OB Final Exam AQ questions
What should be included in a plan of care to limit the development of hyperbilirubinemia in the breastfed neonate? 1. Encouraging more frequent breastfeeding during the first 2 days 2. Instituting phototherapy for 30 minutes every 6 hours for 3 days 3. Substituting formula feeding for breastfeeding on the second day 4. Supplementing breastfeeding with glucose water during the first day
1. Encouraging more frequent breastfeeding during the first 2 days More frequent breastfeeding stimulates more frequent evacuation of meconium, thereby preventing resorption of bilirubin into the circulatory system. Phototherapy is the treatment for hyperbilirubinemia, and it is maintained continuously; it does not prevent the development of hyperbilirubinemia. It is not necessary to feed the infant formula. Early breastfeeding tends to keep the bilirubin level low by stimulating gastrointestinal activity. Increasing water intake does not limit the development of hyperbilirubinemia, because only small amounts of bilirubin are excreted by the kidneys.
Phototherapy is prescribed for a preterm neonate with hyperbilirubinemia. Which nursing intervention is appropriate to reduce the potentially harmful side effects of the phototherapy? 1. Covering the trunk to prevent hypothermia 2. Using shields on the eyes to protect them from the light 3. Massaging vitamin E oil into the skin to minimize drying 4. Turning after each feeding to reduce exposure of each surface area
2. Using shields on the eyes to protect them from the light The lights used for phototherapy can damage the infant's eyes, and eye shields are standard equipment. Maximal effectiveness is achieved when the infant's entire skin surface is exposed to the light. Vitamin E oil massage is contraindicated, because it can cause burns and result in an overdose of the vitamin. The infant should be turned every 2 hours regardless of feeding times so that all body surfaces are exposed to the light and no single body surface is overexposed.
A woman at 39 weeks' gestation whose membranes have ruptured at home arrives at the clinic to be evaluated. Assessment reveals mild irregular contractions 10 to 15 minutes apart, and a fetal heart rate (FHR) of 186 beats/min is auscultated between contractions. In light of this assessment, what does the nurse conclude? 1. The fetus is not at risk. 2. A precipitous birth is imminent. 3. This is a response to an infection. 4. A further assessment is necessary.
4. A further assessment is necessary. The fetal heart rate should be 110 to 160 beats/min; an FHR of 186 is tachycardic, and further evaluation is necessary because the fetus may be at risk. The data indicate that the client is in early labor. Although fetal tachycardia is associated with infection, there are other causes.
The nurse is assessing a term newborn. Which sign should the nurse report to the pediatric primary healthcare provider? 1. Temperature of 97.7° F (36.5° C) 2. Pale-pink to rust-colored stain in the diaper 3. Heart rate that decreases to 115 beats/min 4. Breathing pattern with recurrent sternal retractions
4. Breathing pattern with recurrent sternal retractions A breathing pattern with recurrent sternal retractions is indicative of respiratory distress; the expected pattern is abdominal with synchronous chest movement. A temperature of 97.7° F (36.5° C) is within the expected range of 97.6° F (36.4° C) to 99° F (37.2° C) for a newborn. Pale-pink to rust-colored staining in the diaper is caused by uric acid crystals from the immature kidneys; it is a common occurrence. A decrease in heart rate to 115 beats/min is within the expected range of 110 to 160 beats/min for a newborn.
The nurse places fetal and uterine monitors on the abdomen of a client in labor. While observing the relationship between the fetal heart rate and uterine contractions, the nurse identifies four late decelerations. Which condition is most commonly associated with late decelerations? 1. Head compression 2. Maternal hypothyroidism 3. Uteroplacental insufficiency 4. Umbilical cord compression
3. Uteroplacental insufficiency Late decelerations, suggestive of fetal hypoxia, occur in the setting of uteroplacental insufficiency. Head compression results in early decelerations; this finding is considered benign. Hypothyroidism is unrelated to late decelerations. Umbilical cord compression results in variable decelerations.
The nurse is caring for a client who is admitted to the birthing unit with a diagnosis of abruptio placentae. Which complication associated with a placental abruption should the nurse carefully monitor this client for? 1. Cerebral hemorrhage 2. Pulmonary edema 3. Impending seizures 4. Hypovolemic shock
4. Hypovolemic shock With abruptio placentae, uterine bleeding can result in massive internal hemorrhage, causing hypovolemic shock. A cerebral hemorrhage may occur with a dangerously high blood pressure; there is no information indicating the presence of a dangerously high blood pressure. Pulmonary edema may occur with severe preeclampsia or heart disease, and seizures are associated with severe preeclampsia; there is no information indicating the presence of these conditions.
A client in labor, who is at term, is admitted to the birthing room. The fetus is in the left occiput posterior position. The client's membranes rupture spontaneously. Which observation requires the nurse to notify the primary healthcare provider? 1. Greenish amniotic fluid 2. Shortened intervals between contractions 3. Clear amniotic fluid with specks of mucus 4. Maternal temperature of 99.1° F (37.3° C)
1. Greenish amniotic fluid Greenish amniotic fluid indicates the presence of meconium and should be reported to the primary healthcare provider. The interval between contractions should shorten as labor progresses. Clear fluid with specks of mucus is the description of normal amniotic fluid. There may be a slight increase in temperature related to the stress of labor, and it should be monitored.
