OB Exam 6
The prenatal health nurse is conducting an educational session focusing on alcohol use during pregnancy. The nurse feels the session was a success when a participant makes which statement?
"Alcohol use could cause my baby to be intellectually disabled." Explanation: Disorders included in the grouping fetal alcohol spectrum disorders are alcohol-related neurodevelopmental disorders (ARND). Children with ARND primarily display intellectual disabilities related to behavior and learning. fetal alcohol spectrum disorder is one of the most common known causes of intellectual disability. Nurses should counsel girls and women to avoid any alcohol use during pregnancy. Nurses can also participate in programs for at-risk groups, including adolescents, especially programs about the serious effects of substance use disorder, especially alcohol use disorder, during pregnancy.
Which statement by the nurse would be considered inappropriate when comforting a family who has experienced a stillborn infant?
"I know you are hurting, but you can have another baby in the future." Explanation: Parents who have experienced a stillborn need support from the nursing staff. Statements by the nurses need to be therapeutic for the grieving parents. Statements that offer false hope or diminish the value of the stillborn child cause the parents pain. Telling them that they can have another child is both thoughtless and hurtful.
A nurse is assessing a postpartum client who is at home. Which statement by the client would lead the nurse to suspect that the client may be developing postpartum depression?
"I'm feeling so guilty and worthless lately." Explanation: Indicators for postpartum depression include feelings related to restlessness, worthlessness, guilt, hopeless, and sadness along with loss of enjoyment, low energy level, and loss of libido. The statements about being overwhelmed and fatigued and changing moods suggest postpartum blues. The statement about hearing voices suggests postpartum psychosis.
A nurse is making an initial call on a new mother who gave birth to her third baby 5 days ago. The woman says, "I just feel so down this time. Not at all like when I had my other babies. And this one just doesn't sleep. I feel so inadequate." What is the best response to this new mother?
"It sounds like you have the 'baby blues.' They are common after having a baby when you are not getting enough sleep, are busy with your other children, and are still a bit uncomfortable from the birth. They will most likely go away in a day or two." Explanation: A combination of factors likely contributes to the baby blues. Psychological adjustment along with a physiologic decrease in estrogen and progesterone appear to be the greatest contributors. Additional contributing factors include too much activity, fatigue, disturbed sleep patterns, and discomfort.
The nurse is assessing a toddler at a well-child visit and notes the following: small in stature, appears mildly developmentally delayed; short eyelid folds; and the nose is flat. Which advice should the nurse prioritize to the mother in response to her questions about having another baby?
"It's a good idea to stop drinking alcohol 3 months before trying to get pregnant." Explanation: Alcohol is one of the many teratogenic substances that cross the placenta to the fetus. Fetal alcohol spectrum disorder is often apparent in newborns of mothers with chronic alcoholism and sometimes appears in newborns whose mothers consume low-to-moderate amounts of alcohol. No amount of alcohol is believed to be safe, and women should stop drinking at least 3 months before they plan to become pregnant. The ability of the mother's liver to detoxify the alcohol is apparently of greater importance than the actual amount consumed. Fetal alcohol spectrum disorder is characterized by low birth weight, smaller height and head circumference, short palpebral fissures (eyelid folds), reduced ocular growth, and a flattened nasal bridge. These newborns are prone to respiratory difficulties, hypoglycemia, hypocalcemia, and hyperbilirubinemia. Their growth continues to be slow, and their mental development is delayed despite expert care and nutrition. Smoking is related to respiratory issues. Proper nutrition and glucose control are also important but do not result in fetal alcohol spectrum disorder.
A woman's baby is HIV positive at birth. She asks the nurse if this means the baby will develop AIDS. Which statement would be the nurse's best answer?
"The antibodies may be those transferred across the placenta; the baby may not develop AIDS." Explanation: Infants born of HIV-positive women test positive for HIV antibodies at birth because these have crossed the placenta. An accurate disease status cannot be determined until the antibodies fade at about 18 months. Testing positive for HIV antibodies does not mean the infant has AIDS. Having a cesarean birth does decrease the risk of transmitting the virus to the infant at birth; it does not prevent the transmission of the disease. HIV antibodies do cross the placenta, which is why babies born of HIV positive mothers are HIV positive.
The pregnant woman with diabetes asks the nurse why her last baby weighed 11 pounds. What is the best response by the nurse?
"The fetus increases insulin production in response to elevated glucose levels of the mother, which acts as a fetal growth hormone." Explanation: Consistently elevated fetal insulin levels cause the distinctive growth pattern. Because maternal glucose levels are elevated and glucose readily crosses the placenta, the fetus responds by increasing insulin production. Because insulin acts as a fetal growth hormone, consistently high levels cause fetal macrosomia, birth weight of greater than 4,500 g. Insulin also causes disproportionate fat buildup to the shoulders and upper body, increasing the risk for shoulder dystocia and birth trauma.
