b. Assess fetal well-being. c. Administer acetaminophen for headache. d. Monitor urine output. e. Notify the provider immediately.

ANS: B, E The usual dose of carboprost is 250 mcg, so this excessive dose could lead to uterine rupture. The nurse monitors the woman for signs of this and continually monitors the fetus for well-being. The provider would be notified and agency policy followed for variance reporting. Nausea, vomiting, and headache are side effects of the usual dose of the drug. This drug is excreted through urine, so monitoring urine output is important but not as critical as checking fetal well-being and notifying the provider.

The nurse present at the delivery is reporting to the nurse who will be caring for the neonate after birth. What information might be included for an infant who had thick meconium in the amniotic fluid? a. The infant had Apgar scores of 6 and 8. b. An IV was started immediately after birth to treat dehydration. c. No meconium was found below the vocal cords when they were examined. d. The parents spent an hour bonding with the baby after birth.

ANS: C A laryngoscope is inserted to examine the vocal cords. If no meconium is below the cords, probably no meconium is present in the lower air passages, and the infant will not develop meconium aspiration syndrome. Apgar scores are important but not directly related to meconium. There is no relationship between dehydration and meconium fluid. Bonding is an expected occurrence.

Nursing measures that help prevent postpartum urinary tract infection include which of the following? a. Promoting bed rest for 12 hours after delivery b. Discouraging voiding until the sensation of a full bladder is present c. Forcing fluids to at least 3000 mL/day d. Encouraging the intake of orange, grapefruit, or apple juice

ANS: C Adequate fluid intake of 2500 to 3000 mL/day prevents urinary stasis, dilutes urine, and flushes out waste products. The woman should be encouraged to ambulate early. With pain medications, trauma to the area, and anesthesia, the sensation of a full bladder may be decreased. The woman needs to be encouraged to void frequently. Juices such as cranberry juice can discourage bacterial growth.

Transient tachypnea of the newborn (TTN) is thought to occur as a result of a. a lack of surfactant. b. hypoinflation of the lungs. c. delayed absorption of fetal lung fluid. d. a slow vaginal delivery associated with meconium-stained fluid.

ANS: C Delayed absorption of fetal lung fluid is thought to be the reason for TTN. Lack of surfactant and hypoinflation of the lungs are not related to TTN. A slow vaginal delivery will help prevent TTN.

With regard to eventual discharge of the high-risk newborn or transfer to a different facility, nurses and families should be aware that a. infants will stay in the NICU until they are ready to go home. b. once discharged to home, the high-risk infant should be treated like any healthy term newborn. c. parents of high-risk infants need special support and detailed contact information. d. if a high-risk infant and mother need transfer to a specialized regional center, it is better to wait until after birth and the infant is stabilized.

ANS: C High-risk infants can cause profound parental stress and emotional turmoil. Parents need support, special teaching, and quick access to various resources available to help them care for their baby. Parents and their high-risk infant should get to spend a night or two in a predischarge room, where care for the infant is provided away from the NICU. Just because high-risk infants are discharged does not mean they are normal, healthy babies. Follow-up by specialized practitioners is essential. Ideally, the mother and baby are transported with the fetus in utero; this reduces neonatal morbidity and mortality.

Which statement is true about large for gestational age (LGA) infants? a. They weigh more than 3500 g. b. They are above the 80th percentile on gestational growth charts. c. They are prone to hypoglycemia, polycythemia, and birth injuries. d. Postmaturity syndrome and fractured clavicles are the most common complications.

ANS: C Hypoglycemia, polycythemia, and birth injuries are common in LGA infants. LGA infants are determined by their weight compared to their age. They are above the 90th percentile on the gestational growth charts. Birth injuries are a problem, but postmaturity syndrome is not an expected complication with LGA infants.

A nurse is assessing an SGA infant with asymmetric intrauterine growth restriction. What assessment finding correlates with this condition? a. One side of the body appears slightly smaller than the other. b. All body parts appear proportionate. c. The head seems large compared with the rest of the body. d. The extremities are disproportionate to the trunk.

ANS: C In asymmetric intrauterine growth restriction, the head is normal in size but appears large because the infant's body is long and thin due to lack of subcutaneous fat. The left and right side growth should be symmetric. With asymmetric intrauterine growth restrictions, the body appears smaller than normal compared to the head. The body parts are out of proportion, with the body looking smaller than expected due to the lack of subcutaneous fat. The body, arms, and legs have lost subcutaneous fat so they will look small compared to the head.

