Maternal-Newborn Nursing: Common Questions and Answers, Exams of Nursing

Download Maternal-Newborn Nursing: Common Questions and Answers and more Exams Nursing in PDF only on Docsity!

ATI. MATERNAL-NEWBORN

1. Two days after delivery, a postpartum client prepares for discharge. What should the nurse teach her about lochia flow?

Incorrect: Lochia does change color but goes from lochia rubra (bright red) on days 1-3, to lochia serosa (pinkish brown) on days 4-9, to lochia alba (creamy white) days 10-21.

Incorrect: Numerous clots are abnormal and should be reported to the physician.

Incorrect: Saturation of the perineal pad is considered abnormal and may indicate postpartum hemorrhage.

Correct: Lochia normally lasts for about 21 days, and changes from a bright red, to pinkish brown, to creamy white.

The color of the lochia changes from a bright red to white after four days

Numerous large clots are normal for the next three to four days

Saturation of the perineal pad with blood is expected when getting up from the bed

Lochia should last for about 3 weeks, changing color every few days

2. A nurse monitors fetal well-being by means of an external monitor. At the peak of the contractions, the fetal heart rate has repeatedly dropped 30 beats/min below the baseline. Late decelerations are suspected and the nurse notifies the physician. Which is the rationale for this action?

Incorrect: A nuchal cord (cord around the neck) is associated with variable decelerations, not late decelerations.

Incorrect: Variable decelerations (not late decelerations) are associated with cord compression.

Incorrect: Late decelerations are a result of hypoxia. They are not reflective of the strength of maternal contractions.

Correct: Late decelerations are associated with uteroplacental insufficiency and are a sign of fetal hypoxia. Repeated late decelerations indicate fetal distress.

The umbilical cord is wrapped tightly around the fetus' neck

The fetal cord is being compressed due to rapid descent of the fetal head

Maternal contractions are not adequate enough to deliver the fetus

The fetus is not receiving adequate oxygen and is in distress

3. Which preoperative nursing interventions should be included for a client who is scheduled to have an emergency cesarean birth?

Incorrect: Monitoring O2 saturations and administering pain medications are postoperative interventions.

Incorrect: Taking vital signs every 15 minutes is a postoperative intervention. Instructing the client regarding breathing exercises is not appropriate in a crisis situation when the client's anxiety is high, because information would probably not be retained. In an emergency, there is time only for essential interventions.

Correct: Because this is an emergency, surgery must be performed quickly. Anxiety of the client and the family will be high. Inserting an indwelling catheter helps to keep the bladder empty and free from injury when the incision is made.

Incorrect: The nurse should have assessed breath sounds upon admission. Breath sounds are important if the client is to receive general anesthesia, but the anesthesiologist will be listening to breath sounds in surgery in that case.

Monitor oxygen saturation and administer pain medication.

Assess vital signs every 15 minutes and instruct the client about postoperative care.

Alleviate anxiety and insert an indwelling catheter.

Perform a sterile vaginal examination and assess breath sounds.

4. Which nursing instruction should be given to the breastfeeding mother regarding care of the breasts after discharge?

Incorrect: Engorgement occurs on about the third or fourth postpartum day and is a result of the breast milk formation. The primary way to relieve engorgement is by pumping or longer nursing. Giving a bottle of formula will compound the problem because the baby will not be hungry and will not empty the breasts well.

Incorrect: Applying lotion to the nipples is not effective for keeping them soft. Excessive amounts of lotion may harbor microorganisms.

Correct: In order to stimulate adequate milk production, the breasts should be pumped if the infant is not sucking or eating well, or if the breasts are not fully emptied.

Incorrect: Using soap on the breasts dries the nipples and can cause cracking.

The baby should be given a bottle of formula if engorgement occurs.

The nipples should be covered with lotion when the baby is not nursing.

The breasts should be pumped if the baby is not sucking adequately.

The breasts should be washed with soap and water once per day.

5. A client in preterm labor is admitted to the hospital. Which classification of drugs should the nurse anticipate administering?

Correct: Tocolytics are used to stop labor. One of the most commonly used tocolytic drugs is ritodrine (Yutopar).

Incorrect: Anticonvulsants are used for clients with pregnancy-induced hypertension who are likely to seize.

Incorrect: The glucocorticoids (e.g., betamethasone and dexamethasone) are used for accelerating fetal lung maturation and production of surfactant. They are commonly used if the membranes are ruptured or labor cannot be stopped.

Incorrect: Anti-infective are used if there is infection. Preterm labor may or may not involve ruptured membranes with its accompanying risk of infection.

Tocolytics

Anticonvulsants

Glucocorticoids

Anti-infective

6. Which of the following are probable signs, strongly indicating pregnancy?

Incorrect: The presence of fetal heart sounds is a positive sign of pregnancy; quickening is a presumptive Sign of pregnancy.

Incorrect: These are presumptive signs. They may indicate pregnancy or they may be caused by other conditions, such as disease processes.

