Shared Flashcard Set


final exam
ob final exam-Hope's Notes
Undergraduate 3

Additional Nursing Flashcards




Which of the following correctly defines puerperium?

1. The 1st hour after birth

2. The 6 weeks following birth

3. The days spent in the hospital

4. The duration of breast-feeding
RATIONALES: Puerperium is defined as the 6 weeks postpartum. The other options are incorrect.
A client is 9 days postpartum and breast-feeding her baby. The client experiences pain, redness, and swelling of her left breast and is diagnosed with mastitis. The nurse teaching the client how to care for her infected breast should include which information?

1. Wear a loose-fitting bra to avoid constricting the milk ducts.

2. Stop breast-feeding permanently.

3. Take antibiotics until the pain is relieved.

4. Use a warm moist compress over the painful area.
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.
When assessing the fetal heart rate tracing, the nurse becomes concerned about the fetal heart rate pattern. In response to the loss of variability, the nurse repositions the client to her left side and administers oxygen. These actions are likely to improve which of the following?

1. Fetal hypoxia

2. The contraction pattern

3. The status of a trapped cord

4. Maternal comfort

1. Fetal hypoxia

2. The contraction pattern

3. The status of a trapped cord

4. Maternal comfort
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.
The nurse caring for a 3-day-old neonate notices that he looks slightly jaundiced. Although not a normal finding, it's an expected finding of physiologic jaundice and is caused by which of the following?

1. Poor clotting mechanism

2. High hemoglobin (Hb) levels between 14 and 20 g/100 ml of blood

3. Persistent fetal circulation

4. Large, immature liver
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.
The nurse is monitoring a client who is receiving oxytocin (Pitocin) to induce labor. The nurse should be prepared for which maternal adverse reactions?

1. Hypertension

2. Jaundice

3. Dehydration

4. Fluid overload

5. Uterine tetany

6. Bradycardia
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.
A client in her 15th week of pregnancy has presented with abdominal cramping and vaginal bleeding for the past 8 hours. She has passed several clots. What is the primary nursing diagnosis for this client?

1. Deficient knowledge (pregnancy)

2. Deficient fluid volume

3. Anticipatory grieving

4. Acute pain
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.
A client's membranes rupture during the 36th week of pregnancy. Eighteen hours later, the nurse measures the client's temperature at 101.8° F (38.8° C). After initiating prescribed antibiotic therapy, the nurse should prepare the client for:

1. amniocentesis.

2. delivery.

3. sonography.

4. tocolytic therapy.
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.
The nurse is assessing the psychosocial status of a postpartum client. Which finding is most likely to promote parent-neonate attachment?

1. Parental desire to bond with the neonate

2. Sustained parent-neonate contact immediately after delivery

3. Parental understanding of the importance of parent-neonate bonding

4. Previous positive childbirth experience
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.
A client, age 19, has an episiotomy to widen her birth canal. Delivery extends the incision into the anal sphincter. This complication is called:

1. a first-degree laceration.

2. a second-degree laceration.

3. a third-degree laceration.

4. a fourth-degree laceration
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.
Lochia normally progresses in which pattern?

1. Rubra, serosa, alba

2. Serosa, rubra, alba

3. Serosa, alba, rubra

4. Rubra, alba, serosa
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
A client is admitted to the maternity unit in active labor. Her cervix is dilated 4 cm. The physician prescribes etidocaine (Duranest), 150 mg via epidural catheter. What might account for the physician's choice of etidocaine over other local anesthetic agents?

1. It produces no vasoconstrictor effects.

2. It's least likely to cross the placenta.

3. It has the fastest onset of action.

4. It's least likely to cause cardiac arrhythmias
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.
A client who has been in the latent phase of the first stage of labor enters the transition to the active phase. During the transition, the nurse expects to see which client behavior?

1. A desire for personal contact and touch

2. A full response to teaching

3. Fatigue, a desire for touch, and quietness

4. Withdrawal, irritability, and resistance to touch
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.
After an amniotomy, which client goal should take the highest priority?

1. The client will express increased knowledge about amniotomy.

2. The client will maintain adequate fetal tissue perfusion.

3. The client will display no signs of infection.

4. The client will report relief of pain.
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.
During a health-teaching session, a pregnant client asks the nurse how soon the fertilized ovum becomes implanted in the endometrium. Which answer should the nurse supply?

1. 7 days after fertilization

2. 14 days after fertilization

3. 21 days after fertilization

4. 28 days after fertilization
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.
What is the most likely reason for a temperature of 99.8° F (37.7° C) during the first 24 hours postpartum?

1. Puerperal infection

2. Mastitis

3. Dehydration

4. Chorioamnionitis
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.
The nurse is doing a neurologic assessment on a 1-day-old neonate in the nursery. Which findings would indicate possible asphyxia in utero?