A gravida woman in her second trimester has shared that she still enjoys a glass of wine about once a week with dinner. What response by the nurse is most appropriate?
"There is no amount of alcohol consumption in pregnancy that is considered safe for the fetus." Explanation: Alcohol ingestion during the pregnancy is considered unsafe at all points in the pregnancy. Alcohol can impact the fetus during each of trimester of pregnancy. There are no exact amounts of alcohol that can be ingested safely. Alcohol impacts each pregnancy and fetus differently. The best course of action is to share the dangers with the woman.
The nurse is caring for a client who underwent a cesarean birth one day ago. After listening to the nurse's discussion about the plan of care, the client indicates that she is in a great deal of pain and does not wish to ambulate until the next day. What response by the nurse is most appropriate?
"Walking is the best way to prevent complications such as blood clots." Explanation: The development of blood clots is a potential complication of a cesarean birth. Early ambulation is key in the prevention of the complication. The client needs to be advised of this complication and the best means of clot prevention. Telling the client that failing to walk will prevent her recovery is threatening and does not provide her the needed information. A delay in walking by even one day can be detrimental to her recovery. Recommending pain medication may help the client in her ability and willingness to ambulate, but it does not provide the needed client education.
A pregnant single mom living alone tells the nurse she is considering getting a cat for her 2-year-old daughter. Which is the best response by the nurse?
"You should wait until after you give birth to obtain the cat for your daughter." Explanation: Toxoplasma gondii is a protozoan that can be transmitted via undercooked meat and through cat litter. Having a cat is not an issue, but cleaning the litter box may expose the mother to the infection and result in fetal anomalies. Exposure to the cat litter will not necessitate a cesarean section, and having a cat will not cut down on any jealousy the 2-year-old might feel when the new baby is born. The nurse would discourage the mother from getting cat until after the baby is born.
A client has had a cesarean birth. Which amount of blood loss would the nurse document as a postpartum hemorrhage in this client?
1000 ml Explanation: Postpartum hemorrhage is defined as blood loss of 500 ml or more after a vaginal birth and 1000 ml or more after a cesarean birth.
A newborn is exhibiting signs and symptoms of hypoglycemia. The nurse prepares to administer IV glucose based on which blood glucose level?
36 mg/dl (2.0 mmol/L) Explanation: Any symptomatic newborn with blood glucose less than 40 mg/dl (2.22 mmol/L) is treated promptly with IV glucose
Hypoglycemia in a mature infant is defined as a blood glucose level below which amount?
45 mg/100 ml whole blood Explanation: Because newborns do not manifest symptoms of a reduced glucose level until it decreases well below adult levels, a finding below 45 mg/100 ml whole blood is considered hypoglycemia.
The nurse determines that a woman is experiencing postpartum hemorrhage after a vaginal birth when the blood loss is greater than which amount?
500 ml Explanation: Postpartum hemorrhage is defined as a cumulative blood loss greater than 500 m after a vaginal birth and greater than 1,000 ml after a cesarean birth, with signs and symptoms of hypovolemia within 24 hours of the birth process.
Why is it important for the nurse to thoroughly assess maternal bladder and bowel status during labor?
A full bladder or rectum can impede fetal descent. Explanation: Throughout labor the nurse needs to assess the woman's fluid balance status as well as check skin turgor and mucous membranes. In addition she needs to monitor the bladder and bowel status. A full bladder or rectum can impede fetal descent.
While the placenta is being delivered after labor, a client experiences an amniotic fluid embolism. What should the nurse do first to help this client?
Administer oxygen by nasal cannula. Explanation: The clinical picture of an amniotic fluid embolism is dramatic. The client suddenly experiences sharp chest pain and is unable to breathe as pulmonary artery constriction occurs. The immediate management is oxygen administration by face mask or cannula. Intravenous fluids; pressure on the fundus; or taking short, shallow breaths is not going to help the manifestations of an amniotic fluid embolism.
A newborn with high serum bilirubin is receiving phototherapy. Which is the most appropriate nursing intervention for this client?
Application of eye dressings to the infant Explanation: Continuous exposure to bright lights by phototherapy may be harmful to a newborn's retina, so the infant's eyes must always be covered while under bilirubin lights. Eye dressings or cotton balls can be firmly secured in place by an infant mask. The lights are placed 12 to 30 inches above the newborn's bassinet or incubator. Bilirubin is removed from the body by being incorporated into feces. Therefore, the sooner bowel elimination begins, the sooner bilirubin removal begins. Early feeding (either breast milk or formula), therefore, stimulates bowel peristalsis and helps to accomplish this. Gently shaking the infant is a method of stimulating breathing in an infant experiencing apnea.
The nurse observes an ambulating postpartum woman limping and avoiding putting pressure on her right leg. Which assessments should the nurse prioritize in this client?