Correct: These are probable signs that strongly indicate pregnancy. Hegar’s sign is a softening of the lower uterine segment, and Chadwick's sign is the bluish or purplish color of the cervix as a result of the increased blood supply and increased estrogen. Ballottement occurs when the cervix is tapped by an examiner's finger and the fetus floats upward in the amniotic fluid and then falls downward.

Incorrect: These are presumptive signs that might indicate pregnancy, but they might be caused by other conditions, such as disease processes.

Presence of fetal heart sounds and quickening

Missed menstrual periods, nausea, and vomiting

Hegar's sign, Chadwick's sign, and ballottement

Increased urination and tenderness of the breasts

7. Two hours after delivery the nurse assesses the client and documents that the fundus is soft, boggy, above the level of the umbilicus, and displaced to the right side. The nurse encourages the client to void. Which is the rationale for this nursing action?

Correct: Bladder distention can lead to postpartum hemorrhage. A full bladder displaces the uterus causing it not to contract properly. Emptying the bladder allows the uterus to contract more firmly.

Incorrect: A distended bladder rises out of the abdomen, causing the uterus to be displaced and increasing the risk of hemorrhage. It does not affect the perineum.

Incorrect: Bladder distention can lead to urinary stasis and infection. This, however, does not relate to the soft, boggy uterus or the potential for hemorrhage.

Incorrect: Massaging is uncomfortable regardless of whether the bladder is full or not. A full bladder displaces the uterus causing it not to contract properly, which may lead to postpartum hemorrhage.

A full bladder prevents normal contractions of the uterus.

An overdistended bladder may press against the episiotomy causing dehiscence.

Distention of the bladder can cause urinary stasis and infection.

It makes the client more comfortable when the fundus is massaged.

8. Which site is preferred for giving an IM injection to a newborn?

Incorrect: Ventrogluteal muscles are located in the hip area. It is not the preferred site for injections in the newborn because of lack of muscle mass.

Correct: The middle third of the vastus lateralis is the preferred site for injections.

Incorrect: Ventrogluteal muscles are located in the hip area. It is not the preferred site for injections in the newborn because of lack of muscle mass.

Incorrect: Newborns do not receive injections in the dorsogluteal site (gluteus maximus) due to decreased muscle mass.

Ventrogluteal

Vastus lateralis

Rectus femoris

Dorsogluteal

9. During the first twelve hours following a normal vaginal delivery, the client voids 2,000 mL of urine. How should the nurse interpret this finding?

Incorrect: Urinary tract infections are common during pregnancy and in the postpartum period. Urinary frequency is a common finding. However, voiding large amounts of urine is not a sign of a UTI.

Incorrect: High output renal failure occurs with injury/trauma to the kidneys. There has been no damage to the kidneys. Incorrect: Most women do receive some IV fluids during labor and delivery, however the IV rates are carefully calculated according to weight.

Correct: During pregnancy, the circulating blood volume increases by about 50%. In order to get rid of the excess fluid volume after delivery, the woman experiences an increased amount of urine output during the first few hours.

Urinary tract infection

High output renal failure

Excessive use of IV fluids during delivery

Normal diuresis after delivery

10. If a pregnant client diagnosed with gestational diabetes cannot maintain control of her blood sugar by diet alone, which medication will she receive?

Incorrect: Glucophage is an oral hypoglycemic. Oral hypoglycemic cross the placenta and can cause damage to the fetus. They are not used in gestational diabetes for that reason.

Incorrect: Glucagon is a hormone used to raise blood sugar and manage severe hypoglycemia. Clients with gestational diabetes have hyperglycemia.

Correct: Insulin is the drug of choice for gestational diabetes. Insulin lowers the client's blood sugar without harming the fetus.

Incorrect: DiaBeta is an oral hypoglycemic drug. Oral hypoglycemic agents cross the placenta and can cause damage to the fetus. They are not used for gestational diabetes for that reason.

Metformin (Glucophage)

Glucagon

Insulin

Glyburide (DiaBeta)

11. Which assessment finding indicates that placental separation has occurred during the third stage of labor?

Incorrect: There is usually an increase in bleeding (a sudden gush of blood) when the placenta separates.

Incorrect: Contractions continue in an attempt to expel the placenta. The contractions may not be as intense, but they do not stop. Also, fundal massage helps contract the uterus preventing postpartum bleeding.

Incorrect: Shaking and chills occur about 10-15 minutes after the delivery of the baby, but are not related to the placental detachment. They are a result of the release of pressure on pelvic nerves and the release of epinephrine during labor.

Correct: As the placenta detaches, the cord that has been clamped becomes longer as it slides out of the vagina.

Decreased vaginal bleeding

Contractions stop

Maternal shaking and chills

Lengthening of the umbilical cord

12. The nurse midwife is concerned about a pregnant client who is suspected of having a TORCH infection. Which is the main reason TORCH infections are grouped together? They are:

Incorrect: Most TORCH infections can cause mild flu-like symptoms for the mother. Death may or may not occur in the fetus.