1. The neonate grasps the nurse's finger when she puts it in the palm of his hand.

2. The neonate does stepping movements when held upright with sole of foot touching a surface.

3. The neonate's toes don't curl downward when soles of feet are stroked.

4. The neonate doesn't respond when the nurse claps her hands above him.

5. The neonate turns toward the nurse's finger when she touches his cheek.

6. The neonate displays weak, ineffective sucking.
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.
During the admission assessment of a female neonate, the nurse notes a large lump on the baby's head. Concerned about making the correct assessment, the nurse differentiates between caput succedaneum and a cephalohematoma based on the knowledge that:

1. a cephalohematoma doesn't cross the suture lines.

2. caput succedaneum occurs primarily with primigravidas.

3. a cephalohematoma occurs with a birth that required instrumentation.

4. caput succedaneum occurs primarily with a prolonged second stage of labor.
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.
A client who admits she uses heroin delivers a neonate at 32 weeks' gestation. Which neonatal assessment is most important for the nurse to perform?

1. Auscultation of breath sounds for signs of pulmonary problems

2. Careful observation of respiratory effort because of the neonate's prematurity

3. Evaluation for signs of drug withdrawal

4. Observation for jaundice
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.
During neonatal resuscitation immediately after delivery, chest compressions should be initiated when the heart rate falls below which of the following?

1. 60 beats/minute

2. 80 beats/minute

3. 100 beats/minute

4. 110 beats/minute
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.
The nurse notices that a client in the first stage of labor seems agitated. When the nurse asks why she's upset, she begins to cry and says, "I guess I'm a little worried. The last time I gave birth, I was in labor for 32 hours." Based on this information, the nurse should include which nursing diagnosis in the client's care plan?

1. Anxiety related to the facility environment

2. Fear related to a potentially difficult childbirth

3. Compromised family coping related to hospitalization

4. Acute pain related to labor contractions
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
During the active phase of the first stage of labor, a client undergoes an amniotomy. After this procedure, which nursing diagnosis takes the highest priority?

1. Deficient knowledge (testing procedure) related to amniotomy

2. Ineffective fetal cerebral tissue perfusion related to cord compression

3. Acute pain related to increasing strength of contractions

4. Risk for infection related to rupture of membranes
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.
On the 2nd postpartum day, a client tells the nurse she feels anxious and tearful. Which response by the nurse would be appropriate?

1. "It isn't unusual to have those feelings after delivery."

2. "How have you coped with other problems in your life?"

3. "To whom do you usually talk when you have problems?"

4. "Don't worry. You'll be fine."
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.
During a childbirth education class, a nurse-educator discusses pain control techniques used during labor and delivery. Which technique most effectively helps a client cope with the pain of uterine contractions?

1. Controlled breathing

2. Distraction

3. Cutaneous stimulation

4. Hypnosis
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.
At 28 weeks' gestation, a client is admitted to the labor and delivery area in preterm labor. An I.V. infusion of ritodrine (Yutopar) is started. Which client outcome reflects the nurse's awareness of an adverse effect of ritodrine?

1. "The client remains free from tachycardia."

2. "The client remains free from polyuria."

3. "The client remains free from hypertension."

4. "The client remains free from hyporeflexia."
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.
When preparing a postpartum client for discharge, the nurse teaches her about warning signs during the postpartum period. The nurse should instruct her to report:

1. scant lochia alba 2 to 3 weeks after delivery.

2. a temperature of 99.7° F (37.6° C) for 24 hours or more.

3. breast tenderness that is relieved by analgesics.

4. a red, warm, painful area in the breast.
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.
At 32 weeks' gestation, a client is admitted to the facility with a diagnosis of pregnancy-induced hypertension (PIH). Based on this diagnosis, the nurse expects assessment to reveal:

1. edema.

2. fever.

3. glycosuria.

4. vomiting.
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.
A client has progressed through the first stage of labor. Which assessment finding suggests she's in the transition to the second stage?

1. A decreased urge to push

2. Decreased bloody show

3. Fetal heart rate (FHR) accelerations

4. Bulging of the vaginal introitus
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.
During labor, a client tells the nurse that her last baby "came out really fast." The nurse can help control a precipitous delivery by:

1. applying counterpressure to the fetus's head.

2. encouraging the client to push.

3. massaging and supporting the perineum.

4. instructing the client to contract the perineal muscles.
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.
Late in the first stage of labor, a client receives a spinal block to relieve discomfort. A short time later, her husband tells the nurse that his wife feels dizzy and is complaining of numbness around her lips. What do the client's symptoms suggest?

