VN 3 Maternal

In a local health care facility, a newborn is admitted to the transition nursery for close observation following birth, and to provide attachment time with his parents since his mother is febrile and hypertensive. Assessments will be conducted for what period of time after admission to the nursery?

6 to 12 hours The stabilization and transition time for a newborn is 6 to 12 hours when the nurse will closely observe the newborn, monitoring its blood sugar, heart rate, respiratory status and temperature and complete a full physical exam.

The client is being rushed into the labor and delivery unit. At which station would the nurse document the fetus immediately prior to birth?

+4 As the fetus is being born, the fetus is at +4 station. The fetus is floating and not engaged in the pelvis at -5 station. The fetus is at the level of the ischial spines and engaged at 0 station. The fetus is progressing down the birth canal below the ischial spines at +1 station.

Neonatal screening is done before the infant leaves the hospital. Blood is drawn through a heel stick and tested for several disorders that can cause lifelong disabilities. When is the ideal time to collect this specimen?

24 hours after the newborn's first protein feeding The laws in most states require this initial screening, which is done within 72 hours of birth. The ideal time to collect the specimen is after the newborn is 36 hours old and 24 hours after he has his first protein feeding.

At which time is it most important to monitor for umbilical cord prolapse?

After rupture of membranes The fetus is at highest risk for umbilical cord prolapse after the rupture of membranes. It is important to assess the fetal heart rate for one full minute. The other options are not as high of a risk.

In providing culturally competent care to a laboring woman, which is a priority?

Identify how the client expresses labor pain. Pain is a part of the labor process and management of the pain impacts the labor process itself. The nurse must effectively be able to assess the client's pain level to be able to provide care. Individuals from different cultures express pain in different ways. All of the other options are important to understand but they do not directly relate to the client and birth process.

Which finding would alert the nurse to suspect that a newborn is experiencing respiratory distress?

asymmetrical chest movement Chest movements should be symmetrical. Typical newborn respirations range from 30 to 60 breaths per minute. Acrocyanosis is a common finding in newborns and does not indicate respiratory distress. Periods of apnea of less than 15 seconds are considered normal in a newborn. However, if these periods last more than 15 seconds and are accompanied by cyanosis and heart rate changes, additional evaluation is needed.

A primipara client gave birth vaginally to a healthy newborn girl 48 hours ago. The nurse palpates the client's fundus and documents which finding as normal?

two fingerbreadths below the umbilicus During the first few days after birth, the uterus typically descends downward from the level of the umbilicus at a rate of 1 cm (1 fingerbreadth) per day so that by day 2, it is about 2 fingerbreadths below the umbilicus.

A client who recently gave birth to her third child expresses a desire to have her older two children come to the hospital for a visit. What should the nurse say in response to this request?

"As long as they are well, absolutely. Why don't we give you a dose of pain medication beforehand so that you will enjoy the visit?" Separation from children is often as painful for a mother as it is for her children. A chance to visit the hospital and see the new baby and their mother reduces feelings that their mother cares more about the new baby than about them. It can help to not only relieve some of the impact of separation but also to make the baby a part of the family. Assess to be certain siblings are free of contagious diseases such as upper respiratory tract illnesses or recent exposure to chickenpox before they visit. Then, have them wash their hands and, if they choose, hold or touch the newborn with parental assistance. Allowing the siblings to walk with the baby out in the hall unsupervised would be unsafe.

Which statement made by the client in the early phase of labor requires clarification?

"I have been at 3 cm for hours and I am making no progress." It is important for the mother to understand that even though she is not dilating, other important parts of labor such as effacement are occurring. Women vary in length of time during each stage and phase of the labor process. Nurses and clients hope that all labors are better than the previous. Typically the labors are shorter but that is not guaranteed. In early labor, the contractions are manageable and walking is appropriate

A client is scheduled for a cesarean section under spinal anesthesia. After instruction is given by the anesthesiologist, the nurse determines the client has understood the instructions when the client states:

"I may end up with a severe headache from the spinal anesthesia." Cerebrospinal fluid (CSF) leakage from the needle insertion site and irritation caused by a small amount of air that enters at the injection site and shifts the pressure of the CSF causes strain on the cerebral meninges, initiating pain from a postdural puncture (spinal) headache.

The nurse provides discharge instructions to a postpartum patient. Which patient statement indicates that teaching has been effective?

"I should plan to return to my full-time job after 6 weeks." It is usually advised that a woman not return to an outside job for at least 3 to 6 weeks, not only for her own health but also for enjoyment of the early weeks with the newborn. Stair climbing should be limited to one flight/day for the first week at home. Coitus is safe as soon as the patient's lochia has turned to alba and, if present, an episiotomy is healed. The patient should notify the primary care provider if there is an increase, not a decrease, in lochial discharge.

