VATI Maternal and Newborn

how to treat breast engorgment

For breast engorgement, apply cool compresses between feedings and apply warm compresses or take a warm shower prior to breastfeeding.

what are signs indicative of spontaneous abortion

Steady bleeding and lower abdominal pain is indicative of spontaneous abortion

_______ may be the result of dehydration and preterm labor

Trace protein

______labor is characterized by painless, irregular, and intermittent contractions that decrease in frequency, duration, and intensity with walking or position changes.

_False

Vaginal discharge of blood or fluid may indicate _________, and potentially rupture of membranes.

cervical dilation

A postpartum client is reporting heavy vaginal blood flow. The nurse correctly understands which of the following assessments has the highest priority? Select one: a. Assess episiotomy for bleeding b. Assess the client's last voiding c. Assessing vital signs both lying and sitting d. Assess the fundus for tone and position

d. Assess the fundus for tone and position

The client who is scheduled for a nonstress test (NST) asks the nurse to explain the purpose of the test. Which of the following is the correct response? Select one: a. The purpose of the NST is to determine fetal lie. b. The purpose of the NST helps to determine gestational age. c. The purpose of the NST is to determine fetal breathing. d. The purpose of the NST is to assess the fetal CNS.

d. The purpose of the NST is to assess the fetal CNS.

Beginning to think of the baby as non self and coming up with names of the baby is an expected behavior in the ______ trimester.

second

There is usually no ________ with false labor.

vaginal discharge

what are sx of magnesium sulfate toxicity

If the client is sleepy and difficult to rouse she may be experiencing symptoms of magnesium sulfate toxicity. This should be immediately reported to the provider.

_______ position with a foam wedge under one hip is appropriate for vaginal delivery, not cesarean section.

Lithotomy

_______ are a sign of magnesium toxicity but it is a late sign.

Visual disturbances

A client who is 32 weeks pregnant presents to the emergency room with bright red vaginal bleeding for the last 3 hours. The client reports feeling fetal movement since the bleeding started. Which of the following is the nurse's priority action? Select one: a. Assess maternal vital signs b. Perform a vaginal exam c. Administer a 500 mL fluid bolus d. Assess fetal heart tones

a. Assess maternal vital signs

A nurse is assessing a client in the immediate postpartum period. The fundus is boggy and deviated to the left of the umbilicus. Which of the following is the most appropriate intervention? Select one: a. Assist client to void b. Reassess client in 30 minutes c. Assess lochia d. Begin an oxytocin infusion

a. Assist client to void A displaced and boggy uterus most likely indicate a full bladder and assisting the client to void would have the highest priority.

The client asks the nurse to explain the difference between true and false labor. Which of the following is an example of true labor? Select one: a. In true labor the cervix will dilate and efface b. In true labor walking will cause contractions to slow down c. In true labor the presenting part is engaged d. In true labor contractions are felt in the abdomen above the umbilicus

a. In true labor the cervix will dilate and efface

A nurse is caring for a newborn diagnosed with a neonatal infection. Which of the following risk factors is most important to the care of this client? Select one: a. Maternal history of cytomegalovirus. b. Increased size of neonate's heart. c. Documented birth trauma. d. A decreased number of functional alveoli.

a. Maternal history of cytomegalovirus.

Thirty minutes following initiation of oxytocin infusion a client's contractions are lasting 95 seconds and coming one minute apart. Late decelerations are observed on the fetal monitor. Which of the following is the correct priority nursing intervention? Select one: a. Stop oxytocin infusion and assess contractions and fetal heart rate. b. Notify provider and prepare for an emergency cesarean birth c. Assess vital signs and apply O2 via facemask. d. Stop the oxytocin infusion and administer terbutaline 0.25 mg.

a. Stop oxytocin infusion and assess contractions and fetal heart rate.

A nurse is caring for a client who has been prescribed magnesium sulfate as tocolytic therapy. Several hours after the infusion was started, contractions ceased. Which of the following is the best analysis of this data? Select one: a. The drug is having a therapeutic effect b. The medication dose should be decreased c. Deep tendon reflexes should be assessed d. The medication dose should be increased

a. The drug is having a therapeutic effect

A client reports awaking from sleep by contractions that are occurring every five minutes and lasting 30-40 seconds. Which of the following questions should the nurse ask to assess for true labor versus false labor? Select one: a. "What happens to your contractions when you move about?" b. "Have you noticed any bloody show or fluid coming from your vagina?" c. "When did your contractions begin?" d. "Have you felt fetal movement over the last 24 hours?"

b. "Have you noticed any bloody show or fluid coming from your vagina?"

A nurse is caring for a client diagnosed with pre-eclampsia. The client is receiving Magnesium Sulfate IV. Which of the following assessment findings is the first sign of Magnesium toxicity? Select one: a. Nausea and vomiting b. Decreased deep tendon reflexes c. Visual blurring d. Respiratory depression

b. Decreased deep tendon reflexes

A nurse is caring for a neonate who exhibits abstinence syndrome and demonstrates clinical manifestations of the condition. Which assessment finding is associate with this condition? Select one: a. Increased drowiness b. Hypothermia c. Diminished tendon reflexes d. Negative Startle reflex

b. Hypothermia

A breastfeeding mother develops engorgement on her second postpartum day. Which of the following statements by the client indicates a need for further teaching? Select one: a. I will apply warm packs to each breast prior to feeding. b. I will offer my baby a bottle following each feeding. c. I will feed my baby every 2 hours. d. I will use a breast pump if my breasts do not soften.

b. I will offer my baby a bottle following each feeding.