1. Anesthesia overdose

2. Transition to the second stage of labor

3. Anxiety

4. Dehydration
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.
An assisted birth using forceps or a vacuum extractor may be performed for ineffective pushing, for large infants, to shorten the second stage of labor, or for a malpresentation. The nurse caring for the mother following an assisted birth should keep which of the following in mind?

1. A vacuum extractor is safer than forceps because it causes less trauma to the baby and the mother's perineum.

2. The baby will develop a cephalohematoma as a result of the instrumentation.

3. The use of instruments during the birth process is a fairly rare occurrence.

4. Additional nursing interventions are needed to ensure an uncomplicated postpartum.
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.
The nurse is evaluating the external fetal monitoring strip of a client who is in labor. She notes decreases in the fetal heart rate (FHR) that coincide with the client's contractions. What term does the nurse use to document this finding?

1. Prolonged decelerations

2. Early decelerations

3. Late decelerations

4. Accelerations
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.
Which of the following hormones is responsible for the let-down reflex?

1. Oxytocin

2. Prolactin

3. Estrogen

4. Progesterone
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.
A client who's a gravida 1 para 0 has been admitted to the perinatal admission unit and is in early labor. The client's cervical examination would reveal which of the following?

1. 2 cm dilated; 100% effaced at 0 station

2. 4 to 5 cm dilated; 80% effaced at –1 station

3. 2 cm dilated; 50% effaced at +1 station

4. 3 cm dilated; 50% effaced at 0 station
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.
A nurse in the neonatal nursery is preparing to perform phenylketonuria (PKU) testing. Which baby is ready for the nurse to test?

1. A 3-day-old baby who has been fed I.V. since birth

2. A 2-day-old baby who has been breast-fed

3. A 1-day-old baby receiving formula

4. A breast-fed baby being discharged within 24 hours of birth
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.
The nurse should tell new mothers who are breast-feeding that breast milk is produced when:

1. the placenta is delivered, causing the secretion of prolactin.

2. the newborn begins to suckle and stimulates the anterior pituitary to produce prolactin.

3. oxytocin is released from the posterior pituitary gland.

4. relaxin is released from the ovary.
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.
When caring for a client who has had a cesarean section, which action is not appropriate?

1. Removing the initial dressing for incision inspection

2. Monitoring pain status and providing necessary relief

3. Supporting self-esteem concerns about delivery

4. Assisting with parental newborn bonding
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.
A client is in the third stage of labor. Which finding indicates impending placental separation?

1. Increased maternal anxiety

2. Severe rectal pressure

3. Increased bloody show

4. Umbilical cord lengthening
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.
The nurse is caring for a postpartum client who had a vaginal delivery with a midline episiotomy. Which nursing diagnosis takes priority for this client?

1. Risk for deficient fluid volume related to hemorrhage

2. Risk for infection related to the type of delivery

3. Acute pain related to the type of incision

4. Urinary retention related to periurethral edema
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.
The nurse is assessing a neonate. Health history findings indicate that the mother drank 3 oz (89 ml) or more of alcohol per day throughout pregnancy. Which characteristic should the nurse expect to find?

1. Prominent nasal bridge

2. Thick upper lip

3. Upturned nose

4. Large for gestational age
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.
For a client in active labor, the nurse-midwife plans to use an internal electronic fetal monitoring (EFM) device. What must occur before the internal EFM can be applied?

1. The membranes must rupture.

2. The fetus must be at 0 station.

3. The cervix must be dilated fully.

4. The client must receive anesthesia.
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.
When assessing a neonate who was born at 30 weeks' gestation, the nurse notes bounding femoral pulses, a palpable thrill over the suprasternal notch, tachycardia, tachypnea, and crackles. The nurse suspects:

1. ventricular septal defect.

2. patent ductus arteriosus.

3. tetralogy of Fallot.

4. atrial septal defect.
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
A client has meconium-stained amniotic fluid. Fetal scalp sampling indicates a blood pH of 7.12; fetal bradycardia is present. Based on these findings, the nurse should take which action?

1. Administer amnioinfusion.

2. Prepare for cesarean delivery.

3. Reposition the client.

4. Start I.V. oxytocin infusion as prescribed.
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.
Which of the following describes a preterm neonate?

1. A neonate weighing less than 2,500 g (5 lb, 8 oz)

2. A low-birth-weight neonate

3. A neonate born at less than 37 weeks' gestation regardless of weight

4. A neonate diagnosed with intrauterine growth retardation
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.
The nurse is teaching a client how to perform perineal care to reduce the risk of puerperal infection. Which activity indicates that the client understands proper perineal care?

1. Using a peri bottle to clean the perineum after each voiding or bowel movement

2. Cleaning the perineum from back to front after a bowel movement

3. Spraying water from peri bottle into the vagina

4. Changing perineal pads every 8 hours
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.
Which of the following describes how the nurse interprets a neonate's Apgar score of 8 at 5 minutes?