When collecting data to devise a labor plan for a multiparous woman, which question best allows the nurse to develop individualized strategies?

"Tell me how you handled labor pain in your past deliveries." When the nurse is collecting data, it is best to discuss previous experiences with labor pain. Other questions may include, "What was helpful?" or "What did you not like?" While it is true that every labor is different, understanding the client's perspective from past experiences is valuable in developing individualized strategies. Developing a plan is best as a collaborative effort, not by picking pre-prepared options. It is important to include a support person if desired.

The nurse is assessing a male neonate in the presence of the parents and notes that the neonate has hypospadias. How should the nurse respond when questioned by the parents as to what this means?

"The opening of his urethra in located on the under surface of the tip of the penis." The term "hypospadias" refers to the urinary meatus (external opening of the urethra) being abnormally located on the ventral (under) surface of the glans (the rounded head or tip of the penis). There are no special terms to indicate normal genitalia. Cryptorchidism refers to undescended testes. Hydrocele refers to the collection of fluid in the scrotal sac.

A nurse is performing an assessment on a client in early labor who is discouraged about the seemingly slow progress of her labor. Which response should the nurse prioritize for this client after noting the effacement is progressing even though the cervix is still only 2 cm for the past 2 hours?

"You are still 2 cm dilated, but the cervix is thinning out nicely." Women are anxious to have frequent reports during labor, to reassure them everything is progressing well. If giving a progress report, remember most women are aware of the word dilation (dilatation) but not effacement. Just saying, "no further dilation", therefore, is a depressing report. "You're not dilated a lot more, but a lot of thinning is happening and that's just as important" is the same report given in a positive manner.

A client in her third trimester comes to the clinic for an evaluation. Assessment reveals that the cervix is thinning. The client says, "I know my cervix needs to dilate, but why does it get thinner?" Which response by the nurse would be appropriate?

"You need the cervix to thin so it can stretch more easily." The rigid cervix of pregnancy must become distensible to expel the fetus. Before labor begins, cervical softening and possible cervical dilation with descent of the presenting part into the pelvis occur. These changes can occur 1 month to 1 hour before actual labor begins. As labor approaches, the cervix changes from an elongated structure to a shortened, thinned segment. Cervical collagen fibers undergo enzymatic rearrangement into smaller, more flexible fibers that facilitate water absorption, leading to a softer, more stretchable cervix. These changes occur secondary to the effects of prostaglandins and pressure from Braxton Hicks contractions. Cervical thinning has no effect on contractions or fetal positioning. It is not a sign of true labor.

The nurse is instructing a patient who is in the third trimester of pregnancy on the difference between false and true labor contractions. What should the nurse emphasize as being characteristics of false labor contraction? Select all that apply.

-False labor contractions are irregular. -False labor contractions do not increase in duration, frequency, and intensity. False labor contractions are irregular. True labor contractions increase in duration, frequency, and intensity. False labor contractions disappear when asleep and occur in the abdomen and groin. True labor contractions lead to cervical dilation.

A newborn is born and, at 1 minute of life, is acrocyanotic, HR is 110, is floppy with some flexion, has a weak cry and grimaces. What Apgar score would the nurse assign this infant?

6 According to the Apgar criteria, acrocyanosis is scored as 1, HR over 100 is scored as 2, grimace is scored as 1, some flexion is scored as 1, and a weak cry is scored as 1. This totals 6 for the 1-minute Apgar score.

The nurse tests the pH of fluid found on the vaginal exam and determines that the woman's membranes have ruptured based on which result?

6.5 Amniotic fluid is alkaline, so the membranes are probably ruptured if the pH ranges from 6.5 to 7.5.

The nurse is caring for a client who is at 37 weeks' gestation and has a biophysical profile of 10. Which nursing action is best?

A biophysical profile of 10 is a good score indicating fetal well-being. The nurse would schedule this client for her weekly health care provider appointment. There is no need to immediately notify the health care provider, have the client report to the hospital nor prepare the records for a cesarean birth indicating the fetus needs to be born.

A Chinese mother delivers her newborn and is ready to go home. The grandmother is present and will remain with the mother for 1 month. The grandmother tells the nurse that the mother will not be allowed to leave the house for the first month after delivery. How should the nurse respond to this statement?

Accept the grandmother's statement and do discharge teaching accordingly. In many cultures, new mothers are not allowed to leave the home for at least 1 month to allow her opportunity to rest and keep her healthy. In the Chinese, Middle Eastern and Indian cultures, this is common practice. The nurse should not try to talk the grandmother out of her beliefs on caring for both her daughter and the newborn. Asking the grandmother why she is doing this is challenging and unprofessional.

A client has opted to receive epidural anesthesia during labor. Which of the following interventions should the nurse implement to reduce the risk of a significant complication associated with this type of pain management?