Assess for warmth, erythema, and pedal edema. Explanation: This client is demonstrating potential symptoms of DVT, but is avoiding putting pressure on the leg and limping when ambulating. DVT manifestations are caused by inflammation and obstruction of venous return and can be assessed by the presence of calf swelling, warmth, erythema, tenderness, and pedal edema. The client would not need to bend the knee to assess for pain in the calf. Asking the client to raise her toe and draw a circle is assessing reflexes, and blanching a toe is assessing capillary refill (which may be affected by the DVT but is not indicative of a DVT).
Which postoperative intervention should a nurse perform when caring for a client who has undergone a cesarean birth?
Assess uterine tone to determine fundal firmness. Explanation: When caring for a client who has undergone a cesarean birth, the nurse should assess the client's uterine tone to determine fundal firmness. The nurse should assist with breastfeeding initiation and offer continued support. The nurse can also suggest alternate positioning techniques to reduce incisional discomfort while breastfeeding. Delaying breastfeeding may not be required. The nurse should encourage the client to cough, perform deep-breathing exercises, and use the incentive spirometer every 2 hours. The nurse should assist the client with early ambulation to prevent respiratory and cardiovascular problems.
Which safety precautions should a nurse take to prevent infection in a newborn? Select all that apply.
Avoid coming to work when ill. Use sterile gloves for an invasive procedure. Initiate universal precautions when caring for the infant. Explanation: To minimize the risk of infections, the nurse should avoid coming to work when ill, use sterile gloves for an invasive procedure, and initiate universal precautions. The nurse should remove all jewelry before washing hands, not cover the jewelry. The nurse should use disposable equipment rather than avoid it.
A newborn develops jaundice, and the primary health care provider prescribes phototherapy. Which of the following would the nurse include in the newborn's plan of care? Select all that apply.
Covering the newborn's eyes from the light Removing the newborn from the lights for feeding Monitoring the newborn's temperature frequently Providing frequent feedings to lessen the risk of dehydration Explanation: When using phototherapy, the newborn's eyes should remain covered at all times except when removed from under the lights for feeding. Removing the eye coverings allows for stimulation as well as inspection for drainage or edema. As much skin is exposed as possible, such that the newborn is dressed only in diaper. Frequent feedings are essential to prevent dehydration.
A nurse is caring for a preterm newborn born at 29 weeks' gestation. Which nursing diagnosis would have the highest priority?
Ineffective thermoregulation related to decreased amount of subcutaneous fat Explanation: In the condition of hypothermia, newborns typically metabolize brown fat. This requires the newborn to use glucose and oxygen. A premature infant is at risk for respiratory distress and hypoglycemia. The hypoglycemia can increase the infant's need for glucose and oxygen, which, in turn, could cause more severe disease or further complications.
The nurse in the NICU is caring for preterm newborns. Which guidelines are recommended for care of these newborns? Select all that apply.
Dress the newborn in ways to preserve warmth. Take the newborn's temperature often. Supply oxygen for the newborn, if necessary. Explanation: Controlling the temperature of preterm newborns is often difficult; therefore, special care should be taken to keep these babies warm. Nurses should dress them in a stockinette cap, take their temperature often, and supply oxygen, if necessary. To conserve the energy of small newborns, the nurse should handle them as little as possible. Usually, they will not give them a bath immediately. Parents should be encouraged to bond with their infants.
When an infant is jaundiced, what is the nurse's main role in treatment?
Educate the caregiver. Explanation: Then nurse's main role in treating jaundice is to be an educator. The nurse must educate the caregiver to accurately identify signs and symptoms of jaundice, stressing the importance of assessing for the condition and any changes in jaundice. This condition untreated could lead to brain damage. The other choices represent the basic nursing care of a client.
A nurse identifies the urethral opening of a male newborn to be on the dorsum of the shaft of the penis. How does the nurse document this finding?
Epispadias Explanation: The newborn has epispadias. Hypospadias and epispadias are congenital anomalies in which the urethral opening is malpositioned. Urethral placement may be anywhere along the glands or shaft of the penis. In epispadias, the urethra opens on the dorsal aspect of the penis. In hypospadias, the urethra opens on the ventral aspect of the penis. Talipes equinovarus is a congenital skeletal deformity with the foot in a downward and inward flexed position. Hydrocephalus is an anomaly with infants having an abnormally large head. Omphalocele is a congenital anomaly of the abdominal wall, in which the abdominal contents contained within the peritoneal sac protrude through the external abdominal surface at the base of the umbilical cord.
The nurse assesses that a fetus is in an occiput posterior position. The nurse predicts the client will experience which situation related to this assessment?
Experience of additional back pain Explanation: Most women whose fetus is in a posterior position experience back pain while in labor. Pressure against the back by a support person often reduces this type of pain. An occiput posterior position does not make for a shorter (dilation) dilatation stage of labor. OP position does not indicate the need to have the baby manually rotated, nor does it indicate a necessity for a vacuum extraction birth.
