RATIONALES: Puerperium is defined as the 6 weeks postpartum. The other options are incorrect.

RATIONALES: Warm, moist compresses will reduce inflammation and edema of the infected breast tissue. The woman with mastitis should wear a proper fitting bra with good support. Breast-feeding may resume once the infection is treated. The client will need to pump the breast in the meantime to keep the breast empty of milk and to ensure an adequate milk supply. Antibiotics must be taken for the full course of therapy and not stopped when symptoms subside.

RATIONALES: These actions, which will improve fetal hypoxia, increase the amount of maternal circulating oxygen by taking pressure created by the uterus off the aorta and improving blood flow. These actions won't improve the contraction pattern, free a trapped cord, or improve maternal comfort.

RATIONALES: The primary cause of neonatal jaundice is the immaturity of the liver and its inability to break down red cells effectively. Poor clotting mechanisms, elevated Hb, and persistent fetal circulation contribute to the jaundice but aren't causes of it.

RATIONALES: Adverse reactions to oxytocin in the mother include hypertension, fluid overload, and uterine tetany. The antidiuretic effect of oxytocin increases renal reabsorption of water, leading to fluid overload — not dehydration. Jaundice and bradycardia are adverse reactions that may occur in the neonate. Tachycardia, not bradycardia, is reported as a maternal adverse reaction.

RATIONALES: If bleeding and clots are excessive, this client may become hypovolemic, leading to a diagnosis of Deficient fluid volume. Although the other diagnoses are applicable to this client, they aren't the primary diagnosis.

RATIONALES: After rupture of the membranes in a client who has a fever or other signs or symptoms of infection, the fetus must be delivered promptly. Data obtained by amniocentesis or sonography wouldn't change the decision to deliver the fetus. Tocolytic drugs are used to arrest preterm labor.

RATIONALES: Sustained parent-neonate contact immediately after delivery is most likely to promote parent-neonate attachment. The first period of neonatal reactivity, which occurs during the 1st hour after delivery, is the ideal time for behavior that promotes attachment, such as touching, holding, talking, examining, and breast-feeding. Although parental desire to bond and understanding of the importance of bonding can contribute to parent-neonate attachment, early contact is a prerequisite. A previous positive childbirth experience may enhance parent-neonate attachment but is less crucial than sustained contact immediately after delivery.

RATIONALES: Delivery may extend an episiotomy incision to the anal sphincter (a third-degree laceration) or the anal canal (a fourth-degree laceration). A first-degree laceration involves the fourchette, perineal skin, and vaginal mucous membranes. A second-degree laceration extends to the fasciae and muscle of the perineal body.

RATIONALES: As the uterus involutes and the placental attachment area heals, lochia changes from bright red (rubra), to pinkish (serosa), to clear white (alba). The other options are incorrect

RATIONALES: Etidocaine is least likely to cross the placenta. Local anesthetics, such as etidocaine, don't cause vasoconstriction. If vasoconstriction is needed, the local anesthetic must be combined with a drug such as epinephrine. Although etidocaine has an onset of action of 2 to 8 minutes, prilocaine's onset of action is less than 2 minutes. Local anesthetics, including etidocaine, can cause adverse cardiac arrhythmias if high doses are given.

RATIONALES: During the transition to the active phase of the first stage of labor, increased pain typically makes the client withdrawn, irritable, and resistant to touch. During the latent phase (the early part of the first stage of labor), when contractions aren't intensely painful, the client typically desires personal contact and touch and responds to teaching and interventions. Fatigue, a desire for touch, and quietness are common during the third and fourth stages of labor.

RATIONALES: Amniotomy increases the risk of umbilical cord prolapse, which would impair the fetal blood supply and tissue perfusion. Because the fetus's life depends on the oxygen carried by that blood, maintaining fetal tissue perfusion takes priority over goals related to increased knowledge, infection prevention, and pain relief.

RATIONALES: Implantation occurs at the end of the 1st week after fertilization, when the blastocyst attaches to the endometrium. During the 2nd week (14 days after implantation), implantation progresses and two germ layers, cavities, and cell layers develop. During the 3rd week of development (21 days after implantation), the embryonic disk evolves into three layers, and three new structures — the primitive streak, notochord, and allantois — form. Early during the 4th week (28 days after implantation), cellular differentiation and organization occur.

RATIONALES: A slight temperature elevation from dehydration is common during the first 24 hours after delivery. Infection should be suspected if the client's temperature exceeds 100.4° F (38° C) for 2 successive days after delivery, excluding the first 24 hours.