Administration of 500 mL of IV Ringer's lactate The chief concern with epidural anesthesia is its tendency to cause hypotension because of its blocking effect on the sympathetic nerve fibers in the epidural space. This risk can be reduced by being certain a woman is well hydrated with 500 to 1000 mL of IV fluid, such as Ringer's lactate, before the anesthetic is administered. Ringer's lactate is preferable to a glucose solution, because too much maternal glucose can cause hyperglycemia with rebound hypoglycemia in the newborn. Be certain a woman does not lie supine but remains on her side after an epidural block, to help prevent supine hypotension syndrome. Be sure to caution women not to take acetylsalicylic acid (aspirin) for pain in labor as aspirin interferes with blood coagulation, increasing the risk for bleeding in the newborn or herself.

A client has just received combined spinal epidural. Which nursing assessment should be performed first?

Assess vital signs. The most common side effect of spinal and epidural anesthesia is hypotension, which can lead to fetal bradycardia, decelerations, or fetal distress. Although each is important, assessment of vital signs should be performed first.

An infant born at 35 weeks' gestation is being screened for hypoglycemia. During the first 24 hours of life, when will the nurse screen this infant?

Before feedings To screen for hypoglycemia, a glucose level is obtained prior to the first feeding and then prior to feedings for 24 to 48 hours. Infants are screened even in the absence of symptoms; this is done before feeding to obtain a preprandial measure.

A newborn's vital signs are documented by the nurse and are as follows: HR 144, RR- 36, BP- 128/78, and T- 98.6℉ (37℃). Which finding would be concerning to the nurse?

Blood Pressure The blood pressure of a newborn should be quite low—around 60-70 over 35 to 50. The heart rate and respiratory rate are both high, which are normal findings. The temperature falls within a normal range of 97.7℉ to 99.5℉ (36.5℃ to 37.5℃).

When performing an assessment on a neonate, which assessment finding is suggestive of hypothermia?

Bradycardia Bradycardia is an indicator that the neonate is hypothermic. A cold infant may develop acidosis as a result of metabolism of brown fat. Newborns do not shiver when cold. Hyperglycemia and metabolic alkalosis are not signs or consequences of hypothermia.

A nurse is called into the room of one of the clients where the grandparents are visiting. The grandmother is visibly upset, and says "Just look at my grandson! His head is all soft and swollen here and it shouldn't be. The doctor injured him when he was born." The nurse assesses the newborn and finds an area of swelling about the size of a half-dollar at the center of the upper scalp. The nurse determines this finding is most likely which condition?

Caput succedaneum Caput succedaneum is swelling of the soft tissue of the scalp caused by pressure of the presenting part on a partially dilated cervix or trauma from a vacuum-assisted delivery. This finding is often of concern for the families. Reassure them that the caput will decrease in a few days without treatment. Increased intracranial pressure would involve the entire scalp and not just a small portion. There would also be other neurologic signs accompanying it. Molding is an elongated head shape caused by overlapping of the cranial bones as the fetus moves through the birth canal. This will also resolve in a few days without treatment. The Harlequin sign is characterized by a clown-suit-like appearance of the newborn where the skin is dark red on one side of the body and the other side is pale. This is a harmless condition which occurs most frequently with vigorous crying or with the infant lying on his or her side.

Which cardinal movement of delivery is the nurse correct to document by station?

Descent is documented by station, which is the relationship of the fetal presenting part to the maternal ischial spines. Descent continues throughout labor until the fetus reaches the fetal station of +4. The other options represent fetal movements to accommodate the passage of the fetus.

The nurse is caring for a client who is experiencing a noneventful labor process. Which assessment findings may occur as the client progresses through the stages of labor? Select all that apply.

Dry mucous membranes Nausea Increased white blood cell count Increased urine specific gravity Hyperventilation The nurse is correct to identify that normal changes occur during the labor process. Due to mouth breathing and drinking limited fluids, if any, dehydration with dry mucous membranes and an elevated urine specific gravity are common. Since labor prolongs gastric emptying, the client may experience nausea. An increase in the white blood cell stemming from the immune response is common. Concentrated urine and decreased urine production are common, not diuresis.

A multigravida client is still focusing on her difficult labor and discusses it with the nurse at each opportunity, several hours after the birth. Which action should the nurse prioritize after noting the client's partner is spending more time with the infant than the client?

Encourage her to discuss her experience of the birth and answer any questions or concerns she may have. The client needs to explore her birth experience and clarify her questions. The nurse should allow her to ask questions, be supportive, and encourage her to express her feelings. Redirecting her attention to the baby, asking her to describe how she plans to integrate the new baby into the family, or pointing out positive features of the new baby do not meet the needs of the client at this time.