1. A neonate who's in good condition

2. A neonate who's mildly depressed

3. A neonate who's moderately depressed

4. A neonate who needs additional oxygen to improve the Apgar score
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.
A client, 7 months pregnant, is admitted to the unit with abdominal pain and bright red vaginal bleeding. Which action should the nurse take first?

1. Place the client on her left side and start supplemental oxygen, as ordered, to maximize fetal oxygenation.

2. Administer I.V. oxytocin, as ordered, to stimulate uterine contractions and prevent further hemorrhage.

3. Ease the client's anxiety by assuring her that everything will be all right.

4. Massage the client's fundus to help control the hemorrhage.
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.
The certified nurse midwife places the neonate under the radiant heat unit for the nurse's initial assessment. The initial assessment includes heart rate 110 beats/minute and an irregular respiratory effort. The neonate is moving all extremities and his body is pink. He also has a vigorous cry. The nurse notes copious amounts of clear mucus present both orally and nasally. Based on these assessment findings, what should the nurse do next?

1. Assign an Apgar score of 7, place the neonate in modified Trendelenburg position, and begin artificial respirations.

2. Assign an Apgar score of 6, place in the neonate in modified Trendelenburg position, and initiate a code to gain assistance from the code team.

3. Assign an Apgar score of 9, place the neonate in modified Trendelenburg position, and suction the neonate's nose and oropharynx.

4. Assign an Apgar score of 10, place in the neonate in modified Trendelenburg position, and suction the neonate's nose.
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.
At 5 minutes of age, a neonate is pink with acrocyanosis, has his knees flexed and fists clinched, has a whimpering cry, has a heart rate of 128, and withdraws his foot when slapped on the sole. What 5-minute Apgar score would the nurse record for this neonate? Sign Apgar Score
0 1 2
Heart rate Absent Less than 100 beats/minute (slow) More than 100 beats/minute
Respiratory effort Absent Slow, irregular Good crying
Muscle tone Flaccid Some flexion and resistance to extension of extremities Active motion
Reflex irritability No response Grimace or weak cry Vigorous cry
Color Pallor, cyanosis Pink body, blue extremities Completely pink
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
When assessing a postpartum client, the nurse notes a continuous flow of bright red blood from the vagina. The uterus is firm and no clots can be expressed. Which action should the nurse take?

1. Apply an ice pack to the perineum.

2. Massage the uterus every 15 minutes.

3. Notify the physician.

4. Reassure the client that such bleeding is normal.
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.
One day after a client delivers a neonate, the nurse performs a postpartum assessment. At this time, the nurse expects to find:

1. lochia nigra.

2. lochia alba.

3. lochia serosa.

4. lochia rubra.
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.
When assessing a neonate 1 hour after delivery, the nurse measures an axillary temperature of 95.6° F (35.3° C), an apical pulse of 110 beats/minute, and a respiratory rate of 64 breaths/minute. Which nursing diagnosis takes highest priority at this time?

1. Hypothermia related to heat loss

2. Impaired parenting related to the addition of a new family member

3. Risk for deficient fluid volume related to insensible fluid losses

4. Risk for infection related to transition to the extrauterine environment
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.
The nurse brings a new mother her baby for the first time approximately 1 hour after the baby's birth. After checking the identification, the nurse hands the baby to the mother. Within a few minutes, the mother begins to undress her baby. Which of the following should the nurse do?

1. Call the pediatrician and report the behavior.

2. Anticipate and support the behavior as a normal part of bonding.

3. Encourage the mother to rewrap the baby because the room is cold.

4. Take the baby back to the nursery and recheck the baby's temperature.
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.
A 2-day-old neonate hasn't been eating well, is irritable, and has a temperature of 101° F axillary. The nursery nurse anticipates that the physician will most likely prescribe which tests?

1. Cerebrospinal fluid (CSF) and blood cultures and a complete blood count (CBC)

2. Urinalysis

3. Blood culture and a throat culture

4. CBC and arterial blood gas analysis
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.
A gravida 5 para 2 client delivers a 3,000-gram neonate at 38 weeks' gestation. During the assessment, the nurse notes that the neonate is hyperactive, jittery, and has a hyperactive rooting reflex combined with inconsolable crying. She also notes intrauterine growth retardation and suspect facial characteristics, such as short palebral fissures, flattened midfacies, short upturned nose, thin upper lip, and smooth philtrum. Based on these findings, what information should the nurse include in the mother's discharge plan?

1. Referral to an alcohol treatment counselor

2. Client education on isotretinoin (Retin-A)

3. Instructions on dietary sources of folic acid

4. Referral to cocaine treatment counselor
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.
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