2024 MATERNAL NEWBORN ATI TEST BANK | 450 LATEST QUESTIONS AND CORRECT ANSWERS, Exams of Nursing

Download 2024 MATERNAL NEWBORN ATI TEST BANK | 450 LATEST QUESTIONS AND CORRECT ANSWERS and more Exams Nursing in PDF only on Docsity! 2024 MATERNAL NEWBORN ATI TEST BANK | 450 LATEST QUESTIONS AND CORRECT ANSWERS WITH RATIONALES (ALREADY GRADED A+) | PROFESSOR VERIFIED | LATEST VERSION (JUST RELEASED) 1. When assessing the adequacy of sperm for conception to occur, which of the following is the most useful criterion? A. Sperm count B. Sperm motility C. Sperm maturity D. Semen volume ------CORRECT ANSWER---------------B. Although all of the factors listed are important, sperm motility is the most significant criterion when assessing male infertility. Sperm count, sperm maturity, and semen volume are all significant, but they are not as significant sperm motility. 2. A couple who wants to conceive but has been unsuccessful during the last 2 years has undergone many diagnostic procedures. When discussing the situation with the nurse, one partner states, "We know several friends in our age group and all of them have their own child already, Why can't we have one?". Which of the following would be the most pertinent nursing diagnosis for this couple? A. Fear related to the unknown B. Pain related to numerous procedures. C. Ineffective family coping related to infertility. D. Self-esteem disturbance related to infertility. ------CORRECT ANSWER---------------D. Based on the partner's statement, the couple is verbalizing feelings of inadequacy and negative feelings about themselves and their capabilities. Thus, the nursing diagnosis of self-esteem disturbance is most appropriate. Fear, pain, and ineffective family coping also may be present but as secondary nursing diagnoses. 3. Which of the following urinary symptoms does the pregnant woman most frequently experience during the first trimester? A. Dysuria B. Frequency C. Incontinence D. Burning ------CORRECT ANSWER---------------B. Pressure and irritation of the bladder by the growing uterus during the first trimester is responsible for causing urinary frequency. Dysuria, incontinence, and burning are symptoms associated with urinary tract infections. 4. Heartburn and flatulence, common in the second trimester, are most likely the result of which of the following? A. Increased plasma HCG levels B. Decreased intestinal motility C. Decreased gastric acidity D. Elevated estrogen levels ------CORRECT ANSWER---------------. During the second trimester, the reduction in gastric acidity in conjunction with pressure from the growing uterus and smooth muscle relaxation, can cause heartburn and flatulence. HCG levels increase in the first, not the second, trimester. Decrease intestinal motility would most likely be the cause of constipation and bloating. Estrogen levels decrease in the second trimester. 5. On which of the following areas would the nurse expect to observe chloasma? A. Breast, areola, and nipples B. Chest, neck, arms, and legs C. Abdomen, breast, and thighs D. Cheeks, forehead, and nose ------CORRECT ANSWER---------------D. Chloasma, also called the mask of pregnancy, is an irregular hyperpigmented area found on the face. It is not seen on the breasts, areola, nipples, chest, neck, arms, legs, abdomen, or thighs. 6. A pregnant client states that she "waddles" when she walks. The nurse's explanation is based on which of the following as the cause? A. The large size of the newborn B. Pressure on the pelvic muscles C. Relaxation of the pelvic joints D. Excessive weight gain ------CORRECT ANSWER---------------C. During pregnancy, hormonal changes cause relaxation of the pelvic joints, resulting in the typical "waddling" gait. Changes in posture are related to the growing fetus. Pressure on pregnant couples. Second and third trimester classes may focus on preparation for birth, parenting, and newborn care. 13. Which of the following would be disadvantage of breast feeding? A. Involution occurs more rapidly B. The incidence of allergies increases due to maternal antibodies C. The father may resent the infant's demands on the mother's body D. There is a greater chance for error during preparation ------CORRECT ANSWER----- ----------C. With breast feeding, the father's body is not capable of providing the milk for the newborn, which may interfere with feeding the newborn, providing fewer chances for bonding, or he may be jealous of the infant's demands on his wife's time and body. Breast feeding is advantageous because uterine involution occurs more rapidly, thus minimizing blood loss. The presence of maternal antibodies in breast milk helps decrease the incidence of allergies in the newborn. A greater chance for error is associated with bottle feeding. No preparation is required for breast feeding. 14. Which of the following would cause a false-positive result on a pregnancy test? A. The test was performed less than 10 days after an abortion B. The test was performed too early or too late in the pregnancy C. The urine sample was stored too long at room temperature D. A spontaneous abortion or a missed abortion is impending ------CORRECT ANSWER---------------A. A false-positive reaction can occur if the pregnancy test is performed less than 10 days after an abortion. Performing the tests too early or too late in the pregnancy, storing the urine sample too long at room temperature, or having a spontaneous or missed abortion impending can all produce false- negative results. 15. FHR can be auscultated with a fetoscope as early as which of the following? A. 5 weeks gestation B. 10 weeks gestation C. 15 weeks gestation D. 20 weeks gestation ------CORRECT ANSWER---------------D. The FHR can be auscultated with a fetoscope at about 20 week's gestation. FHR usually is ausculatated at the midline suprapubic region with Doppler ultrasound transducer at 10 to 12 week's gestation. FHR, cannot be heard any earlier than 10 weeks' gestation. 16. A client LMP began July 5. Her EDD should be which of the following? A. January 2 B. March 28 C. April 12 D. October 12 ------CORRECT ANSWER---------------C. To determine the EDD when the date of the client's LMP is known use Nagele rule. To the first day of the LMP, add 7 days, subtract 3 months, and add 1 year (if applicable) to arrive at the EDD as follows: 5 + 7 = 12 (July) minus 3 = 4 (April). Therefore, the client's EDD is April 12. 17. Which of the following fundal heights indicates less than 12 weeks' gestation when the date of the LMP is unknown? A. Uterus in the pelvis B. Uterus at the xiphoid C. Uterus in the abdomen D. Uterus at the umbilicus ------CORRECT ANSWER---------------A. When the LMP is unknown, the gestational age of the fetus is estimated by uterine size or position (fundal height). The presence of the uterus in the pelvis indicates less than 12 weeks' gestation. At approximately 12 to 14 weeks, the fundus is out of the pelvis above the symphysis pubis. The fundus is at the level of the umbilicus at approximately 20 weeks' gestation and reaches the xiphoid at term or 40 weeks. 18. Which of the following danger signs should be reported promptly during the antepartum period? A. Constipation B. Breast tenderness C. Nasal stuffiness D. Leaking amniotic fluid ------CORRECT ANSWER---------------D. Danger signs that require prompt reporting leaking of amniotic fluid, vaginal bleeding, blurred vision, rapid weight gain, and elevated blood pressure. Constipation, breast tenderness, and nasal stuffiness are common discomforts associated with pregnancy. 19. Which of the following prenatal laboratory test values would the nurse consider as significant? A. Hematocrit 33.5% B. Rubella titer less than 1:8 C. White blood cells 8,000/mm3 D. One hour glucose challenge test 110 g/dL ------CORRECT ANSWER---------------B. A rubella titer should be 1:8 or greater. Thurs, a finding of a titer less than 1:8 is significant, indicating that the client may not possess immunity to rubella. A hematocrit of 33.5% a white blood cell count of 8,000/mm3, and a 1 hour glucose challenge test of 110 g/dl are with normal parameters. 20. Which of the following characteristics of contractions would the nurse expect to find in a client experiencing true labor? A. Occurring at irregular intervals B. Starting mainly in the abdomen C. Gradually increasing intervals D. Increasing intensity with walking ------CORRECT ANSWER---------------D. With true labor, contractions increase in intensity with walking. In addition, true labor contractions occur at regular intervals, usually starting in the back and sweeping around to the abdomen. The interval of true labor contractions gradually shortens. 21. During which of the following stages of labor would the nurse assess "crowning"? A. First stage B. Second stage C. Third stage D. Fourth stage ------CORRECT ANSWER---------------B. Crowing, which occurs when the newborn's head or presenting part appears at the vaginal opening, occurs during the second stage of labor. During the first stage of labor, cervical dilation and effacement occur. During the third stage of labor, the newborn and placenta are delivered. The fourth stage of labor lasts from 1 to 4 hours after birth, during which time the mother and newborn recover from the physical process of birth and the mother's organs undergo the initial readjustment to the nonpregnant state. 22. Barbiturates are usually not given for pain relief during active labor for which of the following reasons? 28. When assessing the newborn's heart rate, which of the following ranges would be considered normal if the newborn were sleeping? A. 80 beats per minute B. 100 beats per minute C. 120 beats per minute D. 140 beats per minute ------CORRECT ANSWER---------------B. The normal heart rate for a newborn that is sleeping is approximately 100 beats per minute. If the newborn was awake, the normal heart rate would range from 120 to 160 beats per minute. 29. Which of the following is true regarding the fontanels of the newborn? A. The anterior is triangular shaped; the posterior is diamond shaped. B. The posterior closes at 18 months; the anterior closes at 8 to 12 weeks. C. The anterior is large in size when compared to the posterior fontanel. D. The anterior is bulging; the posterior appears sunken. ------CORRECT ANSWER----- ----------C. The anterior fontanel is larger in size than the posterior fontanel. Additionally, the anterior fontanel, which is diamond shaped, closes at 18 months, whereas the posterior fontanel, which is triangular shaped, closes at 8 to 12 weeks. Neither fontanel should appear bulging, which may indicate increased intracranial pressure, or sunken, which may indicate dehydration. 30. Which of the following groups of newborn reflexes below are present at birth and remain unchanged through adulthood? A. Blink, cough, rooting, and gag B. Blink, cough, sneeze, gag C. Rooting, sneeze, swallowing, and cough D. Stepping, blink, cough, and sneeze ------CORRECT ANSWER---------------B. Blink, cough, sneeze, swallowing and gag reflexes are all present at birth and remain unchanged through adulthood. Reflexes such as rooting and stepping subside within the first year. 31. Which of the following describes the Babinski reflex? A. The newborn's toes will hyperextend and fan apart from dorsiflexion of the big toe when one side of foot is stroked upward from the ball of the heel and across the ball of the foot. B. The newborn abducts and flexes all extremities and may begin to cry when exposed to sudden movement or loud noise. C. The newborn turns the head in the direction of stimulus, opens the mouth, and begins to suck when cheek, lip, or corner of mouth is touched. D. The newborn will attempt to crawl forward with both arms and legs when he is placed on his abdomen on a flat surface ------CORRECT ANSWER---------------A. With the babinski reflex, the newborn's toes hyperextend and fan apart from dorsiflexion of the big toe when one side of foot is stroked upward form the heel and across the ball of the foot. With the startle reflex, the newborn abducts and flexes all extremities and may begin to cry when exposed to sudden movement of loud noise. With the rooting and sucking reflex, the newborn turns his head in the direction of stimulus, opens the mouth, and begins to suck when the cheeks, lip, or corner of mouth is touched. With the crawl reflex, the newborn will attempt to crawl forward with both arms and legs when he is placed on his abdomen on a flat surface. 