Assessment of a pregnant client reveals that she has tested positive for a sexually transmitted infection (STI). The nurse understands that the client's newborn is at risk for which of the following?
neurologic damage Explanation: The nurse should inform the client that children born of mothers with STIs are often born with neurologic damage, congenital abnormalities, and meningitis. Children born of STI mothers are not known to be born with diabetes or hypertension. Low birth weight is associated with smoking during pregnancy.
A pregnant client has been diagnosed with gonorrhea. Which nursing interventions should be performed to prevent gonococcal ophthalmia neonatorum in the baby?
Instill a prophylactic agent in the eyes of the newborn. Explanation: To prevent gonococcal ophthalmia neonatorum in the baby, the nurse should instill a prophylactic agent in the eyes of the newborn. Cephalosporins are administered to the mother during pregnancy to treat gonorrhea but not to prevent infection in the newborn. Performing a cesarean birth will not prevent gonococcal ophthalmia neonatorum in the newborn. An antiretroviral syrup is administered to the newborn only if the mother is HIV positive and will not help prevent gonococcal ophthalmia neonatorum in the baby.
Shoulder dystocia is a true medical emergency that can cause fetal demise because the baby cannot be born. Stuck in the birth canal, the infant cannot take its first breath. Which maneuver is first attempted to deliver an infant with shoulder dystocia?
McRoberts maneuver Explanation: McRoberts maneuver is an intervention that is frequently successful in cases of shoulder dystocia, and it is often tried first. McRoberts requires the assistance of two individuals. Two nurses are ideal; however, a support person or a technician can serve as the second assistant. With the woman in lithotomy position, each nurse holds one leg and sharply flexes the leg toward the woman's shoulders. This opens the pelvis to its widest diameters and allows the anterior shoulder to deliver in almost half of the cases.
Newborns receive an antibiotic in their eyes within the first hour after birth to prevent neonatorum ophthalmia. Which type of bacteria is most likely to cause this condition?
Neisseria gonorrhoeae Explanation: N. gonorrhoeae and Chlamydia trachomatis are the organisms that cause neonatorum ophthalmia.
A postpartum woman is prescribed oxytocin to stimulate the uterus to contract. Which action would be most important for the nurse to do?
Piggyback the IV infusion into a primary line. Explanation: When giving oxytocin, it should be diluted in a liter of IV solution and the infusion set up to be piggy-backed into a primary line to ensure that the medication can be discontinued readily if hyperstimulation or adverse effects occur. It should never be given as an IV bolus injection. Oxytocin may be given if the woman is hypertensive. Oxytocin is not available as a vaginal or rectal suppository.
Which intervention is helpful for the neonate experiencing drug withdrawal?
Place the isolette in a quiet area of the nursery. Explanation: Neonates experiencing drug withdrawal commonly have sleep disturbance. The neonate should be moved to a quiet area of the nursery to minimize environmental stimuli. Medications such as phenobarbital and paregoric should be given as needed. The neonate should be swaddled to prevent him from flailing and stimulating himself.
The nurse is admitting a client in labor. The nurse determines that the fetus is in a transverse lie by performing Leopold maneuvers. What intervention should the nurse provide for the client?
Prepare the client for a cesarean birth. Explanation: If a transverse lie persists, the fetus cannot be born vaginally. Thus, the nurse will prepare the client for a caesarean birth. There is no indication the client will have precipitous labor. Amniotomy, artificial rupture of the membranes, is not indicated when preparing from a caesarean birth. The nurse would not administer analgesic before surgery unless prescribed by the health care provider.
The nurse is caring for a client in active labor. Which assessment finding should the nurse prioritize and report to the team?
Sudden shortness of breath Explanation: Sudden shortness of breath can be a sign of amniotic fluid embolism and requires emergent intervention. This can occur suddenly during labor or immediately after. The woman usually develops symptoms of acute respiratory distress, cyanosis, and hypotension. It must be reported to the care team so proper interventions may be taken. Other symptoms can include hypotension, cyanosis, hypoxemia, uterine atony, seizures, tachycardia, coagulation failure, DIC, and pulmonary edema.
A 39-year-old multigravida with diabetes presents at 32 weeks' gestation reporting she has not felt movement of her fetus. Assessment reveals the fetus has died. The nurse shares with the mother that the institution takes pictures after the birth and asks if she would like one. What is the best response if the mother angrily says no and starts crying?
Tell her that the hospital will keep the photos for her in case she changes her mind. Explanation: Emotional care of the woman is complex, especially one who has suffered the loss of a child. The woman will need time to move through the stages of grief and the responses of grief vary from person to person. The mother may request the items later and they should be stored or kept for a year after the birth. There is no need to apologize to the client. It would be inappropriate to console her with the fact that she has other children. It negates her feelings and is not supportive of the woman at this time.
At birth, the newborn was at the 8th percentile with a weight of 2350 g and born at 36 weeks' gestation. Which documentation is most accurate?
The infant was a preterm, low-birth-weight and small-for-gestational-age Explanation: Born at 36 weeks' gestation is a preterm age (under 37 weeks). The infant was a low birthweight (under 2500 g) and small-for-gestational-age at the 8th percentile (under the 10th percentile). The other documentation is not accurate.