Which nursing intervention best aligns with the priority NANDA nursing diagnosis: Readiness for Enhanced Knowledge?

Encourage prenatal class attendance. A client who is prepared for the labor process by attending prenatal classes better can cope with the stress of labor. Identifying the priority nursing diagnosis of Readiness for Enhanced Knowledge suggests that the client and possibly support person are ready to learn about childbirth. Both the client and support person need instruction on relaxation techniques. A thorough obstetric history provides an understanding of the client's past for the nurse. Providing verbal cues is not as effective as attending prenatal classes.

In which manner is the fetal status best assessed during the active and transition stages of labor?

Fetal heart rate at the peak of a contraction Normal labor stresses the fetus by increasing intracranial pressure, decreasing heart rate and placental blood flow. Assessing the fetal heart rate during the peak of the contraction best indicates how the fetus is tolerating the labor. Fetal movement and fetal kicks can indicate that a fetus is compromised but that is a late sign of distress.

The nurse is caring for a newborn whose mother tested positive for hepatitis B surface antigen (HBsAg). Which intervention(s) will the nurse perform? Select all that apply.

Give Hepatitis B immune globulin. Obtain consent from the mother. Administer Hepatitis B vaccination. Bathe the newborn thoroughly. When a mother has a positive test for hepatitis B surface antigen (HBsAg), the newborn is given the hepatitis B vaccine and hepatitis B immune globulin. Consent must be obtained before administering vaccinations. The newborn should be bathed to remove traces of blood and attempt to limit transmission. Standard precaution should be followed.

Which is the most important nursing assessment of the mother during the fourth stage of labor?

Hemorrhage During the fourth stage of labor, there is a period of recovery for the mother after delivery of the placenta. During this time, the nurse's assessment focuses heavily on watching for signs of hemorrhage. Hemorrhage may occur from such things as lacerations or retained placenta fragments. The mother's psyche is a concern during the labor process. At the conclusion of the birth process, the mother's psyche is typically positive. Blood pressure and heart rate as also monitored and can be an indicator of hemorrhage.

A G2 P1 client, at 37 weeks' gestation, arrives to the unit and announces, "I am pretty sure my water broke about half an hour ago." What action should the LPN prioritize for this client while checking her in?

Inform the RN that your client may have ruptured membranes It is beyond the scope of the LPN to assess if the client's membranes have ruptured and this should be reported immediately to the RN who will then conduct the pelvic exam. The LPN may assist with this examination which could include the fern test. Deep palpations and checking the EFM would not be diagnostic for determining the condition of the membranes.

The nurse is assessing a client in labor for pain and notes she is currently not doing well handling the increased pain. Which opioid can the nurse offer to the client to assist with pain control?

Meperidine is an opioid that is commonly used during labor and birth. Secobarbital and thiopental are barbiturates. Hydroxyzine hydrochloride is a tranquilizer which can be used to supplement the narcotic or reduce anxiety.

a nurse in a clinic is reinforcing instructions with a client of childbearing age about recommended folic acid supplements. which of the following defects can occur in the neonate as a result of folic acid deficiency?

Neural Tube Caused by folic acid deficiency. food sources of folic acid include fresh green leafy vegetables, liver, peanuts, cereals, & whole grain breads.

prenatal diet

Normal BMI 25-35lb 3.5-5lb 1lb/ wk BMI <19 (UW) 28-40lb 5lb 1+lb/wk BMI >19 (OW) 15-25lb 2lb 2-3lb/wk

A nurse is providing discharge instructions to a postpartum client. Which symptom is a possible complication that the nurse should educate the client about?

Notify the health care provider of increased lochia and bright red bleeding. Once the lochia has changed to pink, a change back to bright red may indicate a problem or complication. Palpating the funds to make it soft is not appropriate. The other occurrences are normal and would not need to be reported to the health care provider.

Under which circumstances should gloves be worn in the newborn nursery? Select all that apply.

Providing the first bath Changing a diaper Performing a heel stick Accucheck Universal precautions, such as wearing gloves, is necessary whenever the nurse is likely to come in contact with bodily fluids, such as when changing a diaper, performing the initial bath after birth, and drawing blood for testing. Gloves are not needed with formula feedings or when transporting the newborn in its crib to the mother's room.

A pregnant woman comes to the emergency department stating she thinks she is in labor. Which assessment finding concerning the pain will the nurse interpret as confirmation that this client is in true labor?

Radiates from the back to the front Contractions that begin in the back and then radiate to the front are typical of true labor. Contractions that slow when a woman walks or changes position suggest false labor, as do irregular contractions. Contractions lasting 30 seconds or less commonly suggest Braxton Hicks contractions and are associated with false labor.

Which physical characteristic of the neonate is typically present in the neonate of a primigravid mother?