RATIONALES: If the neonate's toes don't curl downward when the soles of his feet are stroked and he doesn't respond to a loud sound, it may be evidence that neurologic damage from asphyxia has occurred. A normal neurologic response would be the toes curling downward with stroking and extending arms and legs with a loud noise. Weak, ineffective sucking is another sign of neurologic damage. A neonate should grasp a person's finger when it's placed in the palm of his hand, do stepping movements when held upright with the sole of foot touching a surface, and turn toward the nurse's finger when she touches his cheek.

RATIONALES: Cephalohematomas don't cross the suture lines and are the result of blood vessels rupturing in the baby's scalp during labor. Blood outside the vasculature in a neonate increases the possibility of jaundice as the neonate's body tries to reabsorb the blood. Caput succedaneum, which is simply soft tissue edema of the scalp, can occur in any labor and isn't limited to a prolonged second stage of labor.

RATIONALES: After delivery, the neonate of a substance abuser may exhibit signs of drug withdrawal, such as irritability, poor feeding, and continual crying. Auscultating breath sounds, observing respiratory effort, and observing for jaundice are appropriate assessments for any neonate, not just the neonate of a substance abuser.

RATIONALES: The normal neonatal heart rate is 120 to 160 beats/minute. Heart rates lower than 60 beats/minute necessitate chest compressions and ventilatory support.

RATIONALES: A client's ability to cope during labor and delivery may be hampered by fear of a painful or difficult childbirth, fear of loss of control or self-esteem during childbirth, or fear of fetal death. A previous negative experience may increase these fears. Therefore, Fear related to a potentially difficult childbirth is the most appropriate nursing diagnosis. The client's anxiety stems from her past history of a long labor, not from being in the facility; therefore a diagnosis of Anxiety related to the facility environment isn't warranted. There is no evidence of compromised family coping related to hospitalization. Although acute pain related to labor contractions may be a problem, this isn't mentioned in the question

RATIONALES: Amniotomy increases the risk of cord prolapse. If the prolapsed cord is compressed by the presenting fetal part, the fetal blood supply may be impaired, jeopardizing the fetal oxygen supply. Because lack of oxygen to the fetus may cause fetal death, the nursing diagnosis of Ineffective fetal cerebral tissue perfusion takes priority over diagnoses of Deficient knowledge, Acute pain, and Risk for infection.

RATIONALES: Approximately 50% to 70% of postpartum clients experience transient depression during the first 7 to 10 days after delivery. The nurse should ask about the client's previous coping mechanisms and current support persons only after assuring her that her feelings are expected. Telling the client she'll be fine blocks further communication.

RATIONALES: Used by the client or her coach, cutaneous stimulation, such as effleurage, creates organized, controlled sensory input that reduces local irritability. In effleurage, the client concentrates on the sensation of light fingertip stroking of the abdomen or back, rather than the pain of the contraction, to help counteract the perception of pain. Controlled breathing is primarily used to enhance relaxation; although relaxation can reduce pain, it's typically less effective than cutaneous stimulation. Distraction isn't helpful because it diverts the client from the task of labor. Hypnosis is a trancelike state used to reduce attention to external stimuli.

RATIONALES: Ritodrine and other beta-adrenergic agonists may cause tachycardia, hypotension, bronchial dilation, increased plasma volume, increased cardiac output, arrhythmias, myocardial ischemia, reduced urine output, restlessness, headache, nausea, and vomiting. These drugs aren't associated with polyuria, hypertension, or hyporeflexia.

RATIONALES: Postpartum warning signs include a red, warm, painful area in either breast; heavy vaginal bleeding or passage of clots or tissue fragments; and a temperature of 100.2° F (37.9° C) or higher for 24 hours or longer. Scant lochia alba 2 to 3 weeks after delivery, a temperature of 99.7° F (37.6° C) for 24 hours or more, and breast tenderness that is relieved by analgesics are normal postpartum findings.

RATIONALES: Classic signs of PIH include edema (especially of the face), elevated blood pressure, and proteinuria. Fever is a sign of infection. Glycosuria indicates hyperglycemia. Vomiting may be associated with various disorders.

RATIONALES: Signs and symptoms of transition to the second stage of labor include bulging of the vaginal introitus, an increased urge to push, increased bloody show, and grunting. FHR accelerations may occur at any time during labor.

RATIONALES: The nurse can help control a precipitous delivery by stretching the labia, such as by massaging and bracing the perineum with gentle back pressure. This helps prevent perineal lacerations — the primary maternal complication of precipitous delivery. Applying counterpressure to the fetus's head reduces perineal stress temporarily; however, delivery proceeds when the client pushes with uterine contractions. Pushing puts further stress on the perineum, promoting delivery. When the fetus's head exerts pressure on the perineum, contracting the perineal muscles is virtually impossible.

RATIONALES: Dizziness, circumoral numbness, and slurred speech indicate anesthesia overdose. Transition to the second stage of labor is marked by an increased urge to push, an increase in bloody show, grunting, gaping of the anus, involuntary defecation, thrashing about, loss of control over breathing techniques, and nausea and vomiting. Anxiety and dehydration rarely cause dizziness or circumoral numbness.