Incorrect: TORCH is an abbreviation for Toxoplasmosis, Other (syphilis, HIV and Hepatitis B), Rubella, Cytomegalovirus, and Herpes simplex—not all of these are sexually transmitted.

Correct: All TORCH infections have the capability of infecting the fetus or causing serious effects to the newborn.

Incorrect: A vector is a carrier of the disease such as a mosquito. Not all of the TORCH infections are carried by vector.

benign to the woman but cause death to the fetus.

sexually transmitted.

capable of infecting the fetus.

transmitted to the pregnant woman by a vector.

13. During the postpartum period, a hospitalized client complains of discomfort related to her episiotomy. The nurse assigns the diagnosis of “pain related to perineal sutures.” Which nursing intervention is most appropriate during the first 24 hours following an episiotomy?

Incorrect: Petroleum jelly will harbor bacteria, which may hinder healing.

Incorrect: The client should practice Kegel exercises to increase bladder tone, but these exercises would add to the client's discomfort during the first 24hours.Incorrect: Taking a warm sitz bath is recommended after the first 24 hours.

Correct: Ice packs will decrease edema and discomfort, and prevent formation of a hematoma.

Instruct the client to use petroleum jelly on the episiotomy after voiding.

Encourage the client to practice Kegel exercises.

Advise the client to take a warm sitz bath every four hours.

Apply ice packs to the perineum.

14. A client asks the nurse about the benefits of breastfeeding. Which response by the nurse provides the most accurate information?

Incorrect: Breastfeeding does not help speed up weight loss. The lactating mother requires more calories, but usually has an increased appetite to accommodate that need.

Incorrect: Protein amounts are greater in formula and cow's milk.

Correct: Breast milk is easier to digest because of the type of fat and protein in the milk.

Incorrect: Breastfeeding does not prevent to woman from getting pregnant because it does not prevent ovulation. Most women ovulate within the first 6 weeks after delivery.

Breastfeeding helps women lose weight faster.

Breast milk contains a greater amount of protein.

Breast milk is easier to digest than formula.

Breastfeeding is a good method of contraception.

15. Which physiological change takes place during the puerperium?

Incorrect: The puerperium is the first 6 weeks after delivery. The client will experience lochia for the first few weeks, and hormone levels will stabilize. Menstruation cannot occur until ovulation occurs.

Incorrect: This occurs in stage three of labor.

Correct: The uterine changes are called involution. The uterus should return to its pre- pregnancy state within 6 weeks after delivery.

Incorrect: This describes the labor process, not the puerperium.

The endometrium begins to undergo alterations necessary for menstruation.

The placenta begins to separate from the uterine wall.

The uterus returns to a pre-pregnant size and location.

The uterus contracts at regular intervals with dilation of the cervix occurring.

16. A client delivered two days ago and is suspected of having postpartum "blues." Which symptoms confirm the diagnosis?

Correct: These are signs of the postpartum blues, which typically diminishes within three- four days after delivery. Postpartum blues, a transient period of tearfulness, is a result of hormonal shifts. Other symptoms of the blues include: sadness, anxiety about the health of the baby, insomnia, anorexia, anger, feelings of anticlimax.

Incorrect: Postpartum blues, a transient period of tearfulness, is a result of hormonal shifts. Depression and suicidal thoughts are signs of postpartum depression, not the blues and should be followed up with psychiatric treatment.

Incorrect: Excess anxiety and the inability to care for the family are signs of postpartum depression, not the blues. Postpartum blues, a transient period of tearfulness, is a result of hormonal shifts.

Incorrect: Nausea and vomiting are psychosomatic symptoms of postpartum depression and require psychiatric treatment. Postpartum blues, a transient period of tearfulness, is a result of hormonal shifts.

Uncontrollable crying and insecurity

Depression and suicidal thoughts

Sense of the inability to care for the family and extreme anxiety

Nausea and vomiting

17. Shortly after delivery, the nursery nurse gives the newborn an injection of phytonadione (Vitamin K). The infant's grandmother wants to know why the baby got “a shot in his leg.” Which response by the nurse is most appropriate?

Incorrect: Calcium is needed for bone and muscle growth, not Vitamin K.

Incorrect: Vitamin K is used to promote clotting, and does not affect digestion.

Incorrect: The B vitamins are responsible for carbohydrate metabolism and the energy derived from glucose, not Vitamin K.

Correct: Vitamin K is given to prevent bleeding until the intestinal bacteria can start to produce it. The intestines of a newborn are sterile until it starts to feed. Vitamin K helps with the clotting factors necessary to control bleeding.

"Vitamin K promotes bone and muscle growth."

"Vitamin K helps the baby digest milk."

"Vitamin K helps stabilize the baby's blood sugar."

"Vitamin K is used to prevent bleeding."

18. At 10 weeks gestation, a primigravida asks the nurse what is occurring developmentally with her baby. Which response by the nurse is correct?

Incorrect: Wrinkles do not form until late in the pregnancy. Fat stores usually do not form until the third trimester.

Incorrect: The eyelids are fused until about 26 weeks.

Correct: The kidneys are making urine, which is excreted by the fetus into the amniotic fluid.