Visualizing fetal breathing would is done during a _______

biophysical profile.

A nurse provided discharge teaching to new parents on how to care for their newborn following circumcision. Which of the following statements by the parents indicates the need for further clarification? Select one: a. "The circumcision will heal completely within a couple of weeks." b. "I should not remove the yellow exudate on the end of the penis." c. "I can give him a tub bath in two days." d. "I will clean his penis with each diaper change."

c. "I can give him a tub bath in two days."

A nurse is discussing the use of condoms with a female client. Which of the following statements by client represents a need for further teaching? Select one: a. "My partner should leave an empty space at the tip." b. "I can use spermicidal gels or creams to increase effectiveness." c. "I will remove the condom 30 minutes after intercourse." d. "My partner will put the condom on while his penis is erect."

c. "I will remove the condom 30 minutes after intercourse."

A client at 35 weeks gestation is admitted to the birthing unit with preterm labor. Which of the following assessments would require the nurse to immediately notify the provider? Select one: a. B/P 138/80mmHg, contractions every 3-4 minutes b. B/P 110/60mmHg, trace protein, contractions every 3-4 minutes c. FHR 120 b/min with late decelerations, contractions- every 1-2 minutes d. FHR 140 b/min: good variability, contractions every 3-4 minutes

c. FHR 120 b/min with late decelerations, contractions- every 1-2 minutes

A client with gestational diabetes gave birth to a 9 pound neonate 12 hours ago. The neonate is presenting with a high pitched cry and jitteriness. Which of the following is the nurse's priority intervention? Select one: a. Provide oxygen via oxyhood b. Administer subcutaneous insulin c. Offer the neonate breast milk or formula d. Place the neonate under a radiant warmer

c. Offer the neonate breast milk or formula

A nurse is positioning a client on the operating room table in preparation for a cesarean birth. Which of the following is the correct position? Select one: a. Lithotomy position with a foam wedge behind the shoulders. b. Left lateral position with a foam wedge between the legs. c. Supine position with foam wedge positioned under one hip. d. Modified Trendelenburg position with a foam wedge under the legs.

c. Supine position with foam wedge positioned under one hip.

A nurse is caring for a client who has been prescribed magnesium sulfate for pregnancy induced hypertension. On admission the client's B/P is 160/90 mm Hg and urine output is 25mL/hr. Following initiation of magnesium sulfate, which of the following symptoms should be reported to the provider? Select one: a. The client is voiding 40 mL/hr b. The client reports feeling flushed and warm c. The client is drowsy and difficult to rouse d. The client's blood pressure is 130/70 mm Hg

c. The client is drowsy and difficult to rouse

A nurse is caring for a client who is reporting lower abdominal pain. The client has a positive pregnancy test and is estimated to be 10 weeks pregnant. Which of the following best support a possible ectopic pregnancy? Select one: a. Absence of fetal heart tones and fetal movement. b. Steady bleeding with lower abdominal pain. c. Unilateral stabbing abdominal lower abdominal pain. d. Edematous face, hands, and ankles.

c. Unilateral stabbing abdominal lower abdominal pain.

A client diagnosed with pregnancy induced hypertension (PIH) has been receiving a Magnesium Sulfate infusion for three days. Serum drug levels have been between 8-10 mg/dl. Which of the following finding should the nurse expect to assess in the infant after delivery? Select one: a. Hyperactivity and irritability b. Hypothermia and bradycardia c. Tachycardia and respiratory distress d. Lethargy and respiratory depression

d. Lethargy and respiratory depression

Thirty minutes after admission to the nursery an infant appeared jittery and exhibits a weak, high pitched cry. Which of the following would be the nurse's priority action? Select one: a. Feed the infant oral feeding. b. Obtain an order for a drug screening blood test. c. Hold and comfort the infant to stop the crying. d. Perform a heel stick to check serum glucose.

d. Perform a heel stick to check serum glucose.

A nurse is performing a fundal assessment on the client's second postpartum day. Which of the following should the nurse expect if the client is experiencing normal involution? Select one: a. The fundus will be one centimeter above the umbilicus. b. The fundus will be two centimeters below the umbilicus. c. The fundus will be at the level of the umbilicus. d. The fundus will be one centimeter below the umbilicus.

d. The fundus will be one centimeter below the umbilicus.

Contractions are felt where

felt in the lower back or above the umbilicus and often stop with comfort measures (like oral hydration).

Even before assessing vital signs, the nurse should determine if the uterus is firm and midline in the abdomen. If it is not, _______ is urgently indicated,

fundal massage

Hypothermia is associated with heat loss or ____and bradycardia with _______.

infant prematurity cardiac deformities

. Pitocin should be discontinued with any of the following:

prolonged or excessively strong contractions; signs of any fetal hypoxia and or fetal distress; signs of uterine or placenta abruptio; evidence of an antidiuretic affect; and h ypertension

A decreased number of functional alveoli within the lung of newborn may lead to _____

respiratory distress or apnea

The ______phase begins immediately following birth and lasts a few hours to a couple of days. It is characterized by the mother being excited and talkative, reliving her birthing experience, and focusing on her own needs and the overall health of her newborn.

taking-in

how long should it take a circumcision to heal

two weeks

The most common cause of early post-partum bleeding is _____. Even before assessing vital signs, the nurse should determine if the uterus is firm and midline in the abdomen. If it is not, fundal massage is urgently indicated, and if it is not midline, voiding is indicated, as a full bladder will displace the uterus and contribute to uterine atony

uterine atony

If uterus it is not midline, _______ is indicated, as a full bladder will displace this

voiding