RATIONALES: When used properly, a vacuum extractor is a safer delivery with fewer complications for the mother and the baby than a forceps delivery. Cephalohematomas occur more often in assisted births than in unassisted births. Instruments are used during delivery when individually necessary. No additional nursing interventions are needed during the postpartum period.

RATIONALES: A deceleration is a decrease in the FHR below the baseline. When decelerations occur at the same time as uterine contractions, they're called early decelerations. Early decelerations result from head compression during normal labor and don't indicate fetal distress. Prolonged decelerations, also known as reflex bradycardia, are decreases in fetal heart rate that last 60 to 90 seconds. These occur in response to sudden vagal stimulation. Prolonged decelerations may indicate fetal distress. Late decelerations start after the beginning of a contraction. The lowest point of a late deceleration occurs after the contraction ends. Accelerations are transient rises in the fetal heart rate that are normally caused by fetal movements and uterine contractions.

RATIONALES: Oxytocin is responsible for milk let-down, the process that brings milk to the nipple. The other hormones mentioned contribute indirectly to the lactation process. Prolactin stimulates lactation. Estrogen stimulates development of the duct in the breast. Progesterone acts to increase the lobes, lobules, and alveoli of the breasts.

RATIONALES: The nurse must distinguish between the primigravida and multigravida cervical dilation to make a care plan for the laboring client. Primigravidas will efface and then dilate, while multigravidas will efface and dilate at the same time.

RATIONALES: To test for PKU, a baby must have had a sufficient intake of phenylalanine through the ingestion of either formula or breast milk for at least 2 days. A baby who has been receiving I.V. fluids and hasn't yet received breast milk or formula isn't ready to be tested for PKU. A baby who's discharged within 24 hours of delivery will need to see the physician for PKU testing after receiving formula or breast milk for 48 hours.

RATIONALES: Delivery of the placenta causes the secretion of prolactin, which in turn produces breast milk. Thus, retained placental fragments can interfere with the production of milk. When the neonate sucks at the breast, the hypothalamus stimulates the production of prolactin-releasing factor, which further stimulates active production of prolactin to maintain milk production; sucking, however, doesn't initiate prolactin secretion. Oxytocin acts to constrict milk glands and push milk forward in the ducts that lead to the nipple. The role of relaxin is unknown.

RATIONALES: Nursing care should never include removing the initial dressing put on in the operating room. Appropriate nursing care for the incision would include circling any drainage, reporting findings to the physician, and reinforcing the dressing as needed. The other options are appropriate.

RATIONALES: Signs of placental separation include lengthening of the umbilical cord, a sudden gush of dark blood from the vagina, and a change in uterine shape from disklike to globular. Increased maternal anxiety occurs during the transitional phase of the first stage of labor. Severe rectal pressure and increased bloody show are common during the second stage.

RATIONALES: Hemorrhage jeopardizes the client's oxygen supply — the first priority among human physiologic needs. Therefore, the nursing diagnosis of Risk for deficient fluid volume related to hemorrhage takes priority over diagnoses of Risk for infection, Acute pain, and Urinary retention.

RATIONALES: Babies born with fetal alcohol syndrome have upturned noses, flattened nasal bridges, and a thin upper lip. They may also be small for gestational age.

RATIONALES: Internal EFM can be applied only after the client's membranes have ruptured, when the fetus is at least at the –1 station, and when the cervix is dilated at least 2 cm. Although the client may receive anesthesia, it isn't required before application of an internal EFM device.

RATIONALES: Patent ductus arteriosus causes tachycardia, tachypnea, a palpable thrill over the suprasternal notch, hepatomegaly, bounding peripheral pulses, widened pulse pressure, a continuous or systolic heart murmur, increased heart pulsation, and signs of respiratory distress or heart failure (such as increasing respiratory effort, crackles or moist breath sounds, feeding intolerance, fatigue, and decreasing urine output). Ventricular and atrial septal defects rarely cause signs at birth, although a neonate with an atrial septal defect may have a systolic murmur. With tetralogy of Fallot, the neonate typically has cyanosis, dyspnea, and a continuous murmur that is audible across the back

RATIONALES: Fetal blood pH of 7.19 or lower signals severe fetal acidosis; meconium-stained amniotic fluid and bradycardia are further signs of fetal distress that warrant cesarean delivery. Amnioinfusion is indicated when the only abnormal fetal finding is meconium-stained amniotic fluid. Client repositioning may improve uteroplacental perfusion but only serve as a temporary measure because the risk of fetal asphyxia is imminent. Oxytocin administration increases contractions, exacerbating fetal stress.