Incorrect: The heart is already formed and beating at 8 weeks.

"The skin is wrinkled and fat is being formed."

"The eyelids are open and he can see."

"The kidneys are making urine."

"The heart is being developed."

19. A nurse in the clinic instructs a primigravida about the danger signs of pregnancy. The client demonstrates understanding of the instructions, stating she will notify the physician if which sign occurs?

Incorrect: White vaginal discharge is a normal occurrence during pregnancy due to increased amounts of estrogen and increased blood supply to the cervix and vagina. It is not a “danger sign. “

Incorrect: Backache is common in pregnancy due to the alteration of the woman's center of gravity; it is not a “danger sign.” Backaches become worse as the uterus enlarges.

Incorrect: Frequent, urgent urination is a common discomfort; it is not a danger sign. The pressure of the enlarging uterus causes frequency and urgency.

Correct: Abdominal pain is a danger sign and can be indicative of an abruptio placenta. It is important for a physician to evaluate this symptom. It is one of several danger signs, including: headache, rupture of membranes, vaginal bleeding, edema, epigastric pain, elevated temperature, painful urination, prolonged vomiting, blurred vision, change in or absence of fetal movement.

White vaginal discharge

Dull backache

Frequent, urgent urination

Abdominal pain

20. An hour after delivery, the nurse instills erythromycin (Ilotycin) ointment into the eyes of a newborn. The main objective of the treatment is to prevent infection caused by which organism?

Incorrect: Erythromycin (Ilotycin) is an antibiotic ointment used to prevent blindness related to gonorrhea. Antibiotics are effective against bacteria. Rubella is a virus.

Correct: Ilotycin, an antibiotic, is used for the prophylaxis treatment of gonorrhea and chlamydia. If left untreated, it could result in blindness.

Incorrect: Ilotycin, an antibiotic, is not effective in combating syphilis infections.

Incorrect: HIV is a virus. Antibiotics are effective against bacteria. Ilotycinis an antibiotic ointment and therefore not effective against HIV.

Rubella

Gonorrhea

Syphilis

Human immunodeficiency virus (HIV)

21. A woman in active labor receives a narcotic analgesic for pain control. If the narcotic is given a half an hour before delivery, which effect will the medication have on the infant? It will cause the infant's:

Incorrect: Narcotic analgesics cause respiratory depression and do not affect the infant's blood sugar.

Correct: Narcotic analgesics can cause respiratory depression for the infant and also for the mother. This is evidenced by low Apgar scores (apnea and bradycardia) in the infant. If respiratory depression occurs, a narcotic antagonist (Narcan) is usually given.

Incorrect: Narcotic analgesics, if given too close to delivery, can cause bradycardia, not tachycardia.

Incorrect: Narcotics, such as Demerol, cause CNS depression, not hyperactivity.

blood sugar to fall.

respiratory rate to decrease.

heart rate to increase.

movements to be hyperactive.

22. For a client in the second trimester of pregnancy, which assessment data support a diagnosis of pregnancy-induced hypertension (PIH)?

Incorrect: A decrease in hemoglobin is indicative of anemia, while uterine tenderness may indicate abruptio placenta.

Incorrect: Polyuria and weight loss are signs of gestational diabetes.

Correct: PIH is characterized by two components: elevated blood pressure and proteinuria. Vasospasm in the arterioles leads to increased blood pressure and a decrease in blood flow to the uterus and placenta. This results in a questionable outcome for the fetus due to placental insufficiency. Renal blood flow is affected, ultimately resulting in proteinuria.

Incorrect: Elevated blood glucose is a sign of gestational diabetes. Hematuria may indicate a U.T.I.

Hemoglobin 10.2 mg/dL and uterine tenderness

Polyuria and weight loss of 3 pounds in the last month

Blood pressure 168/110 and 3+ proteinuria

Hematuria and blood glucose of 160 mg/dL

23. A 35-week gestation infant was delivered by forceps. Which assessment findings should alert the nurse to a possible complication of the forceps delivery?

Correct: A weak, ineffective suck could be a result of facial paralysis which is a major complication of forceps deliveries. Scalp edema is another complication and should subside within 2-3 days. Other complications of forceps deliveries include: cephalohematomas, intracranial hemorrhage (especially in premature infants) and excessive bruising, which increases the risk for hyperbilirubinemia.

Incorrect: Molding of the head is a common occurrence with vaginal deliveries. Jitteriness is a sign of low blood sugar, not forceps delivery.

Incorrect: A shrill, high-pitched cry and tachypnea are signs of drug withdrawal, not a complication of forceps delivery.

Incorrect: Hypothermia is not a complication of forceps deliveries. The hemoglobin level is quite low (should be about 15-16 g/dL), but unless there is excessive bleeding, the hemoglobin level should be unaffected by the forceps delivery.

Weak, ineffective suck, and scalp edema

Molding of the head and jitteriness

Shrill, high pitched cry, and tachypnea

Hypothermia and hemoglobin of 12.5 g/dL

24. In which position should the nurse place the laboring client in order to increase the intensity of the contractions and improve oxygenation to the fetus?