32. Which of the following statements best describes hyperemesis gravidarum? A. Severe anemia leading to electrolyte, metabolic, and nutritional imbalances in the absence of other medical problems. B. Severe nausea and vomiting leading to electrolyte, metabolic, and nutritional imbalances in the absence of other medical problems. C. Loss of appetite and continuous vomiting that commonly results in dehydration and ultimately decreasing maternal nutrients D. Severe nausea and diarrhea that can cause gastrointestinal irritation and possibly internal bleeding ------CORRECT ANSWER---------------B. The description of hyperemesis gravidarum includes severe nausea and vomiting, leading to electrolyte, metabolic, and nutritional imbalances in the absence of other medical problems. Hyperemesis is not a form of anemia. Loss of appetite may occur secondary to the nausea and vomiting of hyperemesis, which, if it continues, can deplete the nutrients transported to the fetus. Diarrhea does not occur with hyperemesis. 33. Which of the following would the nurse identify as a classic sign of PIH? A. Edema of the feet and ankles B. Edema of the hands and face C. Weight gain of 1 lb/week D. Early morning headache ------CORRECT ANSWER---------------B. Edema of the hands and face is a classic sign of PIH. Many healthy pregnant woman experience foot and ankle edema. A weight gain of 2 lb or more per week indicates a problem. Early morning headache is not a classic sign of PIH. 34. In which of the following types of spontaneous abortions would the nurse assess dark brown vaginal discharge and a negative pregnancy tests? A. Threatened B. Imminent C. Missed D. Incomplete ------CORRECT ANSWER---------------C. In a missed abortion, there is early fetal intrauterine death, and products of conception are not expelled. The cervix remains closed; there may be a dark brown vaginal discharge, negative pregnancy test, and cessation of uterine growth and breast tenderness. A threatened abortion is evidenced with cramping and vaginal bleeding in early pregnancy, with no cervical dilation. An incomplete abortion presents with bleeding, cramping, and cervical dilation. An incomplete abortion involves only expulsion of part of the products of conception and bleeding occurs with cervical dilation. 35. Which of the following factors would the nurse suspect as predisposing a client to placenta previa? A. Multiple gestation B. Uterine anomalies C. Abdominal trauma ------CORRECT ANSWER---------------A. Multiple gestation is one of the predisposing factors that may cause placenta previa. Uterine anomalies abdominal trauma, and renal or vascular disease may predispose a client to abruptio placentae. 36. Which of the following would the nurse assess in a client experiencing abruptio placenta? A. Bright red, painless vaginal bleeding B. Concealed or external dark red bleeding C. Palpable fetal outline D. Soft and nontender abdomen ------CORRECT ANSWER---------------B. A client with abruptio placentae may exhibit concealed or dark red bleeding, possibly reporting sudden intense localized uterine pain. The uterus is typically firm to board-like, and the fetal presenting part may be engaged. Bright red, painless vaginal bleeding, a palpable fetal outline and a soft non-tender abdomen are manifestations of placenta previa. 37. Which of the following is described as premature separation of a normally implanted placenta during the second half of pregnancy, usually with severe hemorrhage? 43. When uterine rupture occurs, which of the following would be the priority? A. Limiting hypovolemic shock B. Obtaining blood specimens C. Instituting complete bed rest D. Inserting a urinary catheter ------CORRECT ANSWER---------------A. With uterine rupture, the client is at risk for hypovolemic shock. Therefore, the priority is to prevent and limit hypovolemic shock. Immediate steps should include giving oxygen, replacing lost fluids, providing drug therapy as needed, evaluating fetal responses and preparing for surgery. Obtaining blood specimens, instituting complete bed rest, and inserting a urinary catheter are necessary in preparation for surgery to remedy the rupture. 44. Which of the following is the nurse's initial action when umbilical cord prolapse occurs? A. Begin monitoring maternal vital signs and FHR B. Place the client in a knee-chest position in bed C. Notify the physician and prepare the client for delivery D. Apply a sterile warm saline dressing to the exposed cord ------CORRECT ANSWER- --------------B. The immediate priority is to minimize pressure on the cord. Thus the nurse's initial action involves placing the client on bed rest and then placing the client in a knee-chest position or lowering the head of the bed, and elevating the maternal hips on a pillow to minimize the pressure on the cord. Monitoring maternal vital signs and FHR, notifying the physician and preparing the client for delivery, and wrapping the cord with sterile saline soaked warm gauze are important. But these actions have no effect on minimizing the pressure on the cord. 45. Which of the following amounts of blood loss following birth marks the criterion for describing postpartum hemorrhage? A. More than 200 ml B. More than 300 ml C. More than 400 ml D. More than 500 ml ------CORRECT ANSWER---------------D. Postpartum hemorrhage is defined as blood loss of more than 500 ml following birth. Any amount less than this not considered postpartum hemorrhage. 46. Which of the following is the primary predisposing factor related to mastitis? A. Epidemic infection from nosocomial sources localizing in the lactiferous glands and ducts B. Endemic infection occurring randomly and localizing in the periglandular connective tissue C. Temporary urinary retention due to decreased perception of the urge to avoid D. Breast injury caused by overdistention, stasis, and cracking of the nipples ------ CORRECT ANSWER---------------D. With mastitis, injury to the breast, such as overdistention, stasis, and cracking of the nipples, is the primary predisposing factor. Epidemic and endemic infections are probable sources of infection for mastitis. Temporary urinary retention due to decreased perception of the urge to void is a contributory factor to the development of urinary tract infection, not mastitis. 47. Which of the following best describes thrombophlebitis? A. Inflammation and clot formation that result when blood components combine to form an aggregate body B. Inflammation and blood clots that eventually become lodged within the pulmonary blood vessels C. Inflammation and blood clots that eventually become lodged within the femoral vein D. Inflammation of the vascular endothelium with clot formation on the vessel wall ------ CORRECT ANSWER---------------D. Thrombophlebitis refers to an inflammation of the vascular endothelium with clot formation on the wall of the vessel. Blood components combining to form an aggregate body describe a thrombus or thrombosis. Clots lodging in the pulmonary vasculature refers to pulmonary embolism; in the femoral vein, femoral thrombophlebitis. 48. Which of the following assessment findings would the nurse expect if the client develops DVT? A. Midcalf pain, tenderness and redness along the vein B. Chills, fever, malaise, occurring 2 weeks after delivery C. Muscle pain the presence of Homans sign, and swelling in the affected limb D. Chills, fever, stiffness, and pain occurring 10 to 14 days after delivery ------ CORRECT ANSWER---------------C. Classic symptoms of DVT include muscle pain, the presence of Homans sign, and swelling of the affected limb. Midcalf pain, tenderness, and redness, along the vein reflect superficial thrombophlebitis. Chills, fever and malaise occurring 2 weeks after delivery reflect pelvic thrombophlebitis. Chills, fever, stiffness and pain occurring 10 to 14 days after delivery suggest femoral thrombophlebitis. 49. Which of the following are the most commonly assessed findings in cystitis? A. Frequency, urgency, dehydration, nausea, chills, and flank pain B. Nocturia, frequency, urgency dysuria, hematuria, fever and suprapubic pain C. Dehydration, hypertension, dysuria, suprapubic pain, chills, and fever D. High fever, chills, flank pain nausea, vomiting, dysuria, and frequency ------ CORRECT ANSWER---------------B. Manifestations of cystitis include, frequency, urgency, dysuria, hematuria nocturia, fever, and suprapubic pain. Dehydration, hypertension, and chills are not typically associated with cystitis. High fever chills, flank pain, nausea, vomiting, dysuria, and frequency are associated with pvelonephritis. 50. Which of the following best reflects the frequency of reported postpartum "blues"? A. Between 10% and 40% of all new mothers report some form of postpartum blues B. Between 30% and 50% of all new mothers report some form of postpartum blues C. Between 50% and 80% of all new mothers report some form of postpartum blues D. Between 25% and 70% of all new mothers report some form of postpartum blues ---- --CORRECT ANSWER---------------C. According to statistical reports, between 50% and 80% of all new mothers report some form of postpartum blues. The ranges of 10% to 40%, 30% to 50%, and 25% to 70% are incorrect. A nurse is reviewing the medical record of a client who is one day postpartum. The client had a vaginal birth with a fourth-degree perineal laceration. The nurse should contact the provider regarding which of the following prescriptions? ------CORRECT ANSWER----------------The nurse should not administer a rectal suppository or enema to a client who has a fourth-degree perineal laceration. These can cause separation of the suture line, bleeding, or infection. A nurse is preparing to administer hepatitis B immune globulin to a newborn. The prescription states, "Administer 5 mcg IM once today." Available is a 5 mL vial with 10 mcg/mL. How many mL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.) ------CORRECT ANSWER----------------STEP 8: Reassess to determine whether the amount to administer makes sense. If there are 10 mcg/mL and the prescription reads 5 mcg, it makes sense to administer 0.5 mL. The nurse should administer hepatitis B immunoglobulin 0.5 mL IM. A staff nurse on an obstetric unit is caring for a client who is scheduled for an induced abortion. The staff nurse informs the nurse manager that she has a moral issue with the client's decision. Which of the following actions should the nurse manager take? ------ CORRECT ANSWER----------------The nurse manager should take into account the staff nurse's moral beliefs and recognize that she also has rights and responsibilities concerning the care of a client who is undergoing an induced abortion. Therefore, the nurse manager should reassign the care of the client to another staff nurse. A nurse is caring for a client who is pregnant and is at the end of her first trimester. The nurse should place the Doppler ultrasound stethoscope in which of the following locations to begin assessing for the fetal heart tones (FHT)? ------CORRECT ANSWER- ---------------At the end of the first trimester of pregnancy, the client's uterus is approximately the size of a grapefruit and is positioned low in the pelvis slightly above the symphysis pubis. Therefore, the nurse