The client brings her infant daughter to the pediatrician's office for her first visit since hospital discharge. At birth, the newborn was at the 8th percentile with a weight of 2,350 g. She was born at 36 weeks' gestation. Which documentation is most accurate?
The infant was a preterm, low-birth-weight and small-for-gestational-age neonate. Explanation: Born at 36 weeks' gestation is a preterm age (under 37 weeks). The infant was a low-birth-weight (under 2,500 g) and small-for-gestational-age infant at the 8th percentile (under the 10th percentile).
A nurse is assigned to care for a newborn with hyperbilirubinemia. The newborn is relatively large in size and shows signs of listlessness. What most likely occurred?
The infant's mother probably had diabetes. Explanation: The nurse should know that the infant's mother more than likely had/has diabetes. The large size of the infant born to a mother with diabetes is secondary to exposure to high levels of maternal glucose crossing the placenta into the fetal circulation. Common problems among infants of mothers with diabetes include macrosomia, respiratory distress syndrome, birth trauma, hypoglycemia, hypocalcemia and hypomagnesemia, polycythemia, hyperbilirubinemia, and congenital anomalies. Listlessness is also a common symptom noted in these infants. Infants born to clients who use alcohol during pregnancy, infants who have experienced birth traumas, or infants whose mothers have had long labors are not known to exhibit these particular characteristics, although these conditions do not produce very positive pregnancy outcomes. Infants with fetal alcohol spectrum disorder or alcohol exposure during pregnancy do not usually have hypoglycemia problems.
The nurse has administered erythromycin ointment to a newborn. What outcome indicates this nursing intervention has been effective?
The newborn does not contract ophthalmia neonatorum. Explanation: Eye prophylaxis is given to prevent (not treat) ophthalmia neonatorum, a severe eye infection contracted in the birth canal of a woman with gonorrhea or chlamydia. This is unrelated to tear production or jaundice.
A client has just given birth at 42 weeks' gestation. What would the nurse expect to find during her assessment of the neonate?
peeling and wrinkling of the neonate's epidermis Explanation: Postdate neonates lose the vernix caseosa, and the epidermis may become peeled and wrinkled. A neonate at 42 weeks' gestation is usually very alert and missing lanugo.
What postpartum client should the nurse monitor most closely for signs of a postpartum infection?
a client who had a nonelective cesarean birth Explanation: The major risk factor for postpartum infection is a nonelective cesarean birth. Antepartum risk factors include history of infection; history of chronic conditions, such as diabetes, anemia, or poor nutrition; infections of the genital tract; smoking; and obesity.
At an amniocentesis just prior to birth, the lecithin/sphingomyelin ratio (L/S) of a fetus was determined to be 1:1. Based on this, she is prone to which type of respiratory problem following birth?
alveolar collapse on expiration Explanation: Without adequate surfactant, infants are unable to sustain respiratory function and, thus, develop respiratory distress syndrome with alveolar collapse on expiration.
Immediately after giving birth to a full-term infant, a client develops dyspnea and cyanosis. Her blood pressure decreases to 60/40 mm Hg, and she becomes unresponsive. What does the nurse suspect is happening with this client?
amniotic fluid embolism Explanation: With amniotic fluid embolism, symptoms may occur suddenly during or immediately after labor. The woman usually develops symptoms of acute respiratory distress, cyanosis, and hypotension.
A pregnant woman in her 39th week of pregnancy presents to the clinic with a vaginal infection. She tests positive for chlamydia. What would this disease make her infant at risk for?
blindness Explanation: A pregnant woman who contracts chlamydia is at increased risk for spontaneous abortion (miscarriage), preterm rupture of membranes, and preterm labor. The postpartum woman is at higher risk for endometritis. The fetus can encounter bacteria in the vagina during the birth process. If this happens, the newborn can develop pneumonia or conjunctivitis that can lead to blindness.
Which measurement best describes delayed postpartum hemorrhage?
blood loss in excess of 500 ml, occurring at least 24 hours and up to 12 weeks after birth Explanation: Late postpartum hemorrhage involves blood loss in excess of 500 ml. Most delayed postpartum hemorrhages occur between the fourth and ninth days postpartum, but can occur any time between 24 hours and 12 weeks after birth The most common causes of a delayed postpartum hemorrhage include retained placental fragments, intrauterine infection, and fibroids.
A fetus is experiencing shoulder dystocia during birth. The nurse would place priority on performing which fetal assessment postbirth?
brachial plexus assessment Explanation: The nurse should identify nerve damage as a risk to the fetus in cases of shoulder dystocia. Other fetal risks include asphyxia, clavicle fracture, central nervous system injury or dysfunction, and death. Extensive lacerations is a poor maternal outcome due to the occurrence of shoulder dystocia, which should be assessed and treated. Cleft palate and cardiac anomalies are not related to shoulder dystocia.