Incorrect: This position is contraindicated because the fetus creates pressure on the mother's vena cava. Incorrect: Squatting widens the pelvic inlet, but does not improve contractions or fetal oxygenation.

Correct: This prevents vena cava compression and, therefore, improves fetal oxygenation; at the same time, it provides a restful position between contractions.

Incorrect: High Fowler's (sitting upright) will assist with the intensity of the contractions because of gravity, but it will not help with fetal oxygenation.

Supine with legs elevated

Squatting

Left side-lying

High Fowler's

25. A woman enters the birthing center in active labor. She tells the nurse that her membranes ruptured 26 hours ago. The nurse immediately takes the client's vital signs. Which is the rationale for the nurse's actions?

Incorrect: Pulse rates increase due to pain, not because of rupture of membranes.

Incorrect: The woman is not reporting pain and ruptured membranes do not cause pain. Lack of fluid (ruptured membranes) has no influence on respiratory rates.

Incorrect: Blood pressure is not affected by prolonged rupture of membranes.

Correct: The membranes are a protective barrier for the fetus. If the membranes are ruptured for a prolonged period of time, microorganisms from the vagina can ascend into the uterus. The longer the membranes have been ruptured, the greater the risk for infection.

Pulse rates rise the longer the membranes are ruptured

Respiratory rates decrease due to lack of fluid in the uterus

Prolonged rupture of membranes can lead to transient hypertension

Infection is a complication of prolonged rupture of membranes

26. A new client's pregnancy is confirmed at 10 weeks gestation. Her history reveals that her first two pregnancies ended in spontaneous abortion at 12 and 20 weeks. She has a4-year-old and a set of 1-year-old twins. How should the nurse record the client's current gravida and para status?

Incorrect: Gravida includes the number of times the woman has been pregnant. She has been pregnant 5 times. A parity of 3 would be obtained by incorrectly counting the 20-week spontaneous abortion as a viable infant.

Incorrect: The woman has been pregnant 5 times, including the present pregnancy. The abortions count as pregnancies, but not in the parity.

Correct: Gravida is the number of times a woman has been pregnant, including the present pregnancy. Para is the number of pregnancies carried past 20 weeks' gestation, regardless of the number of fetuses delivered. The woman has been pregnant five times, including this pregnancy, and has had two pregnancies that have exceeded 20 weeks. Even though she delivered two children as a result of one of those pregnancies, the para for her twin pregnancy remains at 1. The pregnancy after which she delivered her four-year-old child makes her a para 2.

Incorrect: A para of 4 would be obtained by incorrectly counting the 2 spontaneous abortions as viable at delivery.

Gravida 2, para 3

Gravida 4, para 2

Gravida 5, para 2

Gravida 5, para 4

27. A 16-year-old client reports to the school nurse because of nausea and vomiting. After exploring the signs and symptoms with the client, the nurse asks the girl whether she could be pregnant. The girl confirms that she is pregnant, but states that she does not know how it happened. Which nursing diagnosis is most important?

Incorrect: Although this addresses the client's nausea and vomiting, it is not the most important diagnosis at this time. There are no data to indicate that the client actually has a nutritional deficit. Because nausea and vomiting place her at risk for nutritional deficit, a diagnosis of “risk for altered nutrition.. .” would be appropriate. The knowledge diagnosis is an actual problem and should be addressed at this contact with the client; the nutrition problem will be ongoing during the pregnancy.

Incorrect: This diagnosis does not address the reason for the lack of client knowledge—she may be at risk for poor parenting, but this is not the priority because there will be time to address that issue as the pregnancy progresses.

Incorrect: There is no clear evidence of the denial of pregnancy nor of the lack of coping skills.

Correct: This client clearly has a knowledge deficit about the causes of pregnancy and the physiological changes associated with it. It is important for teaching to begin immediately because her understandings essential to her compliance with suggestions for a healthy pregnancy.

Altered nutrition: less than body requirements related to nausea and vomiting

Risk for altered family processes related to the client's age

Ineffective individual coping related to denial of pregnancy

Knowledge deficit related to the client's developmental stage and age

28. A client is admitted to the hospital for induction of labor. Which are the main indications for labor induction?

Incorrect: These are contraindications for labor induction.

Correct: Induction of labor is the stimulation of contractions (usually by the use of Pitocin) before they begin on their own. Maternal indications for induction of labor include: pregnancy induced hypertension, chorioamnionitis, gestational diabetes, chronic hypertension and premature rupture of membranes. Fetal indications include intrauterine growth retardation, post-term dates and fetal demise.

Incorrect: These are contraindications for labor induction.

Incorrect: These are contraindications for labor induction. They are indications for a C-section.

Placenta previa and twins

Pregnancy-induced hypertension and postterm fetus

Breech position and prematurity

Cephalopelvic disproportion and fetal distress

29. A client in active labor receives a regional anesthetic. Which is the main purpose of regional anesthetics?

Incorrect: This choice describes general anesthesia.