should begin assessing for FHTs just above the symphysis pubis. A nurse is planning care for a client who is to undergo a nonstress test. Which of the following actions should the nurse include in the plan of care? ------CORRECT ANSWER----------------Fetal movement may not be evident on the fetal monitor and tracing. Instructing the client to press the button when she detects fetal movement will ensure that the fetal movement is noted. A nurse in the antepartum clinic is assessing a client's adaptation to pregnancy. The client states that she is, "happy one minute and crying the next." The nurse should interpret the client's statement as an indication of which of the following? ------ CORRECT ANSWER----------------The nurse should recognize and interpret the client's statement as an indication of emotional lability. Many women experience rapid and unpredictable changes in mood during pregnancy. Intense hormonal changes may be responsible for mood changes that occur during pregnancy. Tears and anger alternate with feelings of joy or cheerfulness for little or no reason. A nurse is caring for a prenatal client who has parvovirus B19 (fifth disease). Which of the following actions should the nurse take? ------CORRECT ANSWER----------------The nurse should schedule serial ultrasound examinations to monitor the fetus during the pregnancy to detect the possible development of fetal hydrops. A nurse is caring for a client who is at 35 weeks of gestation and is undergoing a nonstress test that reveals a variable deceleration in the FHR. Which of the following actions should the nurse take? ------CORRECT ANSWER----------------Having the client change position is an appropriate intervention for a variable deceleration to relieve umbilical cord compression. A nurse is providing teaching about comfort measures to a client who is breastfeeding and is experiencing engorgement. Which of the following nonpharmacological measures should the nurse include in the teaching? ------CORRECT ANSWER----------------The nurse should suggest applying cold compresses or ice packs to alleviate the discomforts of engorgement in the client who is breastfeeding. A nurse is caring for a client who is in active labor and has had no cervical change in the last 4 hr. Which of the following statements should the nurse make? ------CORRECT ANSWER----------------Insertion of an intrauterine pressure catheter is necessary to determine uterine contraction intensity, which will identify whether or not the contractions are adequate for progression of labor. A nurse in an antepartal clinic is providing care for a client who is at 26 weeks of gestation. Upon reviewing the client's medical record, which of the following findings should the nurse report to the provider? (Click on the "Exhibit" button for additional information about the client. There are three tabs that contain separate categories of data.) ------CORRECT ANSWER----------------Progress Notes Fundal height 30 cm Good fetal movement Not experiencing headache, dizziness, blurred vision, or vaginal bleeding Fetal heart rate 110/min A fundal height measurement of 30 cm should be reported to the provider. Fundal height should be measured in centimeters and is the same as the number of gestational weeks plus or minus 2 weeks from 18 to 32 weeks gestation. Therefore, the nurse should report this finding to the provider. A nurse is assessing a client who is at 30 weeks of gestation during a routine prenatal visit. Which of the following findings should the nurse report to the provider? ------ CORRECT ANSWER----------------Swelling of the face, sacral area, and hands can indicate gestational hypertension or preeclampsia. Reduction in renal perfusion leads to sodium and water retention. Fluid moves out of the intravascular compartment into the tissues, causing edema. A nurse is planning discharge for a client who is 3 days postpartum. Which of the following nonpharmacological interventions should the nurse include in the plan of care for lactation suppression? ------CORRECT ANSWER----------------Plant sterols and salicylates from cabbage leaves can help to relieve swelling and discomfort caused by breast engorgement. A nurse is reviewing the laboratory report of a client who is 24 hr postpartum following a vaginal delivery. Which of the following laboratory results should the nurse identify as an indication of a postpartum infection? ------CORRECT ANSWER----------------The nurse should realize that this value exceeds the expected reference range for a postpartum client and indicates an infection. A nurse is assessing a newborn 12 hr after birth. Which of the following manifestations should the nurse report to the provider? ------CORRECT ANSWER----------------Jaundice occurring within the first 24 hr of birth is associated with ABO incompatibility, hemolysis, or Rh-isoimmunization. The nurse should report this manifestation to the provider. A nurse on a postpartum unit is caring for a client who is experiencing hypovolemic shock. After notifying the provider, which of the following actions should the nurse take next? ------CORRECT ANSWER----------------The greatest risk to the client is hemorrhage. Therefore, the next action the nurse should take is to massage the client's fundus to expel clots and promote contractions. A nurse is caring for a full-term newborn immediately following birth. Which of the following actions should the nurse take first? ------CORRECT ANSWER---------------- When using the urgent vs. nonurgent approach to client care, the nurse should determine that the greatest risk to the newborn is cold stress. Therefore, the first action the nurse should take immediately after delivery is to dry the newborn. A nurse is teaching a client who is pregnant about managing nausea and vomiting. Which of the following instructions should the nurse include in the teaching? ------ complication? ------CORRECT ANSWER----------------Leakage of fluid from the vagina could indicate premature leakage of amniotic fluid and should be reported to the provider. A nurse is caring for a client who has hyperemesis gravidarum and is receiving IV fluid replacement. Which of the following findings should the nurse report to the provider? ---- --CORRECT ANSWER----------------The nurse should report an elevated BUN to the provider since it can indicate dehydration. A nurse is providing discharge teaching to a client who is postpartum and was taking insulin for gestational diabetes mellitus. Which of the following instructions should the nurse include in the teaching? ------CORRECT ANSWER----------------The nurse should instruct the client to get a 2-hr oral glucose tolerance test 6 to 12 weeks postpartum and every 3 years to screen for type 2 diabetes mellitus A nurse is caring for a client who is anemic at 32 weeks of gestation and is in preterm labor. The provider prescribed betamethasone 12 mg IM. Which of the following outcomes should the nurse expect? ------CORRECT ANSWER---------------- Betamethasone is a glucocorticoid that is given to stimulate fetal lung maturity and prevent respiratory distress. A nurse is teaching a client who is in preterm labor about terbutaline. Which of the following statements by the client indicates an understanding of the teaching? ------ CORRECT ANSWER----------------An adverse effect of terbutaline is hypokalemia. Terbutaline is administered subcutaneously every 4 hr for no longer than 24 hr. An adverse effect of terbutaline is hypotension. An adverse effect of terbutaline is hyperglycemia. A nurse is reviewing the medical record of a client who is postpartum and has preeclampsia. Which of the following laboratory results should the nurse report to the provider? ------CORRECT ANSWER----------------A platelet count of 50,000/mm3 is below the expected reference range, which can indicate disseminated intravascular coagulation. The nurse should report this result to the provider. An Hct of 39% is within the expected reference range and is not indicative of a postpartum complication. A serum albumin level of 4.5 g/dL is within the expected reference range. This finding is consistent with mild preeclampsia and does not indicate a worsening of the condition. A WBC of 9,000/mm3 is within the expected reference range. A nurse on the postpartum unit is caring for a client following a cesarean birth. Which of the following assessments is the nurse's priority? ------CORRECT ANSWER---------------- When using the airway, breathing, circulation approach to client care, the nurse should place the priority in the immediate postpartum period on assessing the amount of postpartum lochia. The greatest risk to the client is bleeding and postpartum hemorrhage. A nurse is teaching a client who is at 10 weeks of gestation about nutrition during pregnancy. Which of the following statements by the client indicates an understanding of the teaching? ------CORRECT ANSWER----------------A client who is pregnant should increase her folic acid intake to 600 mcg daily. Folic acid assists with preventing neural tube birth defects. A client who is pregnant should increase her caloric intake by 340 cal during the second trimester and by 452 cal during the third trimester. A client who is pregnant should consume 3 L of water each day. A client who is pregnant should increase her protein intake to 71 g each day during the second and third trimesters. A nurse is teaching a client who is at 35 weeks of gestation about clinical manifestations of potential pregnancy complications to report to the provider. Which of the following manifestations should the nurse include? ------CORRECT ANSWER----------------A headache that is unrelieved by analgesia may indicate preeclampsia and should be reported to the provider. Braxton Hicks contractions are an indication that the uterus is preparing for labor and is an expected clinical manifestation at 35 weeks of gestation. Shortness of breath is related to the enlarging uterus interfering with the expansion of the diaphragm and is an expected clinical manifestation at 35 weeks of gestation. Swelling of feet and ankles is due to the enlarging uterus interfering with blood return to the heart and is an expected clinical manifestation at 35 weeks of gestation. A nurse is caring for a client who becomes unresponsive upon delivery of the placenta. Which of the following actions should the nurse take first? ------CORRECT ANSWER---- ------------The priority action the nurse should take when using the airway, breathing, circulation approach to client care is to determine respiratory function and the need for cardiopulmonary resuscitation. A nurse is caring for a client who is in labor and whose fetus is in the right occiput posterior position. The client is dilated to 8 cm and reports back pain. Which of the following actions should the nurse take? ------CORRECT ANSWER----------------The nurse should apply sacral counterpressure to assist in relieving back labor pain related to fetal posterior position. A nurse is creating a plan of care for a client who is postpartum and adheres to traditional Hispanic cultural beliefs. Which of the following cultural practices should the nurse include in the plan of care? ------CORRECT ANSWER----------------Protecting the client's head and feet from cold air should be included in the plan of care because this is a traditional Hispanic practice during the postpartum period. Offering the client a glass of cold milk with her first meal should not be included in the plan of care because traditional Hispanic practices include drinking warm beverages following birth. Bathing the client within 12 hr following delivery should not be included in the plan of care because traditional Hispanic practices include delaying bathing for 14 days following delivery. Ambulating the client within 24 hr following delivery should not be included in the plan of care