Which nursing measure is appropriate to prevent thrombophlebitis in the recovery period after a cesarean birth? a. Roll a bath blanket and place it firmly behind the knees. b. Limit oral intake of fluids for the first 24 hours. c. Assist the patient in performing gentle leg exercises. d. Ambulate the patient as soon as her vital signs are stable.

ANS: C Leg exercises and passive range of motion promote venous blood flow and prevent venous stasis while the patient is still on bed rest. The blanket behind the knees will cause pressure and decrease venous blood flow. Limiting oral intake will produce hemoconcentration, which may lead to thrombophlebitis. The patient may not have full return of leg movements, and ambulating is contraindicated until she has full motion and sensation.

To provide adequate postpartum care, the nurse should be aware that peripartum depression (PPD) a. is the "baby blues," plus the woman has a visit with a counselor or psychologist. b. does not affect the father who can then care for the baby. c. is distinguished by pervasive sadness that lasts at least 2 weeks. d. will disappear on its own without outside help.

ANS: C PPD is characterized by a persistent depressed state. The woman is unable to feel pleasure or love although she is able to care for her infant. She often experiences generalized fatigue, irritability, little interest in food and sleep disorders. PPD is more serious and persistent than postpartum baby blues. Fathers are often affected. Most women need professional help to get through PPD, including pharmacologic intervention.

Overstimulation may cause increased oxygen use in a preterm infant. Which nursing intervention helps to avoid this problem? a. Group all care activities together to provide long periods of rest. b. While giving your report to the next nurse, stand in front of the incubator and talk softly about how the infant responds to stimulation. c. Teach the parents signs of overstimulation, such as turning the face away or stiffening and extending the extremities and fingers. d. Keep charts on top of the incubator so the nurses can write on them there.

ANS: C Parents should be taught these signs of overstimulation so they will learn to adapt their care to the needs of their infant. This may understimulate the infant during those long periods and overtire the infant during the procedures. Talking in front of the incubator could overstimulate the baby. Placing objects on top of the incubator or using it as a writing surface increases the noise inside.

A preterm infant is on a respirator with intravenous lines and much equipment around her when her parents come to visit for the first time. What action by the nurse is most important? a. Suggest that the parents visit for only a short time to reduce their anxieties. b. Reassure the parents that the baby is progressing well. c. Encourage the parents to touch her. d. Discuss the care they will give her when she goes home.

ANS: C Physical contact with the infant is important to establish early bonding. The nurse as the support person and teacher is responsible for shaping the environment and making the care giving responsive to the needs of both the parents and the infant. The nurse should encourage the parents to touch their baby and show them how to do so safely. Bonding needs to occur, and this can be fostered by encouraging the parents to spend time with the infant. It is important to keep the parents informed about the infant's progression, but the nurse needs to be honest with the explanations. Discussing home care needs to wait until the parents are ready and discharge is closer with known needs.

Decreased surfactant production in the preterm lung is a problem because surfactant a. causes increased permeability of the alveoli. b. provides transportation for oxygen to enter the blood supply. c. keeps the alveoli open during expiration. d. dilates the bronchioles, decreasing airway resistance.

ANS: C Surfactant prevents the alveoli from collapsing each time the infant exhales, thus reducing the work of breathing. It does not cause increased permeability, provide transportation of oxygen or dilate the bronchioles.

The mother-baby nurse must be able to recognize what sign of thrombophlebitis? a. Visible varicose veins b. Positive Homans sign c. Local tenderness, heat, and swelling d. Pedal edema in the affected leg

ANS: C Tenderness, heat, and swelling are classic signs of thrombophlebitis that appear at the site of the inflammation. Varicose veins may predispose the woman to thrombophlebitis but are not a sign. A positive Homans sign may be caused by a strained muscle or contusion. Edema may be caused by other factors, and the edema with thrombophlebitis may be more extensive. Edema may be more involved than pedal.

What action does the nurse add to the plan of care for an infant experiencing symptoms of drug withdrawal? a. Keeping the newborn sedated b. Feeding every 4 to 6 hours to allow extra rest c. Swaddling the infant snugly d. Playing soft music during feeding

ANS: C The infant should be wrapped snugly to reduce self-stimulation behaviors and protect the skin from abrasions. The baby is not kept sedated. The infant should be fed in small, frequent amounts and burped well to diminish aspiration and maintain hydration. The infant should not be stimulated (such as with music), because this will increase activity and potentially increase CNS irritability.