Correct: Regional anesthetics provide numbness and loss of pain sensation to an area. The most common regional blocks are: local, pudendal, epidural, and spinal.

Incorrect: Pain sensations travel to the central nervous system not away from it.

Incorrect: This choice describes the action for narcotic medications, not regional anesthetics.

To relieve pain by decreasing the client's level of consciousness

To provide general loss of sensation by blocking sensory nerves to an area

To provide pain relief by blocking descending impulses from the central nervous system

To relieve pain by decreasing the perception of pain leading to the pain centers in the brain

30. The nursery nurse reviews a newborn's birth history and notes that the Apgar scores were 5 at one minute after birth, and 7 at five minutes after birth. How should the nurse interpret these scores? The infant:

Incorrect: Usually babies that only need suctioning of the mouth and nose have Apgars that are 8 or 9.

Incorrect: If intubation is required, it means that the baby's heart and respiratory rates are not stable, and Apgars would be lower than 5.

Incorrect: Apgar scores are used to quickly assess the well-being of the baby. Apgar scores range from 0-10. A score of 0 indicates that the baby is dead. An Apgar score of 5 indicates that the baby needs assistance.

Correct: Apgar scores of 5 and 7 indicate that the heart rate was below 100, the respiratory effort was irregular, there was little muscle tone, the baby was pink with blue extremities, and there was a grimace. These scores indicate that the baby needed stimulation in order to breathe, and oxygen to increase its oxygen saturation.

needed brief oral and nasal suctioning.

required endotracheal intubation and bagging with a hand-held resuscitator.

was stillborn and required CPR.

required physical stimulation and supplemental oxygen.

31. With routine prenatal screening, a woman in the second trimester of pregnancy is confirmed to have gestational diabetes. How may the nurse explain the role of diet and insulin in the management of blood sugar during pregnancy?

Correct: Insulin is given to gestational diabetic clients because their insulin requirements cannot keep up with the metabolic needs of the fetus in the last trimester. Insulin decreases the blood sugar.

Incorrect: Oral hypoglycemic agents are not given to clients with gestational diabetes because they cross the placenta and are harmful to the fetus.

Incorrect: The client will need frequent follow-up after delivery and into the postpartum period, but she should not need insulin after delivery because in gestational diabetes, blood glucose usually returns to normal after delivery.

Incorrect: Clients with gestational diabetes need to eat three balanced meals and three snacks daily. The glucose load is best when maintained at a steady level throughout the day to avoid

periodic overproduction of insulin. The last snack of the day should contain protein to stabilize the energy production during the night.

"Insulin lowers an elevated blood sugar during pregnancy to meet the increased metabolic needs of the baby."

"You will need to take an oral hypoglycemic, which is a pill to lower your blood sugar."

"There is a good possibility you will be taking insulin for the rest of your life."

"You should eat three large meals per day to maintain steady glucose load."

32. A breastfeeding mother complains of cramping. Which is the main cause of the client's afterpains?

Incorrect: Infection of the suture line can cause pain and discomfort, but is not the cause of afterpains. Afterpains are postpartum uterine contractions.

Incorrect: Constipation and bloating do occur in the postpartum period as peristalsis resumes, but constipation does not cause afterpains, which are uterine contractions.

Correct: Afterpains are caused by uterine contractions that occur for the first 2-3 days postpartum. Breast-feeding mothers have more afterpains due to the release of oxytocin stimulated by the nursing baby. Oxytocin strengthens uterine contractions and compresses blood vessels, preventing blood loss.

Incorrect: Trauma is not the cause of afterpains. Afterpains are postpartum uterine contractions.

Infection of the suture line

Constipation and bloating

Contractions of the uterus

Trauma during delivery

33. A client who is 37 weeks gestation comes to the office for a routine visit. This is the client's first baby and she asks the nurse how she will know when labor begins. Which signs indicate that true labor has begun?

Incorrect: These signs describe Braxton-Hicks contractions, which occur throughout pregnancy and increase in intensity and frequency as labor grows closer.

Incorrect: True labor pains start in the lower back and sweep to the front in waves.

Incorrect: These signs occur with lightening, usually 10-14 days before labor begins.

Correct: These are true signs of labor, along with the rupturing of the membranes and cervical dilatation.

Contractions that are irregular and decrease in intensity when walking

Abdominal pain that starts at the fundus and progresses to the lower back

Increased pressure on the bladder and urinary frequency

Expulsion of pink-tinged mucous and contractions that start in the lower back

34. A multiparous woman with a history of all vaginal births is admitted to the hospital in labor. After several hours, the client's labor has not progressed and she is getting tired and restless. The decision is made to proceed with cesarean delivery. The nurse recognizes the client's knowledge deficit regarding the surgical delivery and care afterbirth. Which is the appropriate expected outcome for correction of the client's knowledge deficit? The client will:

Incorrect: This expected outcome does not address the client's knowledge deficit. Instead, this is an expected outcome for the nursing diagnosis of ineffective individual coping.

Incorrect: This choice does not address the client's knowledge deficit, but instead addresses a problem with interrupted bonding.