Significant head molding Since this is the mother's first birth, the birth canal has never been stretched. The labor process may take longer and may be tighter leading to significant molding as the fetal body, particularly the head, molds to the mother's birth canal. Thick vernix and absence of testicular rugae are a characteristics of prematurity. Genetic conditions such as trisomy 13 have characteristics of a single palmar crease as one of the signs of the potential disorder.

A postpartum patient is reluctant to begin taking warm sitz baths. What should the nurse emphasize when teaching the patient about this treatment approach?

Sitz baths increase the blood supply to the perineal area. Moist heat with a sitz bath is an effective way to increase circulation to the perineum, provide comfort, reduce edema, and promote healing. Sitz baths do not cause postpartal infections. Sitz baths do not cause perineal vasoconstriction and decreased bleeding. Every use of a sitz bath is therapeutic.

What assessment finding would suggest to the care team that the pregnant client has completed the first stage of labor?

The client's cervix is fully dilated. The first stage of labor ends with the client's cervix being fully dilated at 10 cm. The onset of contractions signals the beginning of the first stage and birth occurs at the end of the second stage.

The nurse is looking at the latest lab work for her postpartum client. The client's predelivery hemoglobin and hematocrit (H & H) was 12.8 and 39, respectively. This morning, the client's values are 8.9 and 30. How would the nurse interpret these lab values?

The health care provider needs to be notified of the latest lab values. If there is a significant drop in a postpartum mother's H & H, the health care provider needs to be notified because the client may have experienced a postpartum hemorrhage that went unreported or undetected. The health care provider will decide what measures to take.

The nurse is looking over a newborn's plan of care regarding expected outcomes. Which outcome would not be appropriate according to a newborn's nursing care?

The newborn will experience no bleeding episodes lasting more than 5 minutes. Bleeding episodes should not be occurring at all, and any episodes should be reported to the physician immediately if not responsive to immediate action to stop it. All other outcomes are pertinent to the newborn's care.

Which nurse is practicing in a manner to reduce or eliminate pain in a newborn?

The nurse who suggests to the primary care provider to change ordered IM antibiotics to IV. In order to reduce pain in a newborn, the nurse must think about where painful stimuli comes from and try to eliminate it. The nurse who suggests changing the medication route from IM to IV is the one who is demonstrating how to reduce pain in newborns. Sucrose nipples are used for soothing of newborns, not plain water. Changing the time of day for the procedures does not change the amount of pain, nor does doing it before or after feedings.

The nurse is assisting a client in labor and delivery and notes the placenta is now delivered. What will the nurse document?

The third stage of labor ends with the expulsion of the placenta. Transition precedes the second stage and recovery follows later. The fourth stage begins with completion of the expulsion of the placenta and membranes and ends with the initial physiologic adjustment and stabilization of the mother (1 to 4 hours after birth). Within this fourth stage, the attachment process begins with the mother inspecting the newborn and desiring to cuddle and breastfeed the newborn.

In recording a postpartum mother's urinary output, the nurse notes that she is voiding between 150 and 200 mL with each hourly void. How would the nurse interpret this finding?

The urinary output is normal. Expected urinary output for a postpartum woman is at least 150 mL with each void on an hourly basis. Therefore 150 to 200 mL is a normal volume for each void.

A pregnant woman comes to the clinic for a prenatal visit for her third pregnancy. She reveals she had a previous miscarriage at 12 weeks and her 3-year-old son was born at 32 weeks. How should the nurse document this woman's obstetric history?

The woman's obstetric history would be documented as G3, T0, P1, A1, L1. G (gravida) = 3 (past and current pregnancy), T (term pregnancies) = 0, P (number of preterm pregnancies) = 1, A (number of pregnancies ending before 20 weeks viability to include miscarriage) = 1, and L (number of living children) = 1.

Which method does the nurse use to determine fetal presentation, position and attitude?

Utilize Leopold maneuvers Leopold maneuvers are a noninvasive method of assessing fetal presentation, position and attitude by placing hands on the maternal abdomen and locating fetal body parts. Ultrasounds are not done by nurses and not typically done at this stage of pregnancy. Assessing fetal kicks and a vaginal examination are not accurate.

A primipara client gave birth vaginally to a healthy newborn girl 12 hours ago. The nurse palpates the client's fundus. Which finding would the nurse identify as expected?

at the level of the umbilicus During the first 12 hours postpartum, the fundus of the uterus is located at the level of the umbilicus. Over the first few days after birth, the uterus typically descends from the level of the umbilicus at a rate of 1 cm (one fingerbreadth) per day. By 3 days, the fundus lies two to three fingerbreadths below the umbilicus (or slightly higher in multiparous women). By the end of 10 days, the fundus usually cannot be palpated because it has descended into the true pelvis.