Five minutes after birth, a newborn is given an Apgar score of 8. Twelve hours later the newborn becomes hyperactive and jittery, sneezes frequently, and has difficulty swallowing. What does the nurse suspect is the cause of these clinical findings? 1. Cerebral palsy 2. Neonatal syphilis 3. Opioid drug withdrawal 4. Fetal alcohol syndrome
3. Opioid drug withdrawal These adaptations indicate opioid drug withdrawal; the infant should be monitored for further withdrawal signs during the first 24 hours after birth. Signs of cerebral palsy usually manifest later in infancy. A low-grade fever and copious serosanguineous discharge from the nose are signs of syphilis. Growth deficiencies in length, weight, and head circumference are associated with fetal alcohol syndrome, as are certain facial abnormalities.
While a multiparous client is in active labor, her membranes rupture spontaneously. The nurse notes a loop of umbilical cord protruding from her vagina. What is the priority nursing action at this time? 1. Monitoring the fetal heart rate 2. Covering the cord with a saline dressing 3. Pushing the cord back into the vaginal vault 4. Holding the presenting part away from the cord
4. Holding the presenting part away from the cord Holding the presenting part away from the cord must be done immediately to maintain cord circulation and prevent the fetus from becoming anoxic. The priority is maintaining cord circulation; although monitoring is important, it does not alter the emergency. Keeping the cord moist is secondary; keeping pressure off the cord is the priority. The cord should not be touched, because this increases pressure on the cord, further reducing oxygen flow to the fetus.
*An amniotomy is performed to stimulate labor in a client at 42 weeks' gestation. Place the nursing care actions in their order of priority. 1. Inspecting the perineum for umbilical cord prolapse 2. Checking the fetal heart rate tracings 3. Assessing the characteristics of the amniotic fluid 4. Evaluating the client for signs of an infection
As fluid gushes from the amniotic sac, it may carry the umbilical cord out of the birth canal before the presenting part. The nurse should check for this occurrence first because it is an emergency and, if it occurs, immediate intervention will be necessary to prevent fetal harm.
A neonate born at 39 weeks' gestation is small for gestational age. Which commonly occurring problem should the nurse anticipate when planning care for this infant? 1. Anemia 2. Hypoglycemia 3. Protein deficiency 4. Calcium deficiency
2. Hypoglycemia Hypoglycemia is common in newborns who are small for gestational age because of malnutrition in utero; the nurse can detect this with a blood glucose test and notify the primary healthcare provider. Polycythemia, not anemia, is more likely to occur. Although a protein deficiency may occur, it is not life threatening at this time. Although hypocalcemia may occur, it is not as common as hypoglycemia.
*The nurse is caring for a client during active labor. The recording on the electronic fetal monitor indicates fetal tachycardia. What should the nurse consider as a potential cause of this pattern? 1. Fetal head compression 2. Umbilical cord compression 3. Increased maternal metabolism 4. Pudendal anesthesia administration
3. Increased maternal metabolism A rapid fetal heart rate occurs when the maternal metabolism is accelerated; this can be a result of maternal fever. Fetal head compression causes early decelerations of the fetal heart rate, not fetal tachycardia. Umbilical cord compression is most commonly associated with variable decelerations. Pudendal anesthesia does not affect the fetal heart rate.
The nurse is testing newborns' heel blood for the level of glucose. Which newborn does the nurse anticipate will experience hypoglycemia? Select all that apply. 1. Preterm infant 2. Infant with Down syndrome 3. Small-for-gestational-age infant 4. Large-for-gestational-age infant 5. Appropriate-for-gestational-age infant
1. Preterm infant 3. Small-for-gestational-age infant 4. Large-for-gestational-age infant Preterm infants have low glycogen stores. Small-for-gestational-age infants also have low glycogen stores. Large-for-gestational-age infants are prone to hyperinsulinemia; often they are born to mothers who have diabetes, meaning that they are exposed to a high circulating glucose level while in utero. After prolonged exposure to a high glucose level, hyperplasia of the pancreas occurs, resulting in hyperinsulinemia. Infants with Down syndrome are not at risk for hypoglycemia but are at risk for congenital cardiac defects. Appropriate-for-gestational-age infants are not at risk for hypoglycemia.
The nurse is preparing to discharge a 3-day-old infant who weighed 7 lb (3175 g) at birth. Which finding should be reported immediately to the healthcare provider? 1. Weight of 6 lb 4 oz (2835 g) 2. Hemoglobin of 16.2 g/dL (162 mmol/L) 3. Three wet diapers over the last 12 hours 4. Total serum bilirubin of 10 mg/dL (171 µmol/L)
1. Weight of 6 lb 4 oz (2835 g) A loss of 12 oz (340 g) since birth, or more than 10%, is higher than the acceptable figure of 5% to 6%. Hemoglobin of 16.2 g/dL (162 mmol/L), total serum bilirubin of 10 mg/dL (171 µmol/L), and three wet diapers over the last 12 hours are all normal and expected findings.
*The nurse is caring for the newborn of a mother with diabetes. For which signs of hypoglycemia should the nurse assess the newborn? Select all that apply. 1. Pallor 2. Irritability 3. Hypotonia 4. Ineffective sucking 5. Excessive birth weight
2. Irritability 3. Hypotonia 4. Ineffective sucking An inadequate amount of cerebral glucose causes irritability and restlessness. Hypoglycemia affects the central and peripheral nervous systems, resulting in hypotonia. Feeding difficulties result from hypoglycemic effects on the fetal central nervous system. Hypoglycemia causes cyanosis, not pallor, in the newborn. Excessive birthweight is common but does not indicate hypoglycemia.