Correct: Goals/outcomes should reflect resolution of the stated nursing diagnosis—in this case, knowledge deficit. Verbalization of reasons for the surgery would indicate resolution of the knowledge deficit. If interventions for knowledge deficit are effective, other problems (e.g., anxiety, ineffective coping) may be prevented.

Incorrect: This choice addresses the anxiety that will occur because of the unknown, but does not address the stated problem, knowledge deficit.

demonstrate appropriate coping mechanisms needed to get through the surgery.

accept that the type of delivery will not affect the bonding with the baby.

verbalize understanding about the reason for the unplanned surgery.

demonstrate decreased anxiety and fear of the unknown.

35. The physician performs an amniotomy for a woman in labor. Which nursing action should follow the procedure?

Incorrect: Maternal oxygenation is not affected by an amniotomy.

Incorrect: Maternal pulse and blood pressure are not affected by an amniotomy.

Incorrect: Assessing the perineum should be done after an episiotomy, not after amniotomy.

Correct: An amniotomy, or artificial rupture of membranes (AROM), is used to speed up labor. The nurse must document the color, amount, character and odor of the fluid, and assess for fetal well being.

Check the client's capillary refill and oxygenation.

Monitor the maternal pulse and blood pressure.

Inspect the perineum for lacerations, bleeding, and hematoma.

Assess the fluid for color, odor, and amount.

36. For a pregnant adolescent who is anemic, which foods should the nurse include In the client's dietary plan to increase iron levels?

Incorrect: Milk does not contain iron and it interferes with iron absorption.

Correct: Orange juice enhances the absorption of iron. Apricots are a good source of iron.

Incorrect: Chicken does contain iron, but cottage cheese, a dairy product, does not.

Incorrect: Pickles contain large amounts of salt, not iron. Peanut butter sandwiches do not contain much iron.

Milk and fish

Orange juice and apricots

Chicken and cottage cheese

Pickles and peanut butter sandwiches

37. Which condition must occur in order for identical (monozygotic) twins to develop?

Incorrect: Usually only one ovum is released per month; one sperm cannot fertilize two ova.

Incorrect: This is the case in fraternal (dizygotic) twins. There are two placentas, two chorions, and two amnions. The twins may be the same or different sex.

Correct: One sperm fertilizes one ovum, and then the zygote divides into two individuals with one placenta, one chorion, two amnion and two umbilical cords. These twins are always the same sex.

Incorrect: The enzyme on the head of the sperm dissolves the coating of the ovum so eventually only one sperm penetrates one egg.

One sperm fertilizes two ova

Two sperm fertilize two ova

One sperm fertilizes one ovum

Two sperm fertilize one ovum

38. Which fetal structure is responsible for carrying oxygenated blood from the placenta to the fetus?

Incorrect: The ductus arteriosus is a shunt that connects the lungs to the aorta, allowing the blood to bypass the lungs.

Incorrect: Except in the case of fetal circulation, arteries do carry oxygenated blood; but during pregnancy, the two umbilical arteries carry unoxygenated blood from the fetus to the placenta, where preoxygenation occurs. Incorrect: The portal vein carries blood from the intestine to the liver.

Correct: The umbilical vein carries oxygenated blood from the placenta to the fetus. The direction of blood flow is toward the fetal heart.

Ductus arteriosus

Umbilical artery

Portal vein

Umbilical vein

39. A client at 33 weeks gestation is admitted for suspected abruptio placenta. Which factor in the client's history supports this diagnosis? The client states that she:

Incorrect: Drinking alcohol is not usually associated with abruptio placenta. Incorrect: Clients with abruptio placenta do not have contractions that can be relieved by walking. Usually the pain is quite intense.

Incorrect: Intercourse should not cause an abruptio placenta, although it is contraindicated in clients with placenta previa.

Correct: The use of crack cocaine is associated with the separation of the placenta and the bleeding/ hemorrhage that results. Cocaine use is not usually an isolated incident, so the nurse should ask the client about the frequency/amount of the drug usage.

drinks two glasses of wine before dinner every night.

has intermittent contractions that are relieved by walking.

had intercourse with her partner last night.

used crack an hour before the symptoms began.

40. Which explanation is most appropriate when describing physiological jaundice to the parents of a newborn?

Incorrect: Pathological jaundice, not physiological jaundice, occurs within the first 24 hours and is a result of an ABO incompatibility or Rh incompatibility.

Correct: Physiological jaundice is the result of the breakdown of excessive amounts of red blood cells that are not needed after birth. Physiological jaundice is also related to the inability of the immature liver to rid the body of bilirubin, which occurs as the red blood cells are broken down. The bilirubin accumulates in the blood causing it to be yellow.

Incorrect: Jaundice related to breast milk occurs after the first 7 days, not within the first three. It is not the cause of physiological jaundice.

Incorrect: Hepatitis B may have been acquired during delivery and may cause jaundice, but it is not the cause of physiological jaundice, which this case represents.

"The baby has a minor incompatibility of the blood."