The nurse determines that the fetal heart rate averages approximately 140 beats per minute over a 10-minute period. The nurse identifies this as:

baseline FHR. The baseline FHR averages 110 to 160 beats per minute over a 10-minute period. Fetal bradycardia occurs when the FHR is less than 110 beats per minute for 10 minutes or longer. Short-term variability is the beat-to-beat change in FHR. Baseline variability refers to the normal physiologic variations in the time intervals that elapse between each fetal heartbeat observed along the baseline in the absence of contractions, decelerations, and accelerations.

A nurse working with a woman in preterm labor receives a telephone report for the fetal fibronectin test done 10 hours ago. The report indicates an absence of the protein, which the nurse knows indicates:

birth is unlikely within the 2 next weeks. Fetal fibronectin is a protein that helps the placenta and fetal membranes adhere to the uterus during pregnancy. A negative result (absence of fetal fibronectin) is a reliable indicator that birth is unlikely within 2 weeks following the test. It does not diagnose infection.

A nurse is providing care to a pregnant woman in labor. The woman is in the first stage of labor. When describing this stage to the client, which event would the nurse identify as the major change occurring during this stage?

cervical dilation (dilatation) The primary change occurring during the first stage of labor is progressive cervical dilation (dilatation). Contractions occur during the first and second stages of labor. Fetal movement through the birth canal is the major change during the second stage of labor. Placental separation occurs during the third stage of labor.

The student nurse is learning about normal labor. The teacher reviews the cardinal movements of labor and determines the instruction has been effective when the student correctly states the order of the cardinal movements as follows:

descent, flexion, internal rotation, extension, external rotation, expulsion The six cardinal movements of the fetus, in order, are descent, flexion, internal rotation, extension, external rotation, and expulsion.

A woman is lightly stroking her abdomen in rhythm with her breathing during contractions. The nurse identifies this technique as:

effleurage. Effleurage is a light, stroking, superficial touch of the abdomen in rhythm with breathing during contractions. Acupressure involves the application of a finger or massage at a trigger point to reduce the pain sensation. Patterned breathing involves controlled breathing techniques to reduce pain through a stimulus-response conditioning. Therapeutic touch involves light or firm touch to the energy field of the body using the hands to redirect the energy fields that lead to pain.

The nurse is assisting a primary care provider to attempt to manipulate the position of the fetus in utero from a breech to cephalic position. What does the nurse inform the client the procedure is called?

external cephalic version External cephalic version is the process of manipulating the position of the fetus in order to try to turn the fetus to a cephalic presentation.

A nurse is teaching new parents how to bathe their newborn once they bring the baby home. Place the body areas listed below in the order that the parents clean the newborn's body. Use all options.

eyes face hair extremities diaper area The parents should wash the newborn, progressing from the cleanest to the dirtiest areas: eyes, rest of face, hair, extremities, trunk, and back. The diaper area is washed last.

A client in active labor is given spinal anesthesia. Which information would the nurse include when discussing with the client and family about the disadvantages of spinal anesthesia?

headache following anesthesia The nurse should inform the client and her family about the possibility of headache after spinal anesthesia. The drug is retained in the mother's body and not passed to the fetus. There may be uterine atony, and not excessive uterine contractions, following spinal anesthesia. Spinal anesthesia may lead to bladder atony, and not an increased frequency of micturition.

The nurse is assessing a postpartum woman and is concerned the client may be hemorrhaging. Which assessment finding is the nurse finding most concerning?

increased heart rate Tachycardia in the postpartum woman warrants further investigation as it can indicate postpartum hemorrhage. Typically the postpartum woman is bradycardic for the first 2 weeks. In most instances of postpartum hemorrhage, blood pressure and cardiac output remain increased because of a compensatory increase in heart rate. Hypotension would be another concerning assessment, especially orthostatic hypotension, as it can also indicate hemorrhage. Red blood cell production ceases early in the postpartum period, causing hemoglobin and hematocrit levels to decrease slightly in the first 24 hours and then rise slowly. Hematocrit would be unreliable as an indicator of hemorrhage.

A patient is admitted to the labor and delivery unit. Upon examination, she is found to be dilated 3 cm. The nurse notes that the woman is having contractions that last about 45 seconds and are about 5 minutes apart. Based on this information, in which phase of labor is this patient?

latent phase Contractions during the latent phase of labor are typically 5 to 10 minutes apart and last 30 to 45 seconds. The cervix is dilated 1 to 3 cm, and effacement begins.

The nurse is preparing a teaching plan for new parents about why newborns experience heat loss. Which information about newborns would the nurse include?

limited voluntary muscle activity Newborns have limited voluntary muscle activity or movement to produce heat. They have thin skin with blood vessels close to the surface. They cannot shiver to generate heat. They have limited stores of metabolic substances such as glucose and glycogen.