*A client arrives at the hospital in the second stage of labor. The head of the fetus is crowning, the client is bearing down, and birth appears imminent. What instruction should the nurse provide to the client in this situation? 1. Pant while pushing gently 2. Breathe with her mouth closed 3. Hold her breath while bearing down 4. Pant while resisting the urge to bear down
4. Pant while resisting the urge to bear down Panting prevents the mother from putting pressure on the fetal head by pushing. The nurse applies gentle pressure against the fetus's head as it emerges to prevent a precipitous birth, which could result in central nervous system injury to the fetus and vaginal lacerations in the mother. It is impossible to pant and push at the same time. Breathing with the mouth closed promotes the bearing-down reflex. Bearing down during the birth is unsafe because both fetus and mother could be injured.
*A client's membranes rupture, and the nurse immediately detects the presence of a prolapsed umbilical cord. The nurse alerts another nurse, who calls the primary healthcare provider. Place the following nursing interventions in the order in which they should be performed. 1. Moving the presenting part off the cord 2. Placing the client in the Trendelenburg position 3. Administering oxygen by facemask 4. Checking the fetal heart rate
The priority nursing intervention is to maintain perfusion to the cord by removing the presenting part that is compressing it. The Trendelenburg position will help keep the presenting part off the cord. Oxygen should be administered to the mother to promote optimal oxygenation to the mother and fetus. Evaluating the response to the interventions includes checking the fetal heart rate.
The most appropriate method for a nurse to evaluate the effects of the maternal blood glucose level in the infant of a diabetic mother is by performing a heel stick blood test on the newborn. What specifically does this test determine? 1. Blood acidity 2. Glucose tolerance 3. Serum glucose level 4. Glycosylated hemoglobin level
3. Serum glucose level Obtaining a blood glucose level is a simple, cost-effective method of testing newborns for suspected hypoglycemia. Although the acidity of the blood will indicate whether the newborn has metabolic acidosis as a result of hypoglycemia, it is more important to determine whether the newborn has hypoglycemia so it can be corrected before acidosis develops. The glucose tolerance test and glycosylated hemoglobin level test are not used in newborns.
* The nurse is caring for a neonate who is undergoing phototherapy. What specific care should the nurse plan for this infant? 1. Applying mineral oil to the skin to prevent excoriation 2. Covering the infant's head with a cap to minimize heat loss 3. Regulating radiant heat to maintain optimum skin temperature 4. Discontinuing therapy during feeding to meet the infant's emotional needs
4. Discontinuing therapy during feeding to meet the infant's emotional needs Discontinuing therapy during feedings is necessary to ensure psychosocial contact. Mineral oil may block light rays from acting on bilirubin deposits; cleansing after each voiding and defecation will prevent skin excoriation. All parts of the body may contain bilirubin deposits and should be exposed to the light. Radiant heaters are not used; a fluorescent light source is used.
The nurse is planning to use a newborn's foot to obtain blood for the required newborn metabolic testing. Which part of the foot is the best site to use for the puncture? 1. Big toe 2. Foot pad 3. Inner sole 4. Outer heel
4. Outer heel The outer heel is well perfused and heals quickly. The big toe, foot pad, and inner sole are all inappropriate sites from which to obtain a blood specimen from a newborn.
A client at 40 weeks' gestation is admitted to the birthing unit in early active labor. During her intake assessment, she tells the nurse that her membranes ruptured 26 hours ago. Initial assessments of the fetal heart rate range between 168 and 174 beats/min. What is the priority nursing action? 1. Assessing maternal vital signs 2. Planning for an emergency birth 3. Administering oxygen by way of nasal cannula 4. Preparing for fetal scalp blood sampling
1. Assessing maternal vital signs A prolonged period after the rupture of membranes and fetal tachycardia indicate the possibility of maternal infection; the maternal vital signs should be assessed for fever and increased pulse and respirations. Planning for an emergency birth is premature unless the fetal status deteriorates and intrauterine resuscitation efforts fail. Administration of oxygen should be done with high flow oxygen via nonrebreather if assessment of the external monitoring is not reassuring, but this is not demonstrated in this scenario. Fetal scalp blood testing may be done after additional data are collected and the cause of the tachycardia is determined.
*The nurse is caring for a client who has a newborn with a neurologic impairment. What is the most important nursing action at this time? 1. Assisting the client with the grieving process 2. Performing frequent neurologic assessments of the newborn 3. Arranging for social services to discuss possible placement of the newborn 4. Obtaining a prescription for an antidepressant to help the client cope with the depressing news
1. Assisting the client with the grieving process Grieving is expected and necessary whenever a newborn is born less than healthy. More information is needed to conclude that frequent neurologic assessments are warranted; the frequency of assessments depends on the severity and type of the neurologic problem. Arranging for social services to discuss possible placement of the newborn may be done later; however, it is not the priority at this time. Obtaining a prescription for an antidepressant to help the client cope with the depressing news could result in a delay in the client's ability to actively participate in dealing with feelings.
A preterm newborn is admitted to the neonatal intensive care unit (NICU). Which concern is most commonly expressed by NICU parents? 1. Fear of handling the infant 2. Delayed ability to bond with the infant 3. Prolonged hospital stay needed by the infant 4. Inability to provide breast milk for the infant
1. Fear of handling the infant Because these infants are so tiny and frail, parents most commonly fear handling or touching them; they should be encouraged to do so by the NICU staff. The primary concern is the infant's fragility, not bonding; however, bonding should be encouraged. Although there may be concerns about a long hospital stay, they are not commonly expressed by mothers. The primary concern is the infant's fragility, not breast-feeding. Breasts may be pumped and breast milk given in gavage feedings.