because traditional Hispanic practices include bed rest for 3 days following delivery. A nurse is performing a physical assessment of a newborn. Which of the following clinical findings should the nurse expect? (Select all that apply.) ------CORRECT ANSWER----------------A heart rate of 154/min is correct. The expected reference range for a newborn's heart rate is from 110/min to 160/min while awake. An axillary temperature of 36° C (96.8° F) is incorrect. The expected reference range for a newborn's axillary temperature is from 36.5° C (97.7° F) to 37.8° C (100.0° F). A respiratory rate of 58/min is correct. The expected reference range for a newborn's respiratory rate is from 30/min to 60/min. A length of 43 cm (16.9 in) is incorrect. The expected reference range for a newborn's length is from 45 to 55 cm (17.7 to 21.7 in). A client at 32 weeks' gestation is admitted to labor and delivery with vaginal bleeding and contractions. The physician orders a course of two steroid injections. The client asks why she needs steriods. What is the best explanation by the nurse? The steroids speed up the development of the lungs. The steroids will help to slow the development of infection. The steroids will increase the baby's muscle mass. The steroids will create a layer of fat to help with temperature regulation. ------ CORRECT ANSWER------------------The steroids speed up the development of the lungs. At 8 weeks' gestation a woman experiences severe cramping and vaginal bleeding with clots. The health care provider confirms that she is having a miscarriage. What is the priority laboratory test for the provider to obtain in the care of this client? Rh factor Blood group Hemoglobin and hematocrit Human chorionic gonadotropin level ------CORRECT ANSWER------------------Rh factor The father of a stillborn infant tells the nurse he wants to hold the child. What is the nurse's best response? Dress the infant in a T-shirt and diaper and let him hold the infant. Give him some photographs of the infant. Tell him that it would be better not to hold the infant. Encourage him to discuss this with the mother first. ------CORRECT ANSWER------------- -----Dress the infant in a T-shirt and diaper and let him hold the infant. The nurse's assessment identified signs that the client is depressed. What is the nurse's greatest concern for a client who is depressed? Harm to self Lack of a social network Withdrawal from others Poor nutrition ------CORRECT ANSWER------------------Harm to self The nurse is screening a woman during a home visit following birth. The nurse identifies which risk factors for developing postpartum depression? Select all that apply. Low self-esteem Feeling overwhelmed and out of control Low socioeconomic status Lack of social support Involving family in infant care ------CORRECT ANSWER------------------Low self-esteem Feeling overwhelmed and out of control Low socioeconomic status Lack of social support A 40-year-old woman comes to the clinic reporting having missed her period for two months. A pregnancy test is positive. What is she and her fetus at increased risk for? type 2 diabetes mellitus type 1 diabetes mellitus placental abnormalities postterm birth ------CORRECT ANSWER------------------placental abnormalities An 11-year-old boy was raised in a home where his father beat his mother on a regular basis. Which statement is true regarding children being raised in a home where they have witnessed intimate partner violence? They are at increased risk for being abused. They have higher rates of schizophrenia. It has little impact on child functioning. Female children are more likely to experience depression. ------CORRECT ANSWER---- --------------They are at increased risk for being abused. Following an amniocentesis at 16 weeks' gestation, which instructions would the nurse include in the client's discharge teaching? Select all that apply. "If you experience contractions or severe cramping, call the office." "Avoid strenuous activities for the next 24 hours." "If you have a fever above 100.4°F (38.0°C), call the office." "If you feel the fetus moving, call the office." "Maintain bed rest for the next 24 hours." ------CORRECT ANSWER------------------"If you experience contractions or severe cramping, call the office." "Avoid strenuous activities for the next 24 hours." "If you have a fever above 100.4°F (38.0°C), call the office." A client is being treated for choriocarcinoma following a molar pregnancy. The nurse explains that choriocarcinoma can metastasize to other organs. The nurse schedules the client for testing to assess for signs of metastasis to which organs? Select all that apply. Lung Brain Liver Ovary Uterus ------CORRECT ANSWER------------------Lung Brain Liver The nurse is preparing information for a client who has just been diagnosed with gestational diabetes. Which instruction should the nurse prioritize in this information? Maintain a daily blood glucose log Report any signs of possible urinary tract infection Plan daily menus with dietitian Long term therapy goals ------CORRECT ANSWER------------------Maintain a daily blood glucose log The nurse is preparing to see a client at 36 weeks' gestation. Which lab specimen would the nurse prepare to collect during this visit? Rectal and vaginal swabs for group B streptococcus (GBS) Blood results from oral glucose tolerance test (GTT) for diabetes Fetal fibrionectin level to predict onset of labor Kleihauer-Betke for a maternal-fetal bleed ------CORRECT ANSWER------------------ Rectal and vaginal swabs for group B streptococcus (GBS) A client who was postive for group B streptococcus is 72 hours postbirth. The nurse's assessment is noted in the above chart. These findings are consistent with which condition? Endometritis Mastitis Breast engorgement A pregnant client has been diagnosed with gestational diabetes. Which are risk factors for developing gestational diabetes? Select all that apply. maternal age less than 18 years genitourinary tract abnormalities obesity hypertension previous large for gestational age (LGA) infant ------CORRECT ANSWER------------------ obesity hypertension previous large for gestational age (LGA) infant A pregnant woman with gestational diabetes comes to the clinic for a fasting blood glucose level. When reviewing the results, the nurse determines that which result indicates good glucose control? 88 mg/dL 100 mg/dL 110 mg/dL 120 mg/dL ------CORRECT ANSWER------------------88 mg/dL A G2P1 woman with type 1 diabetes is determined to be at 8 weeks' gestation by her health care provider. The nurse should point out which factor will help the client maintain glycemic control? Vitamin supplements Oral hypoglycemic agents Exercise Plenty of rest ------CORRECT ANSWER------------------Exercise A woman is using basal body temperature to determine her fertile period. Which statement by the client indicates that she understands this method? "I will take my temperature first thing in the morning, before I lift my head off the pillow." "I will take my temperature before going to bed in the evening, just before my head hits the pillow." "I will take my temperature at the same time each day." "I will take my temperature immediately after getting out of bed in the morning." ------ CORRECT ANSWER------------------"I will take my temperature first thing in the morning, before I lift my head off the pillow." The most common neonatal sepsis and meningitis infections seen within 24 hours after birth are caused by: group B beta-hemolytic streptococci. Candida albicans. Escherichia coli. Chlamydia trachomatis. ------CORRECT ANSWER------------------group B beta-hemolytic streptococci. A nurse is teaching a female client who is unable to conceive how to monitor her basal body temperature. Which instruction would the nurse prioritize for this client? Record body temperature every night Record menses and time of intercourse Chart body temperature for at least a month Record body weight along with the temperature ------CORRECT ANSWER------------------ Chart body temperature for at least a month The nurse is teaching a client about her new diagnosis, polycystic ovary syndrome. Which statement by the client indicates she knows the cause of her symptoms? "I have extra androgen in my system." "I have high levels of estrogen in my system." "My ovaries are secreting high levels of progesterone." "My circulating hCG (human chorionic gonadotropin) levels are low." ------CORRECT ANSWER------------------"I have extra androgen in my system." A nurse is caring for a client in labor. The nurse determines that the client is beginning the second stage of labor when which assessment is noted? The cervix is dilated completely. The client begins to leak clear vaginal fluid. The membranes have ruptured. The contractions are regular. ------CORRECT ANSWER------------------The cervix is dilated completely. A 42-year old client at 16 weeks' gestation is scheduled for an amniocentesis. The nurse informs the client that the physician will do an ultrasound first, and then numb an area of her abdomen and withdraw some amniotic fluid. The client looks confused and says, "The doctors said we would skip the screening ultrasound and go straight to the diagnostic amniocentesis, because of my age." What is the best response by the nurse to the client's concern? "This ultrasound is to guide the physician to a pocket of amniotic fluid to collect the specimen." "This is not a screening ultrasound. There will be no pictures of the fetus taken." "The physician needs to locate the position of the placenta, umbilical cord, and the fetus before the procedure." "There is no risk to the ultrasound, so most physicians like to do one with the amniocentesis." ------CORRECT ANSWER------------------"This ultrasound is to guide the physician to a pocket of amniotic fluid to collect the specimen." A client chooses the mini-pill (progestin-only pill) for contraception. What does the nurse teach the client about the effectiveness of this form of contraception? You must take it in the same three-hour window every day or it will not be effective. You must take one pill each day. If you miss one pill you can take 2 the next day. You must take it within 12 hours of having intercourse to prevent conception. You must take one of the supplemental pills just before having intercourse. ------ CORRECT ANSWER------------------You must take it in the same three-hour window every day or it will not be effective. A client receives general anesthesia for an emergency cesarean birth. The nurse should monitor the client for which postpartum complication during the first 2 hours after birth? Uterine atony Endometriosis Pneumonia Urinary retention ------CORRECT ANSWER------------------Uterine atony R: Nuchal cord or the umbilical cord being wrapped tightly around the neck, can cause bruising and petechiae over the face, head and neck A nurse is reviewing the medical record at 1800 for a client who is at 34wks gestation. Based in the chart findings and documentation the nursing plan of care should include which of the following actions? ------CORRECT ANSWER------------------Administer terbutaline R: administer terbutaline to stop contractions because the lab results indicate that the fetus's lungs are not mature enough for delivery A nurse is teaching a client who is at 24 wks regarding a 1 hr glucose tolerance test. Which of the following statements should the nurse include in her teaching? ------ CORRECT ANSWER------------------A blood glucose of 130-140 is considered a positive screening result R: The nurse should teach the client that a blood glucose level of 130 to 149 mg/dL is considered a positive screening. If the client receives a positive result, she will need to undergo a 3-hr glucose tolerance test to confirm if she has gestational diabetes mellitus (DM) A nurse is teaching a client who is at 36 wks