The nurse is making a home visit to a woman who is 5 days' postpartum. Which finding would concern the nurse and warrant further investigation?

lochia rubra Lochia serosa is normal from days 3 to 10 postpartum. However, lochia rubra is present for about the first 3 days and is considered abnormal on the 5th postpartum day. By the fifth postpartum day, the uterus should be approximately 5 cm below the umbilicus. After birth the vagina is edematous and thin with few rugae. It eventually thickens and rugae return in approximately 3 weeks. Diaphoresis is common during the early postpartum period, especially in the first week. It is a mechanism to reduce fluids retained during pregnancy and restore prepregnant body fluid levels.

A urinalysis is done on a postpartum mother 24 hours after delivery. Which findings would be considered normal for this client? Select all that apply.

moderate glycosuria mild ketonuria Occasional RBCs trace WBC Urine in a client in the early postpartum period may display ketonuria secondary to dehydration or prolonged labor, glycosuria from the inability of the kidneys to filter properly immediately following delivery, and RBC's from lochia contamination. Gross proteinuria is an abnormal finding for a urinalysis of this client.

A woman calls the health care facility stating that she is in labor. The nurse would urge the client to come to the facility if the client reports which symptom?

moderately strong contractions every 4 minutes, lasting about 1 minute Moderately strong regular contractions 60 seconds in duration indicate that the client is probably in the active phase of the first stage of labor. Alternating strong and weak contractions, contractions in the front of the abdomen that change with activity, and pink-tinged secretions with irregular contractions suggest false labor.

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 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 monitoring a female client with an epidural block. Which complication would be the most important for the nurse to monitor in the client?

respiratory depression Respiratory depression is a complication of epidural anesthesia and should be closely monitored in laboring clients. A failed block, accidental intrathecal block, and a postdural puncture (spinal) headache are all side effects of a spinal epidural block.

The nurse is caring for a client who has an irregular pattern of uterine contraction. As a result, the nurse anticipates a problem with which?

the powers One of the four "P's" is the power of the uterine contractions. This power begins with regular contractions which become closer together and increase in intensity. The powers push the fetus down the birth canal.

When assessing the newborn's umbilical cord, what should the nurse expect to find?

two smaller arteries and one larger vein When inspecting the vessels in the umbilical cord, the nurse should expect to encounter one larger vein and two smaller arteries. In 0.5% of births (3.5% of twin births), there is only one umbilical artery, which can be linked to cardiac or chromosomal abnormalities.

The nurse is making a home visit to a woman who is 4 days postpartum. Which finding would indicate to the nurse that the woman is experiencing a problem?

uterus 1 cm below umbilicus By the fourth postpartum day, the uterus should be approximately 4 cm below the umbilicus. Being only at 1 cm indicates that the uterus is not contracting as it should. Lochia serosa is normal from days 3 to 10 postpartum. After birth the vagina is edematous and thin with few rugae. It eventually thickens and rugae return in approximately 3 weeks. Diaphoresis is common during the early postpartum period, especially in the first week. It is a mechanism to reduce fluids retained during pregnancy and restore prepregnant body fluid levels.

A woman comes to the clinic for her first postpartum visit. She gave birth to a healthy term neonate 2 weeks ago. As part of this visit, the woman has a complete blood count drawn. Which result would the nurse identify as a potential problem?

white blood cell count 14,000/mm3 (14 ×109/L) The white blood cell count, which increases in labor, remains elevated for the first 4 to 6 days after birth but then falls to 6,000 to 10,000/mm3 (6 to 10 ×109/L). An elevated white blood cell count would be suspicious for infection. The hemoglobin, hematocrit and platelet levels are within normal parameters for this woman.

While visiting a client at home on the 10th day postpartum, the nurse assesses the client's lochia. Which color would the nurse expect the lochia to be?

yellowish white The normal color of lochia on the tenth day of postpartum is yellowish white. The color of lochia changes from red to pink by approximately four or five days postpartum. The color of lochia is never yellowish pink.

a nurse is assisting the charge nurse with reviewing postpartum nutrition needs with a group of new mothers who are breastfeeding their newborns. Which of the following statements by a member of the group indicates an understanding of the teaching?

"I will continue my calcium supplements because I do not like milk" PP women who are at risk for inadequate dietary calcium should continue taking calcium should continue taking calcium supplements during lactation

The nurse discharging a newly delivered mother and her newborn infant needs to assess the mother's knowledge about how to take care of herself and her baby. This is her second child. Which approach would be best to verify the client's understanding of these topics?

Ask her questions and observe her caring for the baby. The best way to determine if a mother understands the information given to her regarding caring for herself and her baby is to ask her and watch her as she cares for the newborn in the hospital.