A nurse in the birthing suite has just admitted four clients. Which client should the nurse anticipate may require a cesarean birth? 1. Multipara with a shoulder presentation 2. Multipara with a documented station of "floating" 3. Primigravida with a fetus presenting in the occiput posterior position 4. Primigravida with a twin gestation with the lowermost twin in the vertex presentation
1. Multipara with a shoulder presentation A shoulder presentation in a multipara is indicative of a transverse lie, and this necessitates a cesarean birth. It is not uncommon for the fetus of a multipara to be high at the beginning of labor; early engagement occurs more often with a primigravida. With an occiput posterior position the labor may be longer, but usually the mother can give birth vaginally. If the first twin is in the vertex presentation, a vaginal birth will be attempted with a double setup; if possible, the birth of the second twin also will be attempted vaginally.
* The nurse is assessing the newborn of a known opioid user for signs of withdrawal. What clinical manifestations does the nurse expect to identify? Select all that apply. 1. Sneezing 2. Hyperactivity 3. High-pitched cry 4. Exaggerated Moro reflex 5. Reduced deep tendon reflexes
1. Sneezing 2. Hyperactivity 3. High-pitched cry 4. Exaggerated Moro reflex Neurologic signs of withdrawal in the neonate of an opioid-addicted mother are manifested by sneezing, hyperactivity, jitteriness, and a shrill, high-pitched cry. The Moro reflex usually becomes exaggerated as the signs of withdrawal become apparent. The deep tendon reflexes are exaggerated during opioid withdrawal.
The nurse is caring for a newborn with a caput succedaneum. What is the priority nursing action? 1. Supporting the parents 2. Recording neurologic signs 3. Applying a hard protective cap on the head 4. Applying ice packs to the hematoma
1. Supporting the parents Parents need support and reassurance that their newborn is not permanently damaged. Caput succedaneum does not cause impaired neurologic function. No special protection of the head is required; routine safety measures are adequate.
A client has delivered her infant by cesarean birth. The nurse monitors the newborn's respiration closely, because infants born via the cesarean method are prone to atelectasis. Why does this occur? 1. The ribcage is not compressed and released during birth. 2. The sudden temperature change at birth causes aspiration. 3. There is usually oxygen deprivation after a cesarean birth. 4. There is no gravity during the birth to promote drainage from the lungs.
1. The ribcage is not compressed and released during birth. The release following compression of the chest during a vaginal birth is the mechanism for expansion of the newborn's lungs; because this does not occur during a cesarean birth, lung expansion may be incomplete, and atelectasis may result. Temperature change is not implicated in aspiration. The infant is monitored closely to prevent oxygen deprivation. The newborn's head may be held lower than the chest to allow gravity to promote drainage from the lungs after a cesarean birth.
*A new mother's laboratory results indicate the presence of cocaine and alcohol. Which craniofacial characteristics indicate to the nurse that the newborn has fetal alcohol syndrome (FAS)? Select all that apply. 1. Thin upper lip 2. Wide-open eyes 3. Small upturned nose 4. Larger-than-average head 5. Smooth vertical ridge in the upper lip
1. Thin upper lip 3. Small upturned nose 5. Smooth vertical ridge in the upper lip The abnormal facial characteristics associated with FAS include: a thin upper lip (vermilion), a small upturned nose, and a smooth vertical ridge (philtrum) in the upper lip, all of which are distinctive in these infants. Infants with FAS have small eyes with epicanthic folds, rather than wide-open eyes, as well as microcephaly (head circumference less than the tenth percentile), rather than a larger-than-average head.
*An infant born in a birthing center is being transferred to a regional neonatal intensive care unit because of respiratory distress. Which nursing action best promotes parent-infant attachment? 1. Encouraging the parents to call their infant by name 2. Allowing the parents to hold their infant before departure 3. Giving the parents a picture of their infant in the intensive care unit 4. Instructing the parents to contact the neonatal intensive care unit daily
2. Allowing the parents to hold their infant before departure Because seeing and touching the newborn infant are species-specific behaviors for human attachment, allowing the parents to hold the infant will promote bonding. Although encouraging the parents to call the infant by name is a useful action, holding and touching will promote bonding more effectively. After touching and holding, having a picture of their infant in the intensive care unit contributes most to bonding. Actual holding and touching promote bonding more than just hearing about the infant's progress.
A client who is having her labor induced with oxytocin has internal fetal monitoring in place. Her contractions are occurring every 2 minutes, are lasting 70 seconds, and are reaching 65 mm Hg on an intrauterine pressure catheter. The baseline fetal heart rate is 130 to 140 beats/min with variability of about 15 beats/min. The nurse notices that with the last two contractions the fetal heart rate began to drop during the peak of the contraction to 110 beats/min, where it remained for about 40 seconds before returning to baseline. What type of pattern is this? 1. Bradycardia 2. Late decelerations 3. Early decelerations 4. Variable decelerations
2. Late decelerations Late decelerations begin during the peak of a contraction and continue after the contraction has ended. Bradycardia is a fetal heart rate slower than 110 beats/min for 10 minutes. Early decelerations mirror the contraction, beginning at the start of the contraction and ending when the contraction is over. Variable decelerations fall and rise abruptly and do not have the uniform appearance noted with early and late decelerations.
A client in labor is admitted with a suspected breech presentation. Which occurrence should the nurse be prepared for? 1. Uterine inertia 2. Prolapsed cord 3. Imminent birth 4. Precipitate labor
2. Prolapsed cord The feet or buttocks do not block the cervical opening effectively. The cord may slip through the cervix and become compressed. This is a life-threatening event for the fetus. Uterine inertia may result from fatigue or cephalopelvic disproportion; it is not related to fetal position. When a fetus is in the breech presentation the labor is usually long and difficult. Rapid dilation and precipitate labor may occur with fetuses in the cephalic position as well as the breech position.