A mother with mastitis is concerned about breastfeeding while she has an active infection. The nurse should explain that a. the infant is protected from infection by immunoglobulins in the breast milk. b. the infant is not susceptible to the organisms that cause mastitis. c. the organisms that cause mastitis are not passed to the milk. d. the organisms will be inactivated by gastric acid.

ANS: C The organisms are localized in the breast tissue and are not excreted in the breast milk. The mother is just producing the immunoglobulin from this infection, so it is not available for the infant. Because of an immature immune system, infants are susceptible to many infections. However, this infection is in the breast tissue and is not excreted in the breast milk. The organism will not get into the infant's gastrointestinal system.

The nurse is observing a parent holding a preterm infant. The infant is sneezing, yawning, and extending the arms and legs. What action by the nurse is best? a. Cover the infant with a warmed blanket. b. Encourage the parent to do kangaroo care. c. Encourage the parent to place the infant back in the warmer d. Have the parent fold the infant's arms across the chest.

ANS: C These are signs that the preterm infant is overstimulated. The parent should place the infant back in her warmer, and the nurse can turn down the lights and limit noise. The other suggestions will not help decrease stimulation.

Near the end of the first week of life, an infant who has not been treated for any infection develops a copper-colored, maculopapular rash on the palms and around the mouth and anus. The newborn is showing signs of a. gonorrhea. b. herpes simplex virus infection. c. congenital syphilis. d. HIV.

ANS: C This rash is indicative of congenital syphilis. The lesions may extend over the trunk and extremities. This is not characteristic of gonorrhea, herpes, or HIV.

When a woman is diagnosed with postpartum psychosis, one of the main concerns is that she may a. have outbursts of anger. b. neglect her hygiene. c. harm her infant. d. lose interest in her husband.

ANS: C Thoughts of harm to one's self or the infant are among the most serious symptoms of PPD and require immediate assessment and intervention. The other problems can be attributed to postpartum psychosis, but the major concern is harm to the infant.

Providing care for the neonate born to a mother who abuses substances can present a challenge for the health care team. Nursing care for this infant requires a multisystem approach. The first step in the provision of this care is a. pharmacologic treatment. b. reduction of environmental stimuli. c. neonatal abstinence syndrome scoring. d. adequate nutrition and maintenance of fluid and electrolyte balance.

ANS: C Various scoring systems exist to determine the number, frequency, and severity of behaviors that indicate neonatal abstinence syndrome. The score is helpful in determining the necessity of drug therapy to alleviate withdrawal. Pharmacologic treatment is based on the severity of withdrawal symptoms. Swaddling, holding, and reducing environmental stimuli are essential in providing care to the infant who is experiencing withdrawal. However, the scoring helps provide definitive care. Fluids and electrolyte balance are appropriate for any infant.

A primigravida has just delivered a healthy infant girl. The nurse is about to administer erythromycin ointment in the infant's eyes when the mother asks, "What is that medicine for?" The nurse responds a. "It is an eye ointment to help your baby see you better." b. "It is to protect your baby from contracting herpes from your vaginal tract." c. "Erythromycin is given to prevent a gonorrheal infection." d. "This medicine will protect your baby's eyes from drying out."

ANS: C With the prophylactic use of erythromycin, the incidence of gonococcal conjunctivitis has declined to less than 0.5%. Eye prophylaxis is administered at or shortly after birth to prevent ophthalmia neonatorum. Erythromycin has no bearing on enhancing vision and is not used for herpes infections or lubrication.

The infant of a mother with diabetes is hypoglycemic. What type of feeding should be instituted first? a. Glucose water in a bottle b. D5W intravenously c. Formula via nasogastric tube d. Breast milk

ANS: D Breast milk is metabolized more slowly and provides longer normal glucose levels. Breast milk is best for nearly all babies. High levels of dextrose correct the hypoglycemia but will stimulate the production of more insulin. Oral feedings are tried first; intravenous lines should be a later choice if the hypoglycemia continues. Formula does provide longer normal glucose levels but would be administered via bottle, not by tube feeding unless the baby is unable to take oral feedings.

Which combination of expressing pain could be demonstrated in a neonate? a. Low-pitched crying, tachycardia, eyelids open wide b. Cry face, flaccid limbs, closed mouth c. High-pitched, shrill cry, withdrawal, change in heart rate d. Cry face, eye squeeze, increase in blood pressure

ANS: D Cry face, eye squeeze, and an increase in blood pressure indicate pain. The other manifestations are not those of pain in the neonate.