At which point along the birth canal must the fetal head extend for successful passage?

At the level of the symphysis pubis Fetal extension occurs late in the labor process as the fetus extends through the final portion of the passageway. The fetal head must extend at the symphysis pubis for successful passage. The next step is the head being born. The pelvic inlet, iliac crest and ischial spines are high in the birth canal.

At which time in a client's labor process would the nurse encourage effleurage?

During the early labor phase Effleurage, a form of touch therapy, is a technique that the client uses in early labor. Light touch stimulates the nerve pathways to the brain and keeps them busy, thereby blocking pain sensation. This technique does not determine true labor, is not helpful in the active stage of labor (as contractions are more intense), nor is it done when the client is ready to give birth.

GTPAL

Gravida, Term, Preterm, Abortions, Living

The nurse writes the above notes upon client admission. Based on this assessment the nurse anticipates which plan of care?

Prepare for an emergency cesarean birth. The client has a class 3 placental abruption (abruptio placentae). There are signs of fetal distress; maternal tachycardia and hypotension; low hematocrit and hemoglobin; and borderline platelet count. To save the baby and mother, the baby needs to be born immediately via cesarean birth.

A woman experiences an amniotic fluid embolism as the placenta is delivered. The nurse's first action would be to:

administer oxygen by mask. An amniotic embolism quickly becomes a pulmonary embolism. The woman needs oxygen to compensate for the sudden blockage of blood flow through her lungs.

A nurse is caring for a client on the second day postpartum. The client informs the nurse that she is voiding a large volume of urine frequently. Which factor should the nurse identify as a potential cause for urinary frequency?

postpartum diuresis The nurse should identify postpartum diuresis as the potential cause for urinary frequency. Urinary overflow occurs if the bladder is not completely emptied. Urinary tract infection may be accompanied by fever and a burning sensation. Trauma to pelvic muscles does not affect urinary frequency.

What is a nursing intervention that helps prevent the most frequent side effect from epidural anesthesia in a pregnant client?

starting an IV and hanging IV fluids Prehydration with IV fluids helps to prevent the most common side effect of epidural anesthesia, which is hypotension (20%). If the client develops hypotension or respiratory depression, then IV ephedrine or IV naloxone, respectively, can be administered, but neither is preventive. Maintaining the client in a supine position is recommended for a spinal headache, which can be a side effect of epidural anesthesia but is not the most common side effect and is not preventive.

A nurse teaches new parents how to soothe a crying newborn. Which statement, by the parents, indicates to the nurse the teaching was effective?

"We will turn the mobile on that's hanging on our baby's crib." Turning on a mobile above the newborn's head is helpful in calming the newborn. The movement is distracting, and the music is comforting. The newborn's back should be rubbed lightly while the parents speak softly or play calming music or white noise. Swaddling the newborn rather placing on a blanket on the floor provides security and comfort. Feeding or burping can be helpful in relieving air or stomach gas.

During a nonstress test, when monitoring the fetal heart rate, the nurse notes that when the expectant mother reports fetal movement, the heart rate increases 15 beats or more above the baseline. This occurs about 4 or 5 times during the testing period. The nurse interprets this as:

A reactive NST includes at least two fetal heart rate accelerations from the baseline of at least 15 bpm for at least 15 seconds within the 20-minute recording period. If the test does not meet these criteria after 40 minutes, it is considered nonreactive. A nonreactive NST is characterized by the absence of two fetal heart rate accelerations using the 15-by-15 criterion in a 20-minute time frame. An increase in the fetal heart rate does not indicate variable decelerations. Fetal tachycardia would be noted as a heart rate greater than 160 bpm.

A 32-year-old woman presents to the labor and birth suite in active labor. She is multigravida, relaxed, and talking with her husband. When examined by the nurse, the fetus is found to be in a cephalic presentation. His occiput is facing toward the front and slightly to the right of the mother's pelvis, and he is exhibiting a flexed attitude. How does the nurse document the position of the fetus?

ROA The nurse should document the fetal position in the clinical record using abbreviations. The first letter describes the side of the maternal pelvis toward which the presenting part is facing ("R" for right and "L" for left). The second letter indicates the reference point ("O" for occiput, "Fr" for frontum, etc.). The last part of the designation specifies whether the presenting part is facing the anterior (A) or the posterior (P) portion of the pelvis, or whether it is in a transverse (T) position.

When planning a labor experience for a primigravid, understanding which characteristic of labor pain is most helpful?

The characteristics of labor pain follow a pattern. While pain is individualized, labor pain is defined and follows a pattern. Since it follows a typical path, education and planning is completed. All pain is not the same. A primigravid needs education and guidance to best navigate the process. A cesarean section is not an option as a method of pain management.