RATIONALES: A preterm neonate is a neonate born at less than 37 weeks' gestation regardless of what the neonate weighs. Neonates weighing less than 2,500 g are described as low-birth-weight neonates. A neonate who's small for gestational age weighs below the 10th percentile (or two standard deviations below the mean) as a result of intrauterine growth retardation.

RATIONALES: Cleaning with a peri bottle (squirt or spray bottle) should be performed after each voiding or bowel movement. The perineum should be cleaned from front to back, to avoid contamination from the rectal area. To keep the perineum clean, perineal pads must be changed when they are soiled. Water from the peri bottle isn't sterile and should never be directed into the vagina.

RATIONALES: An Apgar score of 8 indicates that the neonate has made a good transition to extrauterine life. A score of 4 to 6 would indicate moderate distress; a score of 0 to 3 would indicate severe distress.

RATIONALES: The client's signs and symptoms indicate abruptio placentae, which decreases fetal oxygenation. To maximize fetal oxygenation, the nurse should place the client on her left side to increase placental blood flow to the fetus and administer supplemental oxygen, as ordered, to increase the blood oxygen level. Administering oxytocin isn't appropriate because this drug stimulates contractions, which further reduce fetal oxygenation. The nurse can't assure the client that everything will be all right, only that everything possible will be done to help her and her fetus. Fundal massage is used only during the postpartum period to control hemorrhage.

RATIONALES: The neonate should be assigned an Apgar score of 9 because the neonate is pink, is crying vigorously, is moving all extremities, has a heart rate of 110 beats/minute, and has an irregular respiratory effort. The irregular respiratory effort and the presence of mucus in the nasal and oral cavities signify that the neonate requires suctioning. The neonate doesn't require resuscitation.

RATIONALES: Apgar consists of a 0 to 2 point scoring system for a neonate immediately following birth and at 5 minutes of age. The nurse evaluates the neonate for heart rate, respiratory effort, muscle tone, reflex irritability, and color. This neonate has a heart rate above 100, which equals 2; pink color with acrocyanosis, which equals 1; is well-flexed, which equals 2; has a weak cry, which equals 1; and has a good response to slapping the soles of the feet, which equals 2. Therefore, the nurse should record a total Apgar score of 8

RATIONALES: The nurse should notify the physician because a continuous flow of bright red blood from the vagina and a firm, contracted uterus indicate laceration of the birth canal. Ice application doesn't slow bleeding. Massage isn't necessary because the client's fundus is firm. Telling the client that bleeding is normal would be misleading and would give her a false sense of security.

RATIONALES: Lochia rubra, the first stage of lochia, typically lasts for the first 4 postpartum days. Bright red, it contains a mixture of blood, mucus, and tissue debris. There is no such thing as lochia nigra. Lochia alba, a creamy brown, white, or almost colorless discharge, appears during the 2nd and 3rd weeks postpartum. Lochia serosa, a pinkish serous discharge, typically occurs on postpartum days 5 to 7.

RATIONALES: The neonate's temperature should range from 97° to 97.7° F (36.1° to 36.5° C), and the respiratory rate should be less than 60 breaths/minute. (The respiratory rate increases as hypothermia develops.) Because this neonate's temperature is below normal and because cold stress can lead to respiratory distress and hypoglycemia, a diagnosis of Hypothermia related to heat loss takes highest priority. The other options may be appropriate but don't take precedence over hypothermia, which can be life-threatening.

RATIONALES: The behavior demonstrated by the mother is normal during the "taking-hold" process. The nurse should anticipate and support this behavior. Because this is normal behavior for establishing a relationship, it doesn't need to be reported. It's highly doubtful that the baby would become chilled during this brief time of being undressed. Therefore, rewrapping the baby and taking her back to the nursery to check her temperature isn't necessary.

RATIONALES: The neonate is exhibiting signs and symptoms of sepsis. Effective treatment of sepsis can't be initiated until the cause is identified. The physician will most likely prescribe CBC and obtain CSF and blood cultures to help identify the cause. Urinalysis would indicate whether a urinary tract infection (UTI) is present but it won't identify the cause. Arterial blood gas analysis isn't necessary for this neonate at this time.

RATIONALES: The neonate is displaying signs of fetal alcohol syndrome, which occurs as a result of fetal alcohol exposure. The nurse should include referral to an alcohol treatment counselor as part of the mother's discharge plan. Teratogenic effects of isotretinoin include microtia, central nervous system defects, cleft lip and cleft palate, mental retardation, microphthalmia, and dysmorphic craniofacial features. Folic acid is recommended during pregnancy to prevent neural defects. Teratogenic effects of cocaine use during pregnancy include intrauterine growth retardation, microcephaly, cerebral infarction, and congenital malformations of the limbs, heart, genitourinary tract, and face.