A 16-year-old client has been in the active phase of labor for 14 hours. An ultrasound reveals that the likely cause of delay in dilation (dilatation) is cephalopelvic disproportion. Which intervention should the nurse most expect in this case?
cesarean birth Explanation: If the cause of the delay in dilation (dilatation) is fetal malposition or cephalopelvic disproportion (CPD), cesarean birth may be necessary. Oxytocin would be administered to augment labor only if CPD were ruled out. Administration of morphine sulfate (an analgesic) and darkening room lights and decreasing noise and stimulation are used in the management of a prolonged latent phase caused by hypertonic contractions. These measures would not help in the case of CPD.
Which intervention would be most important when caring for the client with breech presentation confirmed by ultrasound?
continuing to monitor maternal and fetal status Explanation: Once a breech presentation is confirmed by ultrasound, the nurse should continue to monitor the maternal and fetal status when the team makes decisions about the method of birth. The nurse usually plays an important role in communicating information during this time. Applying suprapubic pressure against the fetal back is the nursing intervention for shoulder dystocia and may not be required for breech presentation. Noting the space or dip at the maternal umbilicus and auscultating the fetal heart rate at the umbilicus level are assessments related to occipitoposterior positioning of the fetus.
The nurse is monitoring the uterine contractions of a woman in labor. The nurse determines the woman is experiencing hypertonic uterine dysfunction based on which contraction finding?
erratic. Explanation: Hypertonic contractions occur when the uterus never fully relaxes between contractions, making the contractions erratic and poorly coordinated because more than one uterine pacemaker is sending signals for contraction. Hypotonic uterine contractions are poor in quality, brief, and lack sufficient intensity to dilate and efface the cervix.
A newborn is diagnosed with hemolytic disease of the newborn. When developing the plan of care for this child, the nurse would expect which of the following to be included as part of the treatment plan?
exchange transfusion Explanation: Treatment for hemolytic disease of the newborn includes phototherapy and exchange transfusions. Surfactant is administered if the newborn has a surfactant deficiency. A radiant warmer is used to assist with thermoregulation. Mechanical ventilation is used for severe respiratory distress and for newborns with intraventricular hemorrhage.
A nurse is caring for a client who has just received an episiotomy. The nurse observes that the laceration extends through the perineal area and continues through the anterior rectal wall. How does the nurse classify the laceration?
fourth degree Explanation: The nurse should classify the laceration as fourth degree because it continues through the anterior rectal wall. First-degree laceration involves only skin and superficial structures above muscle; second-degree laceration extends through perineal muscles; and third-degree laceration extends through the anal sphincter muscle but not through the anterior rectal wall.
A client has given birth to a small-for-gestational-age (SGA) newborn. Which finding would the nurse expect to assess?
head larger than body Explanation: A small-for-gestational-age (SGA) newborn will typically have a head that is larger than the rest of his or her body. SGA newborns weigh below the 10th percentile on the intrauterine growth chart for gestational age. They have an angular and pinched face and not a rounded and flushed face. Round flushed face and protuberant abdomen are the characteristic features of large-for-gestational-age (LGA) newborns. Preterm newborns, and not SGA newborns, are covered with brown lanugo hair all over the body.
Assessment of a postpartum client reveals a firm uterus with bright-red bleeding and a localized bluish bulging area just under the skin at the perineum. The woman also reports significant pelvic pain and is experiencing problems with voiding. The nurse suspects which condition?
hematoma Explanation: The woman most likely has a hematoma based on the findings: firm uterus with bright-red bleeding; localized bluish bulging area just under the skin surface in the perineal area; severe perineal or pelvic pain; and difficulty voiding. A laceration would involve a firm uterus with a steady stream or trickle of unclotted bright-red blood in the perineum. Bladder distention would be palpable along with a soft, boggy uterus that deviates from the midline. Uterine atony would be noted by a uncontracted uterus.
The fetus of a pregnant client is in a breech presentation. Where will the nurse auscultate fetal heart sounds?
high in the abdomen Explanation: With a breech presentation, fetal heart sounds usually are heard high in the abdomen. In a breech presentation, fetal heart sounds will not be heard low in the abdomen or over the left or right lateral abdominal regions.
The health care provider is reluctant to provide pain medication to a client delivering a preterm fetus. What should the nurse explain to the client as the reason for the preterm fetus being more affected by medication?
inability of the immature liver to metabolize or inactivate drugs Explanation: A preterm fetus, which has an immature liver and is unable to metabolize or inactivate drugs, is generally more affected by drugs than a term fetus. A preterm fetus does not have an affinity to drugs that are fat-soluble or strongly bound to protein. The preterm fetus is not able to metabolize drugs because of an immature liver, which has nothing to do with the molecular weight of the medication.