*A client with a history of a congenital heart defect is admitted to the birthing unit in early labor. Which position does the nurse encourage the client to assume? 1. Supine 2. Semi-Fowler 3. Trendelenburg 4. Left lateral recumbent
2. Semi-Fowler The head of the bed should be elevated 45 degrees; this permits maximal chest expansion for ventilation. The laboring woman should not assume the supine position, because this would increase the risk of hypotension as a result of decreased venous return. The Trendelenburg position interferes with optimal cardiac function during labor and is contraindicated.
*The nurse is caring for a client whose fetus is in a breech presentation. The membranes rupture and meconium appears in the vaginal introitus. What does the nurse recognize this to indicate? 1. A potential for cord prolapse 2. Evidence of fetal heart abnormalities 3. A common occurrence in breech presentations 4. A condition requiring immediate notification of the primary healthcare provider
3. A common occurrence in breech presentations Sudden rupture of membranes followed by the appearance of meconium occurs in breech presentation when pressure on the fetal abdomen from the contractions forces meconium from the bowel. Cord prolapse is not an absolute; however, it may occur if the presenting part does not fill the pelvic cavity. Fetal heart abnormalities are identified by means of auscultation or continuous electronic fetal monitoring, not by the presence of meconium. Immediate notification of the primary healthcare provider is unnecessary.
A 16-year-old primigravida who appears to be at or close to term arrives at the emergency department stating that she is in labor and complaining of pain continuing between contractions. The nurse palpates the abdomen, which is firm and shows no sign of relaxation. What problem does the nurse conclude that the client is experiencing? 1. Placenta previa 2. Precipitous birth 3. Abruptio placentae 4. Breech presentation
3. Abruptio placentae Abruptio placentae indicates a premature placental separation; the classic signs are abdominal rigidity, a tetanic uterus, and dark-red bleeding. Placenta previa occurs with a low-lying placenta and is manifested by painless bright-red bleeding. Information on cervical effacement, dilation, and station is required before the nurse can come to a conclusion regarding precipitous birth. Fetal presentation is not related to the client's signs and symptoms.
A 24-year-old client is admitted at 40 weeks' gestation. The cervix is dilated 5 cm and is 100% effaced, and the presenting part is at station 0. The nurse assesses that the fetal heart tones are just above the umbilicus. Which fetal presentation does the nurse document? 1. Face 2. Brow 3. Breech 4. Shoulder
3. Breech In the breech presentation, the fetal head is in the fundal portion of the uterus; the chest or back is at or above the umbilicus, where fetal heart tones can be heard. In the vertex presentation the head is the presenting part; the chest and back are in lower quadrants, where the fetal heart is heard. The brow presentation is a type of cephalic presentation in which the fetal head is partially extended; the fetal heart is heard in the lower abdomen, not above the umbilicus. In the shoulder presentation the fetal heart usually is heard in the midabdominal region.
A 20-year-old woman is admitted to the labor and delivery unit after reporting that she is experiencing severe contractions. She is 38 weeks +2 days' gestation. External fetal monitoring has been initiated. During the assessment the nurse notes that the woman is sweating profusely, has dilated pupils and irregular respirations, is hypertensive, and continues to complain of very severe pain with contractions. The external fetal monitor shows fetal tachycardia with excessive fetal activity. What should the nurse suspect? 1. Heroin abuse 2. Marijuana use 3. Cocaine abuse 4. Alcohol withdrawal
3. Cocaine abuse These signs are seen in pregnant women who abuse cocaine. Yawning, diaphoresis, rhinorrhea, restlessness, and excessive tearing are seen in heroin abuse. Chronic redness in the eyes, drowsiness, forgetfulness, and an unusual odor on the clothing or breath are signs of marijuana use. Anxiety, nervousness, shakiness, and slow speech are seen with alcohol withdrawal. The possibility of seizure activity must also be considered.
*A neighbor who is a nurse is called on to assist with an emergency home birth. What should the nurse do to help expel the placenta? 1. Put pressure on the fundus 2. Ask the mother to bear down 3. Have the mother breast-feed the newborn 4. Place gentle continuous tension on the cord
3. Have the mother breast-feed the newborn Suckling will induce neural stimulation of the posterior pituitary gland, which in turn will release oxytocin and cause uterine contractions. Fundal pressure should not be used; it could cause uterine prolapse. Having the mother bear down could cause uterine prolapse. If the placenta is still attached to the uterine wall, placing gentle continuous tension on the cord could cause the cord to detach from the placenta or cause uterine prolapse.
*A nurse is caring for a client with class III heart disease who is beginning the second stage of labor. For which medical intervention does the nurse prepare the client at this time? 1. Elective cesarean birth to conserve energy 2. Pudendal anesthesia to prevent restlessness 3. Instrument extraction to ease a vaginal birth 4. Intravenous tocolytic medication to weaken contractions
3. Instrument extraction to ease a vaginal birth Either the use of outlet forceps or vacuum extraction for the second stage of labor helps decrease the workload of the heart during expulsion, thereby facilitating the vaginal birth. Clients with cardiac problems can give birth vaginally when precautionary measures are instituted; it is preferable to prevent the secondary stress that surgery may impose. Epidural anesthesia is preferred, because there is no pain and energy is conserved. Tocolytic agents are used to halt preterm labor. The goal is to progress with labor as quickly as possible.