If nonsurgical treatment for late postpartum hemorrhage is ineffective, which surgical procedure is appropriate to correct the cause of this condition? a. Hysterectomy b. Laparoscopy c. Laparotomy d. D&C

ANS: D D&C allows examination of the uterine contents and removal of any retained placental fragments or blood clots. Hysterectomy, laparoscopy, and laparotomy are not indicated.

When caring for a postpartum woman experiencing hypovolemic shock, the nurse recognizes that the most objective and least invasive assessment of adequate organ perfusion and oxygenation is a. absence of cyanosis in the buccal mucosa. b. cool, dry skin. c. diminished restlessness. d. decreased urinary output.

ANS: D Hemorrhage may result in hypovolemic shock. Shock is an emergency situation in which the perfusion of body organs may become severely compromised, and death may occur. The presence of adequate urinary output indicates adequate tissue perfusion. The assessment of the buccal mucosa for cyanosis can be subjective in nature. The presence of cool, pale, clammy skin is an indicative finding associated with hypovolemic shock. Restlessness indicates decreased cerebral perfusion.

A nurse is participating in a neonatal resuscitation. What action by the nurse takes priority? a. Suction the mouth and nose. b. Stimulate the infant by rubbing the back. c. Perform the Apgar test. d. Place the infant in a preheated warmer.

ANS: D In a resuscitation situation, the nurse places the newborn in a preheated warmer immediately to reduce cold stress. Next position the infant in a "sniffing" position. Suctioning is the third step. Drying the infant is fourth, although if more than one health care provider is present, drying can occur simultaneously with the other actions.

A mother with diabetes has done some reading about the effects of the condition on her newborn. Which statement shows a misunderstanding that should be clarified by the nurse? a. "Although my baby is large, some women with diabetes have very small babies because the blood flow through the placenta may not be as good as it should be." b. "My baby will be watched closely for signs of low blood sugar, especially during the early days after birth." c. "The red appearance of my baby's skin is due to an excessive number of red blood cells." d. "My baby's pancreas may not produce enough insulin because the cells became smaller than normal during my pregnancy."

ANS: D Infants of diabetic mothers may have hypertrophy of the islets of Langerhans, which may cause them to produce more insulin than they need. The other statements are correct and show good understanding.

The nursing student learns that transmission of HIV from mother to baby occurs in which fashion? a. From the maternal circulation only in the third trimester b. From the use of unsterile instruments c. Only through the ingestion of amniotic fluid d. Through the ingestion of breast milk from an infected mother

ANS: D Postnatal transmission of HIV through breastfeeding may occur. Transplacental transmission can occur at any time during pregnancy. Unsterile instruments are possible sources of transmission but highly unlikely. Transmission of HIV may also occur during birth from blood or secretions. Transmission of HIV from the mother to the infant may occur transplacentally at various gestational ages. This is highly unlikely as most health care facilities must meet sterility standards for all instrumentation.

Which condition is a transient, self-limiting mood disorder that affects new mothers after childbirth? a. Postpartum depression b. Postpartum psychosis c. Postpartum bipolar disorder d. Postpartum blues

ANS: D Postpartum blues, or "baby blues," is a transient self-limiting disease that is believed to be related to hormonal fluctuations after childbirth. Postpartum depression is not the normal worries (blues) that many new mothers experience. Many caregivers believe that postpartum depression is underdiagnosed and underreported. Postpartum psychosis is a rare condition that usually surfaces within 3 weeks of delivery. Hospitalization of the woman is usually necessary for treatment of this disorder. Bipolar disorder is one of the two categories of postpartum psychosis, characterized by both manic and depressive episodes.

One of the first symptoms of puerperal infection to assess for in the postpartum woman is a. fatigue continuing for longer than 1 week. b. pain with voiding. c. profuse vaginal bleeding with ambulation. d. temperature of 38° C (100.4° F) or higher after 24 hours.

ANS: D Postpartum or puerperal infection is any clinical infection after childbirth. The definition used in the United States continues to be the presence of a fever of 38° C (100.4° F) or higher on 2 successive days of the first 10 postpartum days, starting 24 hours after birth. Fatigue is a later finding associated with infection. Pain with voiding may indicate a UTI, but it is not typically one of the earlier symptoms of infection. Profuse lochia may be associated with endometritis, but it is not the first symptom associated with infection.