of gestation and has a rx for NST. Which of the following statements should the nurse include in the teaching? ------CORRECT ANSWER------------------You will be offered OJ to drink during the test R: a nonstress test is performed to measure fetal activity. Having the client drink orange juice, or another beverage high in glucose, will stimulate the fetus during the procedure, helping to obtain results. A nurse is caring for a client who is at 40 wks of gestation and is in early labor. The client has a platelet count of 75,000/mm3 and is requesting pain relief. Which of the following treatment modalities should the nurse anticipate? ------CORRECT ANSWER--- ---------------Attention-focusing R: Attention-focusing and distraction techniques are types of non-pharmacological care that are effective in receiving labor pain Math A nurse is preparing to administer magnesium sulfate 2g/hr IV to a client who is in preterm labor. Available ts 20g magnesium sulfate in 500 ml of dextrose 5% in water (D5W). The nurse should set the IV infusion pump to administer how many ml/hr? (round to whole number) ------CORRECT ANSWER------------------50 ml/hr A nurse is caring for a client who is at 22 wks gestation and reports concern about the blotchy hyper pigmentation of her forehead. Which of the following actions should the nurse take? ------CORRECT ANSWER------------------Explain to the client this is an expected occurrence R: Melasma, also referred to as the mask of pregnancy, is a blotchy, brown hyper pigmentation of the skin over the cheeks, nose, and forehead. It is seen most often in dark-skinned women and is caused by an increase in melantonin during pregnancy. This condition appears after 16 weeks of gestation and increases gradually until delivery for 50 to 70 % of women. Nurse should reassure the client that this is an expected occurrence which usually fades after delivery. A nurse is providing dietary teaching to a client who has hyperemesis gravidarum. Which of the following statements by the client indicates an understanding of the teaching? ------CORRECT ANSWER------------------"I will eat foods that appeal to my taste instead of trying to balance my meals"R: Clients who have hyperemeis gravidrum should eat to taste to avoid nausea A nurse is planing care for a client who is at 24 wks of gestation and reports daily mild headaches. Which of the following instructions should the nurse include in the plan of care? ------CORRECT ANSWER------------------Recommend that the client perform conscious relaxation techniques daily R: The nurse should include conscious relaxation techniques in the plan of care as a way to relieve tension and reduce stress, which can help decrease and eliminate headaches a nurse in a provider's office is reviewing the medical record of a client who is in her first trimester of pregnancy. which of the following findings should the nurse identify as a risk factor for the development of preeclampsia ------CORRECT ANSWER------------------ Pregestational diabetes mellitus increases a client's risk for the development of preeclampsia. Other risk factors include preexisting hypertension, renal disease, systemic lupus erythematosus, and rheumatoid arthritis. A nurse is providing discharge teaching to a parent whose newborn has just had a circumcision. Which of the following instructions should the nurse include? ------ CORRECT ANSWER------------------Apply slight pressure with a sterile gauze pad for mild bleeding a nurse is assessing a client who is postpartum. The client's fundus is two fingerbreadths above the umbilicus, deviated to the right of the midline, and less firm than previously noted. Which of following actions should the nurse take? ------ CORRECT ANSWER------------------assist the client to the bathroom to void A nurse is caring for a client who has recently experienced a perinatal death. Which of the following statements should the nurse make to the client? ------CORRECT ANSWER------------------"I'm sad for you"R: the nurse is offering empathy to the client to facilitate further communication about the perinatal death A nurse is caring for a client who has uterine hypotonicity and is experiencing postpartum hemorrhage. Which of the following actions is the nurse's priority? ------ CORRECT ANSWER------------------Massage the client's fundus A nurse is teaching about effective breastfeeding to a client who is 3 days postpartum. Which of the following information should the nurse include? ------CORRECT ANSWER- -----------------"Your newborn should appear content after each feeding" A nurse is teaching a client who has pregestational type 1 diabetes mellitus about management during pregnancy. Which of the following statements by the client indicates an understanding of the teaching? ------CORRECT ANSWER------------------"I will continue taking my insulin if I experience nausea and vomiting." A nurse is admitting a client to the labor and delivery unit when the client states. my water just broke. Which of the following interventions is the nurse's priority? ------ CORRECT ANSWER------------------Begin FHR monitoring R: The greatest risk to the client to the client and her fetus following a rupture of membranes is umbilical cord prolapse, The nurse should monitor the fetus closely to to ensure well-being. Therefore. this is the priority action the nurse should take. A nurse is assessing a client who is 12 hr postpartum. The client's funds is two finger breadths above the umbilicus, deviated to the right of the midline, and less firm than previously noted. Which of the following actions should the nurse take? ------CORRECT ANSWER------------------Assist the client to the bathroom to void A nurse is performing a physical assessment of a newborn upon admission to the nursery. Which of the following clinical manifestations should the nurse expect? ------ CORRECT ANSWER------------------Creases over two-thirds of the soles of the feet Molding of the head Lanugo of the shoulders a Nurse is preparing to perform Leopold maneuvers for a client. Identify the sequence the nurse should follow. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.) ------CORRECT ANSWER--------------- ---The first step the nurse should take when performing Leopold maneuvers is to palpate the client's fundus to identify the fetal part. Second, the nurse should determine the location of the fetal back. Third, the nurse should palpate for the fetal part presenting at the inlet. Finally, the nurse should palpate the cephalic prominence to identify the attitude of the head A nurse is assessing FHR for a client who is preg. The nurse has determined as left occipital anterior (LOA). To which of the following areas of the clients abdomen should the nurse apply the ultrasound transducer in order to assess the PMI of the fetal heart? ------CORRECT ANSWER------------------Left lower quadrant R: The fetal heart tones of a fetus in the occipital anterior position are best heard in the left lower quadrant. A nurse is providing education about the family bonding to parents who recently adopted a newborn. The nurse should make which of the following suggestions to aid the family 7-yr old in accepting the new family member? ------CORRECT ANSWER------- -----------Obtain a gift from the newborn to present to the sibling A nurse is speaking with a client who is trying to make a decision about uterine tube occlusion. The client asks what effects will this procedure have on my sec life? Which of the following responses should the nurse make? ------CORRECT ANSWER----------------- -v a nurse is performing a newborn assessment. which of the following images should the nurse identify as an indication of spina bifida occulta? ------CORRECT ANSWER---------- --------The first picture - looks like a bruise and small opening maybe at top of buttock. The nurse should identify this as an image of spina bifida occulta. External indications of this neural tube defect include a dimpled area over the defect and the presence of a birthmark or hairy patch above the area A nurse is teaching clients in a prenatal class about the importance of taking folic acid during preg. The nurse should instruct the clients to consume an adequate amount of folic acid from various sources to percent which of the following fetal abnormalities ------ CORRECT ANSWER------------------Neural tube defect R: folic acid sources include fortified cereals, grain products, oranges, artichokes, liver, broccoli and asparagus A school nurse is providing teaching to an adolescent about levonorgestrel contraception. Which of the following information should the nurse include in the teaching? ------CORRECT ANSWER------------------You should take the medication w/in 72 hrs following unprotected sexual intercourse R: considered the emergency contraceptive which inhibits ovulation to prevent conception A nurse is developing an educational program for adolescents about nutrition during the third trimester of preg. Which of the following statements should the nurse include in the program? ------CORRECT ANSWER------------------"Consume three to four servings of dairy each day" A nurse is assessing four newborns. Which of the following findings should the nurse report to the provider. ------CORRECT ANSWER------------------An axillary temperature greater than 37.5° C (99.5° F) is above the expected reference range for a newborn and can be an indication of sepsis. Therefore, the nurse should report this finding to the provider. A nurse is performing a vaginal exam on a client who is in labor and reports severe pressure and pain in the lower back. The nurse notes that the fetal head is in a posterior position. The nurse should identify that which of the following is the best non pharmacological intervention to perform to relieve the client's discomfort? ------ CORRECT ANSWER------------------Counter pressure A nurse is providing d/c teaching to the parents of a newborn about using a car seat properly. Which of the following instructions should the nurse include? ------CORRECT ANSWER------------------Position the car seat rear-facing in the back seat of the vehicle R: The nurse should instruct the parents to position the car seat rear-facing in the back seat of the vehicle because it avoids injury from front seat airbags and protects the newborn's heavy head and weak neck in the event of a sudden stop or collision. Infants and toddlers should remain rear-facing in the backseat until they are 2 years old or reach the height and weight requirements of the car seat manufacturer. A nurse is developing a plan of care for a client who has preeclampsia and is receiving magnesium sulfate via a continuous IV infusion. Which of the following interventions should the nurse include in the plan? ------CORRECT ANSWER------------------Monitor the FHR continuously A nurse is planning care for a client who is 2 hr postpartum. Which of the following interventions should the nurse plan to implement during the taking-hold phase of postpartum behavioral adjustment? ------CORRECT ANSWER------------------ Demonstrate to the client how to perform a newborn bath. A nurse is preparing to collect a blood specimen from a newborn via a heel stick. Which of the following techniques should the nurse use to help minimize the pain of the procedure to a newborn? ------CORRECT ANSWER------------------Place the newborn skin to skin on the mother's chest A nurse is caring for a client who is to receive oxytocin to augment her labor. which of the following findings contraindicates the initiation of the oxytocin infusion and requires notification of the provider ------CORRECT ANSWER------------------Late decelerations A nurse is planning care for a client who is in labor and is requesting epidural anesthesia for pain control. Which of the following actions should the nurse include in the plan of care? ------CORRECT