A newborn is admitted to the nursery. The newborn weighs 10 lb, 2 oz (4592 g), which is 2 lb (907 g) more than the birthweight of any of the neonate's siblings. Which intervention should the nurse implement in relation to this baby's birth weight? 1. Document the findings 2. Delay starting oral feedings 3. Perform serial glucose readings 4. Place the newborn in a heated crib
3. Perform serial glucose readings A large newborn may be the result of gestational diabetes; it is necessary to check the neonate for hypoglycemia, because maternal glucose is no longer available. The nurse should do more than document the findings; the primary healthcare provider should be notified after the serial glucose readings are taken. Placing the infant in a heated crib is indicated if the temperature is low and the newborn needs additional warmth. The infant may be hypoglycemic and require the glucose in an oral feeding immediately.
A multipara whose membranes have ruptured is admitted in early labor. Assessment reveals a breech presentation, cervical dilation of 3 cm, and fetal station at -2. For what complication should the nurse assess when caring for this client? 1. Vaginal bleeding 2. Urinary tract infection 3. Prolapse of the umbilical cord 4. Meconium in the amniotic fluid
3. Prolapse of the umbilical cord A breech presentation results in a larger space between the cervix and the fetal sacrum than does a vertex presentation. When the client is a multipara, the muscle tone of the cervix may be relaxed; therefore the umbilical cord may prolapse and become compressed, leading to fetal hypoxia and potential fetal demise. Unless there are other complications, vaginal bleeding is not expected. A urinary tract infection is not related to a breech presentation. As the fetal sacrum is compressed during labor, meconium may be expelled; this is not a fetal life-threatening concern with a breech presentation.
Which finding in a newborn whose temperature over the last 4 hours has fluctuated between 98.0° F (36.7° C) and 97.4° F (36.3° C) would be considered critical? 1. Respiratory rate of 60 breaths/min 2. White blood count greater than 15,000 mm3 3. Serum calcium level of 8 mg/dL (2 mmol/L) 4. Blood glucose level of 36 mg/dL (3.8 mmol/L)
4. Blood glucose level of 36 mg/dL (3.8 mmol/L) Instability of the newborn's temperature is an indication of hypoglycemia. A glucose level below 40 mg/dL (1.7 mmol/L) does not provide enough energy to maintain the body temperature at a normal level. A serum calcium level of 8 mg/dL (2 mmol/L), respiratory rate of 60 breaths/min, and a white blood cell count greater than 15,000 mm3 are all normal findings and do not affect body temperature.
A client at 35 weeks' gestation who has had no prenatal care arrives in labor and delivery and is found to be 20% effaced and 2 cm dilated. Her membranes are intact and contractions are 3 minutes apart. The nurse notices some ruptured blisterlike vesicles in the genital area. What should the nurse's next action be? 1. Educating the client on what to expect during labor 2. Discussing pain management options available during labor 3. Discussing the possibility of using oxytocin to move labor along 4. Contacting the primary healthcare provider regarding the need for a cesarean birth
4. Contacting the primary healthcare provider regarding the need for a cesarean birth Transmission of genital herpes simplex virus (HSV-2) to the newborn can occur during vaginal delivery when active lesions are present. Blindness, brain damage, or death could result if early measures are not taken. The priority is informing the primary healthcare provider of the presence of active genital herpes lesions so preparations for a cesarean birth may be made. The nurse would not want to enhance contractions; instead the nurse will begin preparations for a cesarean birth as soon as possible.
A client exhibits oligohydramnios at 36 weeks' gestation. What newborn complication should the nurse anticipate? 1. Spina bifida 2. Imperforate anus 3. Tracheoesophageal fistula 4. Intrauterine growth restriction (IUGR)
4. Intrauterine growth restriction (IUGR) Oligohydramnios is associated with IUGR; risk factors for IUGR include inadequate maternal nutrition and other high-risk conditions such as diabetes and preeclampsia. Spina bifida does not affect amniotic fluid volume; it is associated with an increased alpha-fetoprotein level. Imperforate anus does not affect amniotic fluid volume. Tracheoesophageal fistula is often associated with polyhydramnios, which is excessive amniotic fluid.
A client who is at 38 weeks' gestation is admitted to the birthing unit because her membranes ruptured 24 hours ago and contractions have started. The fetus is in a breech presentation. The nurse observes that the amniotic fluid is green. What does the nurse conclude from these findings? 1. The fetus has a neural tube defect 2. Fetal well-being is compromised 3. Intrauterine infection has developed 4. Meconium is being expelled with contractions
4. Meconium is being expelled with contractions In a breech presentation, the pressure of the contractions on the fetus's lower abdomen causes meconium to be expelled into the amniotic fluid with each contraction. Meconium in the amniotic fluid is not a sign of a neural tube defect, regardless of presentation. Greenish amniotic fluid does not indicate a compromised fetus if there is a breech presentation. The data do not indicate signs of malodorous amniotic fluid or maternal pyrexia, each of which is indicative of infection.
*A pregnant client with severe abdominal pain and heavy bleeding is being prepared for a cesarean birth. What is the priority medical intervention? 1. Teaching coughing and deep-breathing techniques 2. Sterilizing the surgical site and administering an enema 3. Providing a sterile gown and inserting an indwelling catheter 4. Obtaining informed consent and assessing the client for drug allergies
4. Obtaining informed consent and assessing the client for drug allergies In an emergency surgical situation when invasive techniques are necessary, it is important to have a signed consent on file as well as a history of the client's known allergies. Teaching coughing and deep-breathing techniques is not a priority in an emergency such as this. In an emergency, sterilization of the surgical site is performed in the operating room; an enema usually is not given before a cesarean, especially to a client who is bleeding, because it may stimulate contractions and worsen the hemorrhage.