A nurse is educating a group of nursing students about the treatment of congenital syphilis in newborns. Which pharmacologic treatment would the nurse include in the teaching?
intravenous penicillin G Explanation: Congenital syphilis is a serious bacterial infection that a newborn contracts from the mother during pregnancy. The correct treatment for congenital syphilis is intravenous penicillin G. Penicillin G is the drug of choice for treating all stages of syphilis, including congenital syphilis in newborns. It is effective in killing the bacterium Treponema pallidum, which causes syphilis, and can cross the placental barrier to treat the infection in the fetus.
A client presents to her postpartum appointment with vague reports. The nurse suspects postpartum depression based on which assessment finding?
lack of pleasure Explanation: Some signs and symptoms of postpartum depression include feeling restless, worthless, guilty, hopeless, moody, sad, overwhelmed; crying a lot; exhibiting a lack of energy and motivation; experiencing a lack of pleasure; changes in appetite, sleep, or weight; withdrawing from friends and family; feeling negatively toward her baby; or showing lack of interest in her baby.
A newborn is suspected to have fetal alcohol syndrome as a result of maternal use of alcohol during pregnancy. Which of the following would the nurse expect to assess?
low nasal bridge Explanation: A low nasal bridge is seen in fetal alcohol syndrome (FAS). The other features of FAS include thin, flat upper lip, small eyes with short palpebral fissure, flattened midface with a short nose. The facial features result from damage to the embryonic cells in early pregnancy.
A nurse is conducting a class for expectant parents about newborns. As part of the class, the nurse describes newborns with birth weight variations. The nurse determines that the teaching was successful when the class identifies which variation if a newborn weighs 5.2 lb (2,358 g) at any gestational age?
low-birth-weight Explanation: A low-birth-weight newborn weighs less than 5.5 lb (2,500 g) but more than 3 lb 5 oz (1,587 g). A very-low-birth-weight newborn would weigh less than 3 lb 5 oz (1,587 g) but more than 2 lb 3 oz (1,000 g). An extremely-low-birth-weight newborn weighs less than 2 lb 3 oz (1,000 g). A small-for-gestational-age newborn typically weighs less than 5 lb 8 oz (2,500 g) at term.
At 40 weeks' gestation and after 26 hours of labor a woman gives birth by cesarean section to a neonate weighing 4550 grams. The nurse implements which standard of care for this infant?
macrosomic infant Explanation: A birth weight of 4500 grams or greater classifies the infant as macrosomic. A macrosomic infant is at risk for hypothermia, hypoglycemia, and other complications. Therefore, close monitoring is needed. A post-mature infant is one born after 41 weeks' completed gestation.
In the infant born with a cleft lip and a cleft palate, the highest priority of the nurse is related to which intervention?
maintaining the nutritional needs of the infant Explanation: The major goals for the infant with a cleft lip and palate include maintaining adequate nutrition. Feeding the newborn is a challenge and may be time-consuming and tedious because the newborn's ability to suck is inadequate.
The nurse is assessing the breast of a woman who is 1 month postpartum. The woman reports a painful area on one breast with a red area. The nurse notes a local area on one breast to be red and warm to touch. What should the nurse consider as the potential diagnosis?
mastitis Explanation: Mastitis usually occurs 2 to 3 weeks after birth and is noted to be unilateral. Mastitis needs to be assessed and treated with antibiotic therapy.
By preventing fetal distress during the intrapartum period, which condition is less likely?
meconium aspiration syndrome Explanation: A primary cause of meconium aspiration syndrome is fetal distress. Meconium is the thick, pasty, greenish black substance that is present in the fetal bowel. When the fetus releases the meconium in utero, the fetus can inhale the meconium into the lungs. Hemolytic disease of the newborn is caused by blood incompatibility. Transient tachypnea of the newborn is from fluid in the fetal lungs. Neonatal abstinence syndrome is caused by maternal use of drugs or alcohol.
In twin-to-twin transfusion syndrome, the arterial circulation of one twin is in communication with the venous circulation of the other twin. One fetus is considered the donor twin, and one becomes the recipient twin. Observation of the recipient twin would most likely show which condition?
polycythemia Explanation: The recipient twin in twin-to-twin transfusion syndrome (also known as twin-twin transfusion syndrome) is transfused by the other twin. The recipient twin then becomes polycythemic and commonly has heart failure due to circulatory overload. The donor twin becomes anemic. The recipient twin has polyhydramnios, not oligohydramnios. The recipient twin is usually large, whereas the donor twin is usually small.
The nurse is assessing a client at a postpartum visit and notes the client is emotionally sensitive, complains about being a failure, and appears extremely sad. The nurse concludes the client is presenting with which potential condition?
postpartum depression Explanation: The client is showing signs of postpartum depression. Postpartum blues are due to lack of sleep and emotional labilities. Postpartum psychosis is symbolized by confusion, hallucinations, and delusions. Postpartum anxiety disorders involve shortness of breath, chest pain, and tightness.