ANSWER------------------Monitor the client's blood pressure every 5 min following the first dose of anesthetic solution A nurse is teaching a new mother how to use a bulb syringe to suction her newborn's secretions. Which of the following instructions should the nurse include? ------ CORRECT ANSWER------------------Stop suctioning when the newborn's cry sounds clear. A nurse is assessing a late preterm newborn. Which of the following clinical manifestations is an indication of hypoglycemia? ------CORRECT ANSWER----------------- -Respiratory distress When determining the frequency of contractions, the nurse would measure which period of time? A. Start of one contraction to the start of the next contraction B. Beginning of one contraction to the end of the same contraction C. Peak of one contraction to the peak of the next contraction D. End of one contraction to the beginning of the next contraction ------CORRECT ANSWER-----------------A. Start of one contraction to the start of the next contraction Which fetal lie is most conducive to a spontaneous vaginal birth? A. Transverse B. Longitudinal C. Perpendicular D. Oblique ------CORRECT ANSWER-----------------B. Longitudinal Places the fetus in a vertical position, which would be the most conductive for a spontaneous vaginal birth ** cannot deliver a vaginal birth with oblique or transverse lie** Which observation would suggest that placental separation is occurring? A. Uterus stops contracting altogether. B. Umbilical cord pulsations stop. C. Uterine shape changes to globular. D. Maternal blood pressure drops. ------CORRECT ANSWER-----------------C. Uterine shape changes to globular After the placenta separates from the uterine wall, the uterine shape changes from discoid to globular As the nurse is explaining the difference between true versus false labor to her childbirth class, she states that the major difference between them is A. discomfort level is greater with false labor. B. progressive cervical changes occur in true labor. C. there is a feeling of nausea with false labor. D. there is more fetal movement with true labor. ------CORRECT ANSWER----------------- B. progressive cervical changes occur in true labor. The most intense time during labor is during the A. latent phase. B. active phase. C. membranes breaking. D. placental expulsion phase. ------CORRECT ANSWER-----------------C. membranes breaking. (Transition phase) Which assessment would indicate that a woman is in true labor? A. Membranes are ruptured and fluid is clear. B. Presenting part is engaged and not floating. C. Cervix is 4 cm dilated, 90% effaced. D. Contractions last 30 seconds every 5 to 10 minutes. ------CORRECT ANSWER-------- ---------C. Cervix is 4 cm dilated, 90% effaced. Which interventions are underutilized in promoting a normal birth? Select all that apply. A. Oral nutrition and fluids in labor B. Open-glottis pushing in the second stage of labor C. Skin-to-skin contact after birth for infant bonding D. Routine artificial rupture of membranes (amniotomy) E. Labor induction with intravenous Pitocin F. Routine episiotomy to shorten labor length ------CORRECT ANSWER-----------------A. Oral nutrition and fluids in labor B. Open-glottis pushing in the second stage of labor C. Skin-to-skin contact after birth for infant bonding Physiologic preparation for labor would be demonstrated by A. a decrease in Braxton Hicks contractions felt by mother. B. weight gain and an increase in appetite by mother. C. lightening, when the fetus drops into true pelvis. D. fetal heart rate accelerations and increased movements. ------CORRECT ANSWER-- ---------------C. lightening, when the fetus drops into true pelvis. A laboring woman is admitted to the labor and birth suite at 4-cm dilation. She would be in which phase of labor? A. Latent B. Active C. Late D. Early ------CORRECT ANSWER-----------------B. Active When assessing a patient in true labor which of the following is most likely to be seen? - -----CORRECT ANSWER-----------------Bloody Show When true labor occurs, the cervix becomes softened and dilated and effacement occurs; this process is evident by a bloody show, which is the expulsion of cervical mucus that is pinkish in color. This typically occurs during true labor, however can sometimes occur in false labor if early cervical changes have occurred. A. "You have a one in four (25%) chance." B. "The risk is 12.5%, or a one in eight chance." C. "The chance is 100%." D. "Your risk is 50%, or a one in two chance." ------CORRECT ANSWER-----------------D. "Your risk is 50%, or a one in two chance." What is the first step in determining a couple's risk for a genetic disorder? A. Observing the client and family over time B. Conducting extensive psychological testing C. Obtaining a thorough family health history D. Completing an extensive exclusionary list ------CORRECT ANSWER-----------------C. Obtaining a thorough family health history A nurse is working in a women's health clinic. Which woman would genetic counseling be most appropriate for? A. Had her first miscarriage at 10 weeks B. Is 30 years old and planning to conceive C. Has a history with a close relative with Down syndrome D. Is 18 weeks pregnant with a normal triple screen result ------CORRECT ANSWER---- -------------A. Had her first miscarriage at 10 weeks Which of the following is an example of an autosomal dominant disorder? A. Phenylketonuria B. Tay-Sachs disease C. Polycystic kidney disease D. Cystic fibrosis ------CORRECT ANSWER-----------------C. Polycystic kidney disease Which of the following is the major goal of genetic counseling? A. Identify and determine the role of heredity B. Reinforce previously presented test data C. Emphasize good communication skills D. Offer referral to community support groups ------CORRECT ANSWER-----------------A. Identify and determine the role of heredity Which of the following data on a client's health history would the nurse identify as contributing to the client's risk for an ectopic pregnancy? A) Use of oral contraceptives for 5 years B) Ovarian cyst 2 years ago C) Recurrent pelvic infections D) Heavy, irregular menses ------CORRECT ANSWER-----------------C) Recurrent pelvic infections In a woman who is suspected of having a ruptured ectopic pregnancy, the nurse would expect to assess for which of the following as a priority? A) HemorrhageB) JaundiceC) EdemaD) Infection ------CORRECT ANSWER---------------- -A) Hemorrhage Which of the following findings would the nurse interpret as suggesting a diagnosis of gestational trophoblastic disease? A) Elevated hCG levels, enlarged abdomen,quickening B) Vaginal bleeding, absence of FHR, decreasedhPL levels C) Visible fetal skeleton on ultrasound, absenceof quickening, enlarged abdomen D) Gestational hypertension, hyperemesisgravidarum, absence of FHR ------CORRECT ANSWER-----------------D) Gestational hypertension, hyperemesisgravidarum, absence of FHR It is determined that a client's blood Rh is negative and her partner's is positive. To help It is determined that a client's blood Rh is negative and her partner's is positive. To help prevent Rh isoimmunization, the nurse anticipates that the client will receive RhoGAM at which time? A) At 34 weeks' gestation and immediatelybefore discharge B) 24 hours before delivery and 24 hours afterdelivery C) In the first trimester and within 2 hours ofdelivery D) At 28 weeks' gestation and again within 72 ------CORRECT ANSWER-----------------D) At 28 weeks' gestation and again within 72hours after delivery The nurse is developing a plan of care for a woman who is pregnant with twins. The nurse includes interventions focusing on which of the following because of the woman's increased risk? A) Oligohydramnios B) Preeclampsia C) Post-term labor D) Chorioamnionitis ------CORRECT ANSWER-----------------B) Preeclampsia A woman hospitalized with severe preeclampsia is being treated with hydralazine to control blood pressure. Which of the following would the lead the nurse to suspect that the client is having an adverse effect associated with this drug? A) Gastrointestinal bleeding B) Blurred vision C) Tachycardia D) Sweating ------CORRECT ANSWER-----------------C) Tachycardia After reviewing a client's history, which factor would the nurse identify as placing her at risk for gestational hypertension? A) Mother had gestational hypertension duringpregnancy. B) Client has a twin sister. C) Sister-in-law had gestational hypertension. D) This is the client's second pregnancy. ------CORRECT ANSWER-----------------A) Mother had gestational hypertension duringpregnancy. A client with hyperemesis gravid arum is admitted to the facility after being cared for at home without success. Which of the following would the nurse expect to include in the client's plan of care? A) Clear liquid diet B) Total parenteral nutrition C) Nothing by mouth D) Administration of labetalol ------CORRECT ANSWER-----------------C) Nothing by mouth The nurse is reviewing the laboratory test results of a pregnant client. Which one of the following findings would alert the nurse to the development of HELLP syndrome? B) Insidious onset C) Absence of pain D) Rigid uterus E) Absent fetal heart tones ------CORRECT ANSWER-----------------A) Dark red vaginal bleedingD) Rigid uterusE) Absent fetal heart tones The health care provider orders PGE2 for a woman to help evacuate the uterus following a spontaneous abortion. Which of the following would be most important for the nurse to do? A) Use clean technique to administer the drug. B) Keep the gel cool until ready to use. C) Maintain the client for 1/2 hour afteradministration. D) Administer intramuscularly into the deltoidarea. ------CORRECT ANSWER-------------- ---C) Maintain the client for 1/2 hour afteradministration. A nursing student is reviewing an article about preterm premature rupture of membranes. Which of the following would the student expect to find as factor placing a woman at high risk for this condition? (Select all that apply.) A) High body mass index B) Urinary tract infection C) Low socioeconomic status D) Single gestationsE) Smoking ------CORRECT ANSWER-----------------B) Urinary tract infectionC) Low socioeconomic statusE) Smoking A woman with hyperemesis gravid arum asks the nurse about suggestions to minimize nausea and vomiting. Which suggestion would be most appropriate for the nurse to make? A) "Make sure that anything around your waist isquite snug." B) "Try to eat three large meals a day with lesssnacking." C) "Drink fluids in between meals rather thanwith meals." D) "Lie down for about an hour after you eat" ------CORRECT ANSWER-----------------C) "Drink fluids in between meals rather thanwith meals." A woman with gestational hypertension experiences a seizure. Which of the following would be the priority? A) Fluid replacement B) Oxygenation C) Control of hypertension D) Delivery of the fetus ------CORRECT ANSWER-----------------B) Oxygenation A woman is receiving magnesium sulfate as part of her treatment for severe preeclampsia. The nurse is monitoring the woman's serum magnesium levels. Which level would the nurse identify as therapeutic? A) 3.3 mEq/L B) 6.1 mEq/L C) 8.4 mEq/L D) 10.8 mEq/L ------CORRECT ANSWER-----------------B) 6.1 mEq/L How long does sperm live in the female reproductive system after intercourse? a) 1 week b) 2-3 days c) 5-6 days d) 2 weeks ------CORRECT ANSWER----------------b) 2-3 days For fertilization to occur, intercourse must happen ______ days before ovulation or _______ after ovulation. ------CORRECT ANSWER----------------2-3 days BEFORE 24 hrs AFTER What is spinnbarkeit? ------CORRECT ANSWER----------------Cervical mucous Thin, clear, stretchy Promotes sperm passage Occurs around day 14 of menstrual cycle Does basal body temperature increase or decrease before or after ovulation? ------ CORRECT ANSWER----------------Decreases BEFORE ovulation