A client who is having a difficult labor is found to have cephalopelvic disproportion. Which prescription should the nurse question? 1. Maintain nothing by mouth (NPO) status. 2. Start a peripheral intravenous (IV) drip of 25% normal saline. 3. Record fetal heart tones every 15 minutes. 4. Piggyback another 10-unit bag of oxytocin.
4. Piggyback another 10-unit bag of oxytocin. When there is cephalopelvic disproportion, a cesarean birth is indicated; infusing oxytocin at this time could result in fetal compromise and uterine rupture. The NPO status is appropriate in anticipation of a cesarean birth. A peripheral IV is needed not only for hydration but also for venous access if IV medications become necessary. The client probably has an electronic monitor recording the fetal heart rate and uterine contractions; the findings of these assessments should be documented regularly in accordance with hospital protocol.
Based on the assessment of a full-term infant, the nurse suspects a cardiac anomaly. Which clinical manifestation does the nurse identify that indicates a cardiac anomaly? 1. Projectile vomiting 2. Irregular respiratory rhythm 3. Hyperreflexia of the extremities 4. Unequal peripheral blood pressures
4. Unequal peripheral blood pressures A discrepancy in blood pressures from the arms to the legs indicates arterial stenosis caused by coarctation of the aorta. Projectile vomiting commonly results from pyloric stenosis; it is not of cardiac origin and does not occur immediately after birth. An irregular respiratory rhythm is common and expected in the healthy newborn. Hyperreflexia of the extremities may be indicative of a neurologic, not cardiac, problem.
A neonate born at 32 weeks' gestation and weighing 3 lb (1361 g) is admitted to the neonatal intensive care unit. When should the nurse take the neonate's mother to visit the infant? 1. When the infant's condition has stabilized 2. When the infant is out of immediate danger 3. When the primary healthcare provider has provided written permission 4. When the mother is well enough to be taken to the intensive care unit
4. When the mother is well enough to be taken to the intensive care unit The mother should see her infant as soon as possible so that she may acknowledge the reality of the birth and begin bonding. A delay impedes maternal-infant bonding. A prescription is not needed, because this is an independent nursing action. The infant's condition is not a controlling factor in determining when the mother initially visits.
Five minutes after birth, a newborn is pale; has irregular, slow respirations; has a heart rate of 120 beats/min; displays minimal flexion of the extremities; and has minimal reflex responses. What is this newborn's Apgar score? Record your answer using a whole number. _____
5 The Apgar score is 5. According to the Apgar scoring system, the newborn receives 2 points for heart rate, 0 for color, 1 for respiratory effort, 1 for muscle tone, and 1 for reflex irritability. An Apgar score of 3 is low. Scores of 5 and 6 are higher, but the newborn may still require stimulation and oxygen.
*A 17-year-old client at 38 weeks' gestation is being prepared for an emergency cesarean birth because of abruptio placentae and severe fetal compromise. The client received 10 mg of nalbuphine intravenously 30 minutes ago. Because the client is too sedated to sign the consent form, what should the nurse do? 1. Call the client's mother and request a verbal consent. 2. Proceed with the preparation and forgo written consent. 3. Have the surgeon and attending primary healthcare provider sign the consent form. 4. Sign the consent form and have the nurse manager countersign the form.
3. Have the surgeon and attending primary healthcare provider sign the consent form. The data indicate a life-threatening emergency, and if the client is unable to sign an informed consent it is the legal responsibility of the surgeon and the primary healthcare provider to sign the consent form so that further injury to the client and her fetus may be prevented. There is not enough time to obtain verbal consent. It is illegal to perform the surgery without a signed consent. Legally a nurse is not allowed to countersign an informed consent unless the client has signed it first.
The nurse assessing a newborn suspects Down syndrome. Which characteristics support this conclusion? Select all that apply. 1. Hypotonia 2. High-pitched cry 3. Rocker-bottom feet 4. Epicanthal eye folds 5. Singe transverse palmar crease
1. Hypotonia 4. Epicanthal eye folds 5. Singe transverse palmar crease Hypotonia is typical of newborns with Down syndrome. Their muscle tone is flaccid; they have less control of the head than a healthy newborn does because of their weak muscles. The single crease across the palm of the hand is typical of newborns with Down syndrome. Epicanthal eye folds give the newborn with Down syndrome the typical slant-eyed appearance. A high-pitched cry is characteristic of newborns with brain damage, cerebral irritability (opioid withdrawal), and cerebral edema (hydrocephaly). Rocker-bottom feet are found in newborns with trisomy 18.
*A neonate born at 35 weeks' gestation has Apgar scores of 8 and 9. At 4 hours of age the newborn begins to experience respiratory distress, has a below-normal temperature in a warm environment, and has a low blood glucose level. What problem does the nurse suspect? 1. Hypoglycemia 2. Bacterial sepsis 3. Cocaine withdrawal 4. Meconium aspiration
2. Bacterial sepsis Preterm neonates react to infection with respiratory distress and subnormal temperatures. Although hypothermia is one sign of hypoglycemia, the newborn is not exhibiting other signs, such as tremors and lethargy. The data do not indicate that meconium was present at birth. Four hours of age is too early for signs of cocaine withdrawal to occur.
A small-for-gestational-age (SGA) newborn has just been admitted to the nursery. Nursing assessment reveals a high-pitched cry, jitteriness, and irregular respirations. With which condition are these signs associated? 1. Hypervolemia 2. Hypoglycemia 3. Hypercalcemia 4. Hypothyroidism
2. Hypoglycemia SGA infants may exhibit hypoglycemia, especially during the first 2 days of life, because of depleted glycogen stores and inhibited gluconeogenesis. These are not signs of hypervolemia. Hypervolemia is usually the result of excessive intravenous infusion. It is unlikely that a full-term SGA infant will need intravenous supplementation. Hypercalcemia is uncommon in newborns. These signs are unrelated to hypothyroidism; signs of hypothyroidism are difficult to identify in the newborn.