“The baby is breaking down the extra red blood cells that were present at birth.”

“The baby is getting too much breast milk, but this is not dangerous.”

“The baby may have gotten exposed to hepatitis B during the delivery.”

41. A woman at 42 weeks gestation enters the hospital for induction of labor. Since the infant is postterm, which complications should the nurse anticipate when planning for the delivery?

Incorrect: Cephalopelvic disproportion is seen in large-for-gestational age infants, not postterm infants. Hypothermia occurs in premature and small-for-gestational age infants.

Correct: Asphyxia is a result of chronic hypoxia in utero because of the progressive degeneration of the placenta. Meconium stained amniotic fluid is a result of the relaxation of the anal sphincter and the passage of meconium into the fluid related to hypoxia. If the meconium stained fluid is aspirated into the infant's lungs at delivery, pneumonia (and possibly death) will result. If there is meconium stained fluid, the infant's mouth and throat are suctioned as soon as the head is delivered.

Incorrect: Intraventricular hemorrhage occurs as a major complication in premature infants, not postterm infants. Dry, cracked skin is a normal finding of postterm infants and is not considered a complication.

Incorrect: Hyperbilirubinemia is not a complication of postterm infants at birth. Hypocalcemia is a complication in small-for gestational age infants

Cephalopelvic disproportion and hypothermia

Asphyxia and meconium aspiration

Intraventricular hemorrhage and dry, cracked skin

Hyperbilirubinemia and hypocalcemia

42. Which method of temperature regulation would safely and effectively prevent cold stress in a newly delivered infant?

Incorrect: The baby should be wrapped snuggly with a warm blanket in order to preserve heat loss.

Incorrect: It helps to cover the feet, of course. However, because the scalp is so vascular (and the blood is close to the surface) and because the head makes up a large portion of the baby's surface area, most heat loss occurs via the head initially. Peripheral circulation is sluggish at first, so not much blood would be cooled by circulating through cold feet.

Correct: Newly delivered infants lose a great deal of heat as the amniotic fluid evaporates from the surface of the skin. To prevent rapid heat loss, the baby's face and head should be dried and a hat placed on the baby's head.

Incorrect: Infants should NEVER be placed on a heating pad because of risk for burns.

Wrap the baby loosely with a blanket.

Be sure the baby's feet are covered.

Cover the baby's head with a hat.

Position the baby on a heating pad.

43. The nurse performs Leopold's maneuvers for a client admitted in labor. Which is the main goal of Leopold's maneuvers?

Incorrect: Sterile vaginal exams are used to assess the dilation of the cervix.

Incorrect: Leopold's maneuvers are not used to assess contraction frequency or intensity. However, some nurses do place their hands on the abdomen to palpate the intensity and frequency of the contractions.

Incorrect: Leopold's maneuvers are not used to assess membrane rupture. Sterile vaginal exams may assess this if membranes are intact.

Correct: Leopold's maneuvers are a method of determining fetal position by abdominal palpation. It assesses the position, presentation and engagement of the fetus. It also assists in the location of fetal heart sounds.

To determine whether the client's cervix has dilated

To assess the frequency and intensity of the contractions

To assess whether membranes have been ruptured

To determine the presentation and position of the fetus

44. Immediately after birth, the nurse places the newborn under a radiant warmer. Which is the primary rationale for the nurse's action?

Correct: Temperature regulation is the priority for the newborn. Infants who are cold stressed are at risk for respiratory complications or death.

Incorrect: Placing the infant in the warmer does assist the nurse with easier access, but temperature regulation is the main priority.

Incorrect: Most infants are not connected to the cardiac monitor unless the Apgar scores are low.

Incorrect: The warmer does provide easy access for the family, but this is not the main reason for its use.

To facilitate an efficient means of thermoregulation

To facilitate initial assessment by the nurse

To permit the use of the cardiac monitor

To permit close observation by the family members

45. A client, gravida 1, para 0, in active labor, is becoming increasingly anxious. Which statement by the nurse will block therapeutic communication with the client?

Incorrect: Since this is the client's first baby, there will be concerns/anxiety because of the unknown expectations. This response is appropriate, and will help decrease anxiety by allowing identification and ventilation of fears.

Incorrect: This response will encourage the client to talk and will foster good communication.

Correct: This is an example of meaningless reassurance and will block therapeutic communication because the needs of the client are not being met.

Incorrect: This response will facilitate communication, not block it.

"What concerns are you having now?"

"Tell me how you are feeling."

"Everything is going just fine."

"You seem a little nervous."

46. A nurse prepares to teach a class regarding postpartum care and includes infections in the teaching plan. Which is the main cause of mastitis in the postpartum client?

Correct: Poor breast-feeding technique and improper positioning of the baby are the main reasons for mastitis. Improper release of the baby's suction can lead to sore, cracked nipples, creating a portal of entry for pathogens.

Incorrect: Poor hand washing is not the main reason that a woman gets mastitis but can be a contributing cause. For example, if the woman touches her perineal pad and then the breast, the bacteria on the hands can cause an infection.