A nurse is providing preoperative care to a female newborn client with the congenital abnormality myelomeningocele. Which intervention is the priority?
preventing infection Explanation: A congenital condition of the newborn with a spinal deformity puts the newborn at risk for infection. A myelomeningocele is a fluid-filled sac on the spine that includes part of the spinal cord defect and the meninges. This cyst on the outside of the newborn requires surgical intervention. Although nutrition, GI function, and motor function are all important to the health of the newborn, the spinal and meninges defect puts the newborn at high risk for infection.
The nurse is assisting with a vaginal birth. The client is fully dilated, 100% effaced, and is pushing. The nurse observes the "turtle sign" with each push and there is no progress. What does the nurse suspect may be occurring with this fetus?
shoulder dystocia Explanation: The "turtle sign" is the classic sign that alerts the practitioner to the probability of shoulder dystocia. The fetal head delivers, but then retracts similar to a turtle. The fetal head may wiggle from side to side and fail to rotate.
A nurse is conducting a presentation at a community health center about congenital malformations. The nurse describes that some common congenital malformations can occur and are recognized to be caused by multiple genetic and environmental factors. Which example would the nurse most likely cite?
spina bifida Explanation: Spina bifida is a multifactorial inherited disorder thought to be due to multiple genetic and environmental factors. Cystic fibrosis is considered an autosomal recessive inherited disorder, while color blindness and hemophilia are considered X-linked inheritance disorders.
The nurses at a local free clinic are concerned there may be an increase in small-for-gestational-age infants in the community. When collecting data to research the situation, the nurses will exclude infants above which category?
the 10th percentile for gestational age Explanation: The small-for-gestational-age (SGA) infant would fall below the 10th percentile for gestational age using the weight, length, and head circumference as a guideline.
The nursing instructor is leading a discussion with a group of nursing students who are analyzing the preterm infant's physiologic immaturity and the associated difficulties the newborn and family must deal with. The instructor determines the session is successful when the students correctly choose which body system that presents with the most critical concerns related to this immaturity?
the respiratory system Explanation: Immaturity causes difficulties involving all body systems, the most critical of which is the respiratory system, the last to fully develop. Typically, respirations are shallow, rapid, and irregular with periods of apnea (absence of breathing) that lasts for at least 20 seconds or that causes cyanosis and/or bradycardia. Although difficulties may occur in the other systems, the most critical is the respiratory system.
The nurse is caring for a large-for-gestational-age infant born to a client with diabetes mellitus. Why should the nurse schedule routine blood glucose measurements for the infant?
to detect rebound hypoglycemia Explanation: Large-for-gestational age infants need to be carefully assessed for hypoglycemia in the early hours of life because large infants require large amounts of nutritional stores to sustain their weight. If the mother had diabetes that was poorly controlled, the infant would have had an increased blood glucose level in utero to match the mother's glucose level; this caused the infant to produce elevated levels of insulin. After birth, these increased insulin levels will continue for up to 24 hours of life, possibly causing rebound hypoglycemia. Frequent blood glucose monitoring in large-for-gestational-age infants is not done to determine insulin dosage, to explain the effects of maternal hyperglycemia on the baby, or to estimate the amount of calories to provide the infant through formula.
The nurse is assisting the mother to push. The nurse suspects shoulder dystocia is present when which symptom is present?
turtle sign Explanation: Turtle sign is often the first indication of shoulder dystocia. With turtle sign the fetal head is born but the cheeks of the newborn rest on the maternal introitus as the anterior is unable to pass beneath the symphysis pubis. The fetal head remaining at 0 station is an indication of failure to descend. Continuous back pain is associated with an occiput posterior (OP) position. The battle sign is related to a head injury.
Which factor puts a multiparous client on her first postpartum day at risk for developing hemorrhage?
uterine atony Explanation: Multiparous women typically experience a loss of uterine tone due to frequent distentions of the uterus from previous pregnancies. As a result, this client is also at higher risk for hemorrhage. Thrombophlebitis does not increase the risk of hemorrhage during the postpartum period. The hemoglobin level and lochia flow are within acceptable limits.
Which factor in a client's history would alert the nurse to an increased risk for postpartum hemorrhage?
uterine atony, placenta previa, operative procedures Explanation: Risk factors for postpartum hemorrhage include a precipitous labor less than three hours, uterine atony, placenta previa or abruption, labor induction or augmentation, operative procedures such as vacuum extraction, forceps, or cesarean birth, retained placental fragments, prolonged third stage of labor greater than 30 minutes, multiparity, and uterine over distention such as from a large infant, twins, or hydramnios.
A nurse is assigned to care for a client with a uterine prolapse. Which of the following would be most important for the nurse to assess when determining the severity of the prolapse?
uterine protrusion into the vagina Explanation: To determine if the uterine prolapse in the client is mild or severe, the nurse should assess for uterine protrusion of the cervix and uterus into the vagina. As more of the uterus descends, the vagina becomes inverted. Uterine bleeding, foul-smelling lochia, and pain or tenderness in the lower abdomen are all characteristic manifestations of late postpartum hemorrhage.