A newborn is admitted to the nursery and classified as small for gestational age (SGA). What is the priority nursing intervention for this infant? 1. Testing the infant's stools for occult blood 2. Monitoring the infant's blood glucose level 3. Placing the infant in the Trendelenburg position 4. Comparing the infant's head circumference and chest circumference
2. Monitoring the infant's blood glucose level SGA infants are prone to hypoglycemia, because they have little subcutaneous fat or glycogen stores. Intestinal bleeding is not common in SGA infants. Placing an SGA infant in the Trendelenburg position is of no therapeutic value. Hydrocephalus or microcephaly is not a characteristic of SGA infants.
Which medication should be administered to prevent symptoms of withdrawal in a laboring client who routinely uses heroin? 1. Butorphanol (stadol) 2. Pentazocine (Talwin) 3. Nalbuphine (Nubain) 4. Dolophine (methadone)
4. Dolophine (methadone) Methadone is a narcotic analgesic used to prevent withdrawal symptoms in pregnant women who have stopped using heroin or other opioid drugs. Butorphanol, pentazocine, and nalbuphine are all narcotic agonist-antagonists and may cause acute withdrawal symptoms in the woman and fetus.
An infant is admitted to the nursery after a difficult shoulder dystocia vaginal birth. Which condition should the nurse carefully assess this newborn for? 1. Facial paralysis 2. Cephalhematoma 3. Brachial plexus injury 4. Spinal cord syndrome
3. Brachial plexus injury Brachial plexus paralysis (Erb-Duchenne palsy) is the most common injury associated with dystocia related to a shoulder presentation; it is caused by pressure and traction on the brachial plexus during the birth process. The newborn's face is not involved with a shoulder presentation. Cephalhematoma is a soft-tissue injury of the head and is not related to shoulder dystocia. Spinal cord syndrome is associated with a breech presentation and is not related to shoulder dystocia.
When entering the room of a client in active labor to answer the call light, the nurse sees that she is ashen gray, dyspneic, and clutching her chest. What should the nurse do immediately after pressing the emergency light in the client's room? 1. Administer oxygen by facemask 2. Check for rupture of the membranes 3. Begin cardiopulmonary resuscitation (CPR) 4. Increase the rate of intravenous (IV) fluids
1. Administer oxygen by facemask The client is exhibiting signs and symptoms of an amniotic fluid embolism; increasing oxygen intake is essential. The client is experiencing an emergency situation; checking for rupture of membranes is irrelevant at this time. The client is breathing and conscious; CPR is not indicated, but it may become necessary if her condition worsens. It is not necessary to increase the IV fluid rate, although the current rate should be maintained.
A 36-year-old woman, G1 P0, is admitted to the labor and delivery unit for oxytocin induction. She is at 40 weeks' gestation. Which condition is a contraindication to the use of oxytocin induction? 1. Chorioamnionitis 2. Postterm pregnancy 3. Active genital herpes infection 4. Hypertension associated with pregnancy
3. Active genital herpes infection Oxytocin is not administered when a woman has an active genital herpes infection. In this case, the baby would be delivered by means of cesarean section to prevent it from being infected during birth. Chorioamnionitis, hypertension associated with pregnancy, and postterm pregnancy are all indications for the use of oxytocin induction.
A mother asks the neonatal nurse why her infant must be monitored so closely for hypoglycemia when her type 1 diabetes was in excellent control during the entire pregnancy. How should the nurse best respond? 1. "A newborn's glucose level drops after birth, so we're being especially cautious with your baby because of your diabetes." 2. "A newborn's pancreas produces an increased amount of insulin during the first day of birth, so we're checking to see whether hypoglycemia has occurred." 3. "Babies of mothers with diabetes do not have large stores of glucose at birth, so it's difficult for them to maintain the blood glucose level within an acceptable range." 4. "Babies of mothers with diabetes have a higher-than-average insulin level because of the excess glucose received from the mothers during pregnancy, so the glucose level may drop."
4. "Babies of mothers with diabetes have a higher-than-average insulin level because of the excess glucose received from the mothers during pregnancy, so the glucose level may drop." The infant of a diabetic mother (IDM) produces a higher level of insulin in response to the increased maternal glucose level; after birth it takes several hours for the newborn to adjust to the loss of the maternal glucose. A healthy newborn's glucose level does not drop significantly after birth. A newborn's pancreas usually produces more insulin as a response to the maternal glucose level, but this response is not specific to the IDM. IDMs have the same glucose stores as other newborns; their responses to the loss of maternal glucose levels differ.
After a client's membranes rupture spontaneously, the nurse visualizes the umbilical cord protruding from the vagina. Place the nursing interventions in order of priority. 1. Call for assistance and don sterile gloves. 2. Insert two fingers into the vagina and exert upward pressure against the fetal presenting part. 3. Put a rolled towel under one hip and place the patient in the modified Sims position. 4. Administer oxygen to the mother and monitor fetal heart tones.
This is an emergency, and additional personnel should be sought immediately. Sterile gloves should be donned before fingers are placed in the client's vagina. Exerting pressure against the presenting part relieves compression of the umbilical cord. The rolled towel and modified Sims position augment the relief of pressure against the cord. Oxygen administration increases the amount of oxygen perfusing the placenta. Fetal response to the event should be assessed with continuous monitoring of the fetal heart tone.