Which is true about newborns classified as small for gestational age (SGA)? a. They weigh less than 2500 g. b. They are born before 38 weeks of gestation. c. Placental malfunction is the only recognized cause of this condition. d. They are below the 10th percentile on gestational growth charts.

ANS: D SGA infants are defined as below the 10th percentile in growth when compared with other infants of the same gestational age. SGA is not defined by weight. Infants born before 38 weeks are defined as preterm. There are many causes of SGA babies.

A nurse is caring for an SGA newborn. What nursing action is most important? a. Observe for respiratory distress syndrome. b. Observe for and prevent dehydration. c. Promote bonding. d. Prevent hypoglycemia by early and frequent feedings.

ANS: D The SGA infant has poor glycogen stores and is subject to hypoglycemia. Respiratory distress syndrome is seen in preterm infants. Dehydration is a concern for all infants and is not specific for SGA infants. Promoting bonding is a concern for all infants and is not specific for SGA infants.

What teaching does the nurse provide to help new mothers prevent postpartum depression? a. Stay home and avoid outside activities to ensure adequate rest. b. Be the only caregiver for your baby to facilitate infant attachment. c. Keep feelings of sadness and adjustment to your new role to yourself. d. Realize that this is a common occurrence that affects many women.

ANS: D The new mother should understand that postpartum depression is common. Rest is important, but she does not need to confine herself to the house. Others need to help care for the baby so the mother can rest. Women need to be open and discuss their feelings.

Because of the premature infant's decreased immune functioning, what nursing diagnosis should the nurse include in a plan of care for a premature infant? a. Delayed growth and development b. Ineffective thermoregulation c. Ineffective infant feeding pattern d. Risk for infection

ANS: D The nurse needs to know that decreased immune functioning increases the risk for infection. The other diagnoses are appropriate for the premature infant but not related directly to immune function.

A pregnant woman at 37 weeks of gestation has had ruptured membranes for 26 hours. A cesarean section is performed for failure to progress. The fetal heart rate before birth is 180 beats/min with limited variability. At birth, the newborn has Apgar scores of 6 and 7 at 1 and 5 minutes and is noted to be pale and tachypneic. Based on the maternal history, the cause of this newborn's distress is most likely a. hypoglycemia. b. phrenic nerve injury. c. respiratory distress syndrome. d. sepsis.

ANS: D The prolonged rupture of membranes and the tachypnea (before and after birth) both suggest sepsis. There is no evidence of phrenic nerve damage or respiratory distress syndrome. Early signs of sepsis may be difficult to distinguish from other problems such as hypoglycemia, but the prolonged rupture of membranes puts this baby at high risk of sepsis.

Four hours after delivery of a healthy neonate of an insulin-dependent diabetic woman, the baby appears jittery, irritable, and has a high-pitched cry. Which nursing action has top priority? a. Start an intravenous line with D5W. b. Notify the clinician stat. c. Document the event in the nurses' notes. d. Test for blood glucose level.

ANS: D These are signs of hypoglycemia in the newborn. The nurse should test the infant's blood glucose level and then feed the infant if it is low. It is not common practice to give intravenous glucose to a newborn prior to feeding. Feeding the infant is preferable because the formula or breast milk will last longer. The provider needs to be notified after corrective action has been taken. Documentation should occur but is not the priority.

A macrosomic infant is born after a difficult, forceps-assisted delivery. After stabilization, the infant is weighed, and the birth weight is 4550 g (9 pounds, 6 ounces). What action by the nurse is most appropriate? a. Leave the infant in the room with the mother. b. Take the infant immediately to the nursery. c. Perform a gestational age assessment. d. Monitor blood glucose levels frequently.

ANS: D This infant is macrosomic (over 4000 g) and is at high risk for hypoglycemia. Blood glucose levels should be monitored frequently, and the infant should be observed closely for signs of hypoglycemia. The infant can stay with the mother, but this is not the best answer since it does not include the close monitoring needed. Regardless of gestational age, this infant is macrosomic.

Which statement by a postpartum woman indicates that teaching about thrombus formation has been effective? a. "I'll stay in bed for the first 3 days after my baby is born." b. "I'll keep my legs elevated with pillows." c. "I'll sit in my rocking chair most of the time." d. "I'll put my support stockings on every morning before rising."

ANS: D Venous congestion begins as soon as the woman stands up. The stockings should be applied before she rises from the bed in the morning. As soon as possible, the woman should ambulate frequently. The mother should avoid knee pillows because they increase pressure on the popliteal space. Sitting in a chair with legs in a dependent position causes pooling of blood in the lower extremities.