Increases AFTER When should women take their basal body temperature if tracking menstrual cycle / ovulation periods? ------CORRECT ANSWER----------------Immediately upon waking up When should prenatal vitamins and folic acid be introduce to women? ------CORRECT ANSWER----------------During the PLANNING phase of pregnancy What is Mittelschmerz? ------CORRECT ANSWER----------------Lower abdominal pain associated with ovulation *think Moan List 6 Presumptive signs of pregnancy... ------CORRECT ANSWER----------------*Noticed by the women - Breast changes - Amenorrhea (missed period) - N/V - Frequent urnation - Fatigue - Quickening (fetal movement felt by the mother is still not FOR SURE) List 5 Probable signs of pregnancy... ------CORRECT ANSWER----------------*Noticed my examiner - Positive pregnancy test - Braxton hicks (womb contracts and relaxes) - Goodell Sign (softening of the cervical tip) - Chadwick Sign (blush vaginal mucosa & cervix) - Hegar Sign (softening of the lower uterine segment) List 3 Positive signs of pregnancy... ------CORRECT ANSWER----------------*Proof of fetus - Ultrasound (5-6 weeks) - Fetal heart tones heard by ultrasound, doppler, or stethoscope - Fetal movement palpated or visible BY MEDICAL PROFESSIONAL (Dr./NP/Nurse/Midwife) Should a pregnant mother be going in hot tubs or taking hot baths? ------CORRECT ANSWER----------------No Can cause birth defects What does smoking while pregnant commonly cause? ------CORRECT ANSWER--------- -------Sudden infant death syndrome (SIDS) Low birth weight Infant Viability = __________ weeks Term = __________ weeks ------CORRECT ANSWER----------------Infant Viability = 24 weeks Term = 37-40 weeks Normal FHR in utero = _________ bpm ------CORRECT ANSWER----------------120-160 bpm What is the number one leading cause of neonatal mortality? How is it transmitted? ----- -CORRECT ANSWER----------------Group B Strep Transmitted from mother to baby after rupture of membranes through the birth canal screening done at 35 weeks and delivery How is Group B Strep treated? ------CORRECT ANSWER----------------Prophylactically with Penicillin (this is not an STI) What is an ultrasound? What must mom do before hand? ------CORRECT ANSWER----- -----------Safest method to monitor fetal growth and development Used to confirm pregnancy and/or miscarriage Mother must FILL bladder to bring uterus to the surface for better visualization What is a non-stress test? How does it work? ------CORRECT ANSWER---------------- Measures the response of fetal heart rate (FHR) to fetal movement. Mother wears a fetal heart monitor and presses a button when she feels movement What is considered a Reactive Non-stress test? ------CORRECT ANSWER---------------- As the fetus moves, the FHR. should increase 85% of the time and then decrease again Minimum of 2 accelerations in a 20 minute period lasting 15 seconds at an increase of 15bpm = Reactive Absence of acceleration if sleeping is normal The lack of 2 (+) accelerations within 20 minutes = Nonreactive (needs further assessment) What is an amniocentesis? ------CORRECT ANSWER----------------the sampling of amniotic fluid using a needle inserted into the uterus, to screen for developmental abnormalities in a fetus. Done after 14 weeks What is fundal height? ------CORRECT ANSWER----------------Measurement of the uterine height (fundus) during 2nd trimester Indicates gestational age and fetal growth 22-24 weeks should rise to the umbilicus Full-term can reach the xyphoid process Measurement should be + 1-2 cm gestational age What is a biophysical profile? ------CORRECT ANSWER----------------scoring system to evaluate fetal well being (high risk pregnancies, or when there is materna/physician concern like decreased fetal movements or non-reactive NST) Five parameters: 1) Fetal size and head circumference 2) Fetal tone 3) Fetal movement 4) Fetal breathing 5) amniotic fluid volume 8-10 is considered normal repeated only once or twice weekly until term for high risk pregnancies How does gestational diabetes occur? ------CORRECT ANSWER----------------- Fetal nutrition demands rise and maternal insulin resistance increases due to placental hormones - The pancreas is unable to produce sufficient insulin for mom and baby OR insulin isn't used efficiently What contributing factors may lead to gestational diabetes? (Select all that apply) a) Previous diagnosis of Type 1 Diabetes b) Age (over 25) c) Overweight d) Family history ------CORRECT ANSWER----------------b) Age (over 25) c) Overweight d) Family history Are all women screened for gestational diabetes? If so, when? ------CORRECT ANSWER----------------Yes, all women are screening in regards to history, risk factors, blood sugar levels Glucose screening usually begins 24-28 weeks for high risk patients How does blood sugar screening work for gestational diabetes? What is administered? What do the results mean? ------CORRECT ANSWER----------------50g oral glucose given and blood sugar taken at one hour NORMAL = < 7.21 - 7.77 If abnormal (> 7.77) a 3 hour glucose tolerance test is done The 3 hour test is a fasting blood sugar 100g of oral glucose given, blood sugar taken at 1, 2, 3 hours. Positive if 2 of the following are met... What causes preeclampsia? ------CORRECT ANSWER----------------Cause remains unknown Thought is that new blood cells in the placenta don't develop properly and are narrow causing insufficient blood flow to the uterus (thin, non-adaptable uterine arteries) What are S&S of preeclampsia? Select all that apply a) Sudden weight loss b) Edema in face/hands c) Hypotension d) Proteinuria e) Visual disturbances ------CORRECT ANSWER----------------b) Edema in face/hands d) Proteinuria e) Visual disturbances How is preeclampsia diagnosed? ------CORRECT ANSWER----------------No reliable test/screening tool Based on Hypertension, proteinuria and dependent edema What is HELLP Syndrome? H EL LP ------CORRECT ANSWER----------------Hemolysis Elevated liver enzymes Low platelets Severe preeclampsia in the 3rd trimester or within 48hrs of birth Name a few risk factors for preeclampsia... ------CORRECT ANSWER---------------- Primigravidity (pregnant for the first time) Extreme ages (<19/>40) Obesity Family history What is a high risk complication related to preeclampsia? ------CORRECT ANSWER----- -----------Placental Abruption What is the ONLY cure for preeclampsia? ------CORRECT ANSWER---------------- delivery of baby What medication classes are involved in care of preeclampsia? ------CORRECT ANSWER----------------Anti-hypertensives Corticosteroids (improve liver function, especially for HELLP syndrome) - Betamethasone - increases surfactant in fetal lungs Anticonvulsants - Magnesium Sulphate What is eclampsia? ------CORRECT ANSWER----------------uncontrolled preeclampsia + seizures Medical emergency for mom and baby Birth is immediately induced regardless of gestational age List S&S specific to eclampsia... ------CORRECT ANSWER----------------Severe headache*** Increased right upper abdominal pain Blurred vision Altered LOC What possible complications are included in relation to eclampsia? ------CORRECT ANSWER----------------Death of mom and baby Multi-system organ failure HELLP syndrome Stroke/MI What is #1 drug of choice to treat Eclampsia related seizures? ------CORRECT ANSWER----------------IV Magnesium Sulfate Maintain airway What can happen to the uterine membrane after a maternal seizure? ------CORRECT ANSWER----------------Convulsions make the uterus become hypercontractile and membranes can rupture How do mothers with Eclampsia usually give birth? ------CORRECT ANSWER------------- ---Labor induced Usually c-section upon stabilization of mom What is Magnesium Sulfate? ------CORRECT ANSWER----------------Sedative, anticonvulsant Mg vasodilates Hypertonic solution (decreases edema) Excreted by the kidneys What do we do if your patient receiving Mg Sulfate decreases in output? ------ CORRECT ANSWER----------------STOP the Mg What is an alternate use for Mg Sulfate in pregnant women? ------CORRECT ANSWER- ---------------Mg stops labor, given to treat preterm labor Labor will only occur with the use of oxytocin How should we never position a pregnant women? ------CORRECT ANSWER-------------- --On her back This impartial kidney perfusion, placental perfusion and cardiac output How do we position pregnant women in bed? ------CORRECT ANSWER---------------- ALWAYS on their side Cardiac output is best when laying on LEFT side (avoids compression of vena cava) How are women monitored post hydatidiform mole termination? ------CORRECT ANSWER----------------hCG levels are monitored weekly until normal for 3 consecutive weeks Then taken monthly for 6 months These women are followed for 1 year What is placenta previa? ------CORRECT ANSWER----------------When the placenta partially or completely covers the cervix. Can cause serious bleeding before/during delivery Hemorrhage is greatest concern #1 S&S for placenta previa? ------CORRECT ANSWER----------------Bright RED PAINLESS vaginal bleeding with or without cramping What does partial placenta previa look like? ------CORRECT ANSWER---------------- Placenta partially covers cervix What does complete placenta previa look like? ------CORRECT ANSWER---------------- Placenta covering the cervix completely How are placenta previa babies birthed? ------CORRECT ANSWER---------------- ALWAYS c-section Otherwise, placenta would be delivered first vaginally What is the #1 worry regarding placenta previa? ------CORRECT ANSWER---------------- Hemorrhage pt. sent home if bleeding stops and asymptomatic Return to hospital if bleeding begins again within 48 hours What is abruptio placentae? ------CORRECT ANSWER----------------Premature separation of a normally implanted placenta after the 20th week but before birth #1 S&S for abruptio placentae? ------CORRECT ANSWER----------------PAINFUL vaginal bleeding PAINFUL abdomen PAINFUL uterine contractions (it is possible to have no bleeding if the placenta traps it within, fundal height would increase due to expansion... pain would still be significant) Why is abruptio placentae dangerous? ------CORRECT ANSWER----------------Can deprive baby of oxygen/nutrients and cause maternal hemorrhage What are major complications related to abruptio placentae? ------CORRECT ANSWER- ---------------Shock and kidney failure DIC (40%) Fetal mortality (50%) How do we treat abruptio placentae? ------CORRECT ANSWER----------------Fluid/blood transfusions Observation and bedrest in hospital Sent home if bleeding stops and asymptomatic Return to hospital if bleeding begins again within 48 hours IF the fetus is mature and there is moderate bleeding... Immediate Birth (vaginal preferred, c-section if necessary) Previa vs. Abruptio Placenta: Pain: Blood: Labor type: ------CORRECT ANSWER----------------Previa vs. Abruptio Covering cervix | Prematurely separates Absent | Intense Always (bright red) | Yes or No (dark red) C-section | Vaginal preferred What is labour engagement? ------CORRECT ANSWER----------------When the presenting part has passed through the pelvic inlet Best case scenario = head What is the nurses first priority when membranes rupture (water breaks)... ------ CORRECT ANSWER----------------Check FHR and assess for prolapsed cord What is fetal station? ------CORRECT ANSWER----------------relation of the presenting part of the fetus to the maternal ischial spines, measures the degree of descent of the fetus in cm. *think +4 = on the floor 0 = ischial spine During a prenatal clinic, a women asks you when she should go to the hospital for the birth of her child... How should the nurse respond? ------CORRECT ANSWER-------------- --Go to the hospital if your membrane ruptures or when your contractions are regular, become stronger, last longer and occur close together What is false labor? ------CORRECT ANSWER----------------Uterine contractions that do not lead to cervical dilation (irregular and isolated as abdominal pain) Example is Braxton Hicks What is true labor? ------CORRECT ANSWER----------------Contractions are regular and increasing and are not relieved by change in position. In fact, activity makes pain worse. Discomfort in back radiates around to abdomen. What position should mom be in when initiating an epidural? ------CORRECT ANSWER- ---------------Side-lying in modified sims position Back curved to widen intervertebral space Explain Early Decelerations ------CORRECT ANSWER----------------Drop in FHR matches Maternal contractions (head compression) Explain Late Decelerations ------CORRECT ANSWER----------------Drop in FHR doesn't match Maternal contraction patterns and occurs LATE in the contraction (placental insufficiency) Explain Variable Decelerations ------CORRECT ANSWER----------------FHR drops in response to umbilical cord compression Can sometimes be corrected by repositioning mom Prolonged is dangerous What is shoulder dystocia? ------CORRECT ANSWER----------------Shoulder of the fetus prevents progress of labour (common with vaginal delivery) Can cause fetal hypoxia and increases risk for forcep injuries (maternal tearing, lacerations) What is turtle sign? ------CORRECT ANSWER----------------Retraction of fetal head against the perineum immediately following its emergence Retraction of the baby's head back into the vagina, known as "turtle sign". Cord compression results in variable decels in FHR, what is the nurses next interventions? ------CORRECT ANSWER----------------Monitor fetal heart tones Put mother knee to chest Apply O2 Manually lift the head of the fetus into the uterus to relieve pressure until OB arrives NEVER attempt to put the cord back in What 2 medications aid in halting labor? ------CORRECT ANSWER---------------- Terbutaline Mg Sulfate You anticipate pre-term labor for your patient, what should the nurse administer to aid in surfactant stimulation? How many doses? ------CORRECT ANSWER---------------- Betamethasone IM 2 injections 24 hours apart Given to mother to mature fetal lungs When should placental delivery occur? ------CORRECT ANSWER----------------30 mins after baby #1 worry is retained placental fragments Inspect for intactness What is significant about lochia order? ------CORRECT ANSWER----------------It should NOT trend backwards. Alba --> Rubra is a medical emergency What is normal postpartum bleeding? ------CORRECT ANSWER----------------Clots okay if <2cm and soft Should not have foul odour More than 1 pad in an hour is hemorrhage What does a boggy fundus indicate? ------CORRECT ANSWER----------------Hemorrhage Fundus should be firm and midline (ensure bladder is emptied) Gentling massage a boggy fundus until firm Maternal postpartum vital signs... ------CORRECT ANSWER----------------BP returns to normal Bradycardia is common (40-50bpm) Temp increase (38.0) is normal in 1st 24hrs Low BP think hemorrhage Tachycardia think hemorrhage Diuresis should commence in 12 hrs - No output think SHOCK List 2 big postpartum risks... ------CORRECT ANSWER----------------Infection Hemorrhage # 1 cause = uterine atony, retained placental fragments, lacerations, etc Uterine atony, retained placental fragments, lacerations, etc, what is the number 1 drug of choice? ------CORRECT ANSWER----------------Oxytocin How does the uterus return to normal post birth? ------CORRECT ANSWER---------------- 2 cm BELOW umbilicus directly after birth Within 12 cm it is 1cm ABOVE umbilicus Descends 1-2cm q24hrs Is non-palpable after 2 weeks Returns to non-pregnant location by 6 weeks What is done with the umbilical cord immediately after birth? ------CORRECT ANSWER- ---------------Cord clamped and cut What 2 drugs are administered to babies immediately after birth? ------CORRECT ANSWER----------------Erythromycin drops/ointment to prevent gonorrhea/chlamydia Phytonadione (Vit K) IM injection into vastus laturalus for clotting factors When is APGAR score taken? ------CORRECT ANSWER----------------1 minute and 5 minutes immediately after birth What is the Grasp reflex? When should it disappear? ------CORRECT ANSWER----------------Place finger in infants palm and infants hand will grasp finger Disappear = 3-4 months What is the Tonic Neck (fencing) reflex? When should it disappear? ------CORRECT ANSWER----------------Turning the infants head to one side while laying on their back will cause them to assume a fencing position The arm to which the head is turned will be straight out (extended), while the other will be bent up (flexed) Disappear = 3-4 months What is the Moro reflex? When should it disappear? ------CORRECT ANSWER----------------Hold infant in laying position and allow heat to slightly drop or create a loud startling noise: The infant will arch back, extend legs, bring arm in close to the body ?? Though it was opposite ... google confirms --> It is a response to a sudden loss of support and involves three distinct components: spreading out the arms (abduction) pulling the arms in (adduction) crying (usually) Disappear = 6 months How do we discontinue breastfeeding? Select all that apply a) Use cabbage leaves for inflammation b) Stimulate the breasts each day c) Use ice packs d) Take oral Pitocin e) Initiate analgesics if needed ------CORRECT ANSWER----------------a) Use cabbage leaves for inflammation c) Use ice packs e) Initiate analgesics if needed What is Mastitis? ------CORRECT ANSWER----------------Infected breast tissue causing pain/swelling/redness/warmth How do we treat Mastitis? Select all that apply a) Antibiotics b) Breastfeeding c) Warm compress before feeds d) Offer affected breast first e) Take ABX before feeding ------CORRECT ANSWER----------------a) Antibiotics b) Breastfeeding c) Warm compress before feeds d) Offer affected breast first Feed before antibiotics Additionally, take analgesics/antipyretics prn What is meconium? ------CORRECT ANSWER----------------A thick, green, tar-like substance that lines your baby's intestines during pregnancy. Typically this substance is not released in your baby's bowel movements until after birth. However, sometimes a baby will have a bowel movement prior to birth, excreting the meconium into the amniotic fluid. How often should we instruct mothers to breastfeed? ------CORRECT ANSWER----------- -----8-12 times in 24 hours Wake baby to feed if necessary How long should babies breastfeed? ------CORRECT ANSWER----------------Exclusively recommended for the first 6 moths and up tp 2 years What is Colostrum? ------CORRECT ANSWER----------------A nutrient-rich fluid produced by female mammals immediately after giving birth. Rich in immunoglobulins Mature milk at day 10 Milk changes with each stage of growth to meet infant requirements (supply and demand) Should babies use nutrition supplementation? ------CORRECT ANSWER---------------- Not if the infant is getting enough Determined by output and weight gain Vit D supplements recommended How often should a newborn void? How much? ------CORRECT ANSWER----------------1 wet diaper in 1st 24 hours Increased by one per day until 5 days Normal is 5-6 wet diapers in 24 hours 3 BMs per day or more (up to 10 can be normal as long as weight gain continues) What do normal infant BMs look like? ------CORRECT ANSWER----------------Yellow or yellowish brown by the end of the first week. The stools of breastfed babies tend to be more yellow than those of formula-fed babies. They may also be seedy-looking. How soon should a mother attempt breastfeeding after birth? a) 15 mins b) 30 mins c) 45 mins d) 60 mins ------CORRECT ANSWER----------------b) 30 mins How much should a breastfeeding mother increase her caloric intake by? ------ CORRECT ANSWER----------------500 calories / day What is cluster feeding? What does it help establish? ------CORRECT ANSWER---------- ------Cluster feeding is a time when your baby wants lots of short feeds over a few hours. It's normal and often happens in the early days of breastfeeding. Your pregnant patient is being prepped for a C-section. Is she getting more or less sedatives and hypnotics than general surgery? ------CORRECT ANSWER---------------- SAME AMOUNT However, she gets less narcotics because these can cross the placenta If guided imagery does not help ease contraction pain, what is the nurses next intervention? ------CORRECT ANSWER----------------Reposition patient (ambulation makes pain WORSE in true labor) What is the number 1 medication for contractions? What should we monitor? ------ CORRECT ANSWER----------------Oxytocin (Pitocin) Palpate uterus frequently! Can cause prolonged contractions and ruptured uterus What is the most dangerous complication after birth? ------CORRECT ANSWER----------- -----Hemorrhage What is the number one cause of hemorrhage in a pregnant women? ------CORRECT ANSWER----------------Uterine atony Massage the fundus! if not midline, empty bladder If lochia smells foul, what should the nurse suspect? ------CORRECT ANSWER------------ ----Infection When should nurses NEVER perform and internal vaginal exam? ------CORRECT ANSWER----------------When there is unexplained bleeding First stage of labor, how should mom be instructed to breath? ------CORRECT ANSWER----------------Shallow panting breathing during contractions Why should we check a pregnant ladies urine pH during labor? ------CORRECT ANSWER----------------Amniotic fluid is alkaline Urine is acidic Do we reinsert an umbilical cord into the mother? ------CORRECT ANSWER---------------- NEVER If in doubt, how should we position mother during labor? ------CORRECT ANSWER------ ----------Left side (best for cardiac output) What does the internal fetal monitor look for during labour? ------CORRECT ANSWER--- -------------Hypoxia What is Fetal Alcohol Syndrome (FAS)? ------CORRECT ANSWER----------------A group of alcohol-related birth defects that include physical and mental problems Small head circumference (microcephaly), low birth weight, undeveloped facial nerves, small eyes, thin upper lip What is Phenylketonuria (PKU)? ------CORRECT ANSWER----------------Individuals with PKU are unable to break down phenylalanine. If PKU is no diagnosed at birth it can lead to possible brain damage and intellectual impairment. However if a baby is diagnosed early and put on a special diet that doesn't contain phenylalanine it will grow and develop normally. First test after newborn is 24 hours old only one blood sample needed What do we give mothers who have an infant with PKU? ------CORRECT ANSWER------ ----------Lofenalac formula Is an infant powder formula prescribed to replace milk in the diets of Phenylketonuria (PKU) sufferers in the infant and child stage. It can be used to make ice cream, pudding and cake. What is milia? ------CORRECT ANSWER----------------Tiny white bumps on infants NORMAL What is Mongolian spots? ------CORRECT ANSWER----------------Dark spots on lower back NORMAL How much weight loss is normal immediately after birth? ------CORRECT ANSWER------ ----------10% You admit an infant to the ER with a fever, vomiting, diarrhea, and depressed fontanelle... should the nurse insert and IV or assess the babies ability to take oral fluids? ------CORRECT ANSWER----------------assess the babies ability to take oral fluids What is cold stress? S&S? ------CORRECT ANSWER----------------Heat loss through convection, conduction, evaporation and radiation Mottling of skin, acrocyanosis, and irregular respirations of 60 What is birth asphyxia? ------CORRECT ANSWER----------------Asphyxia can be caused by injury to or obstruction of breathing passageways, as in strangulation or the aspiration of food (choking) or large quantities of fluid (near-drowning or drowning). meconium stains amniotic fluid What is menopause? ------CORRECT ANSWER----------------Occurs when menses have creased for an entire year