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HESI Maternity / HESI Maternity Exam 2 | Verified Questions and Answers, 100% Correct. (GRADED A)

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HESI Maternity Exam 2 A primigravida asks the nurse about signs she can look for that would indicate that the onset of labor is getting closer. The nurse should describe: A) weight gain of 1 to 3 ... lbs. B) quickening. C) fatigue and lethargy. D) bloody show. The nurse should tell a primigravida that the definitive sign indicating that labor has begun would be: A) progressive uterine contractions with cervical change. B) lightening. C) rupture of membranes. D) passage of the mucous plug (operculum). On completion of a vaginal examination on a laboring woman, the nurse records: 50%, 6 cm, -1. What is a correct interpretation of the data? A) The fetal presenting part is 1 cm above the ischial spines. B) Effacement is 4 cm from completion. C) Dilation is 50% completed. D) The fetus has achieved passage through the ischial spines. In order to accurately assess the health of the mother accurately during labor, the nurse should be aware that: A) The woman's blood pressure increases during contractions and falls back to prelabor normal between contractions. B) Use of the Valsalva maneuver is encouraged during the second stage of labor to relieve fetal hypoxia. C) Having the woman point her toes reduces leg cramps. D) The endogenous endorphins released during labor raise the woman's pain threshold and produce sedation. The nurse knows that the second stage of labor, the descent phase, has begun when: A) the amniotic membranes rupture. B) The cervix cannot be felt during a vaginal examination. C) The woman experiences a strong urge to bear down. D) The presenting part is below the ischial spines. Nurses can help their clients by keeping them informed about the distinctive stages of labor. What description of the phases of the first stage of labor is accurate? A) Latent: mild, regular contractions; no dilation; bloody show; duration of 2 to 4 hours B) Active: moderate, regular contractions; 4 to 7 cm dilation; duration of 3 to 6 hours C) Lull: no contractions; dilation stable; duration of 20 to 60 minutes D) Transition: very strong but irregular contractions; 8 to 10 cm dilation; duration of 1 to 2 hours Which position would the nurse suggest for second-stage labor if the pelvic outlet needs to be increased? A) Semirecumbent B) Sitting C) Squatting D) Side-lying Concerning the third stage of labor, nurses should be aware that: A) the placenta eventually detaches itself from a flaccid uterus B) The duration of the third stage may be as short as 3 to 5 minutes C) it is important that the dark, roughened maternal surface of the placenta appear before the shiny fetal surface D) the major risk for women during the third stage is a rapid heart rate The charge nurse on the maternity unit is orienting a new nurse to the unit and explains that the 5 Ps of labor and birth are: (Select all that apply.) A) passenger. B) placenta. C) passageway. D) psychologic response. E) powers. F) position. Nurses can advise their patients that which of these signs precede labor? (Select all that apply.) A. A return of urinary frequency as a result of increased bladder pressure B. Persistent low backache from relaxed pelvic joints C. Stronger and more frequent uterine (Braxton Hicks) contractions D. A decline in energy, as the body stores up for labor E. Uterus sinks downward and forward in first-time pregnancies. The maternity nurse should notify the health care provider about which assessment findings during labor? (Select all that apply.) A. Positive urine drug screen B. Blood glucose level of 78 mg/dL C. Increased systolic blood pressure during first stage D. Elevated white blood cell count E. Oral temperature of 99.8° F F. Respiratory rate of 10 breaths/min A laboring woman becomes anxious during the transition phase of the first stage of labor and develops a rapid and deep respiratory pattern. She complains of feeling dizzy and light-headed. The nurse's immediate response would be to: A. encourage the woman to breathe more slowly. B. help the woman breathe into a paper bag. C. turn the woman on her side. D. administer a sedative. A woman is in the second stage of labor and has a spinal block in place for pain management. The nurse obtains the woman's blood pressure and notes that it is 20% lower than the baseline level. Which action should the nurse take? A. Encourage her to empty her bladder. B. Decrease her intravenous (IV) rate to a keep vein-open rate. C. Turn the woman to the left lateral position or place a pillow under her hip. D. No action is necessary since a decrease in the woman's blood pressure is expected. A woman in latent labor who is positive for opiates on the urine drug screen is complaining of severe pain. Maternal vital signs are stable, and the fetal heart monitor displays a reassuring pattern. The nurse's MOST appropriate analgesic for pain control is: A. fentanyl (Sublimaze). B.promethazine (Phenergan). C. butorphanol tartrate (Stadol). D. nalbuphine (Nubain). A woman is experiencing back labor and complains of constant, intense pain in her lower back. An effective relief measure is to use: A. counterpressure against the sacrum. B. pant-blow (breaths and puffs) breathing techniques. C. effleurage. D. biofeedback. Nurses should be aware of the difference experience can make in labor pain, such as: A. sensory pain for nulliparous women often is greater than for multiparous women during early labor. B. affective pain for nulliparous women usually is less than for multiparous women throughout the first stage of labor. C. women with a history of substance abuse experience more pain during labor. D. multiparous women have more fatigue from labor and therefore experience more pain. With regard to what might be called the tactile approaches to comfort management, nurses should be aware that: A. either hot or cold applications may provide relief, but they should never be used together in the same treatment. B. acupuncture can be performed by a skilled nurse with just a little training. C. hand and foot massage may be especially relaxing in advanced labor when a woman's tolerance for touch is limited. D. therapeutic touch (TT) uses handheld electronic stimulators that produce sympathetic vibrations. With regard to systemic analgesics administered during labor, nurses should be aware that: A. systemic analgesics cross the maternal blood-brain barrier as easily as they do the fetal blood-brain barrier. B. effects on the fetus and newborn can include decreased alertness and delayed sucking. C. IM administration is preferred over IV administration. D. IV patient-controlled analgesia (PCA) results in increased use of an analgesic. After change of shift report, the nurse assumes care of a multiparous patient in labor. The woman is complaining of pain that radiates to her abdominal wall, lower back, buttocks, and down her thighs. Before implementing a plan of care, the nurse should understand that this type of pain is: A. visceral. B. referred. C. somatic. D. afterpain. When monitoring a woman in labor who has just received spinal analgesia, the nurse should report which assessment findings to the health care provider? (Select all that apply.) A. Maternal blood pressure of 108/79 B. Maternal heart rate of 98 C. Respiratory rate of 14 breaths/min D. Fetal heart rate of 100 beats/min E. Minimal variability on a fetal heart monitor After delivering a healthy baby boy with epidural anesthesia, a woman on the postpartum unit complains of a severe headache. The nurse should anticipate which actions in the patient's plan of care? (Select all that apply.) A. Keeping the head of bed elevated at all times B. Administration of oral analgesics C. Avoid caffeine D. Assisting with a blood patch procedure E. Frequent monitoring of vital signs When assessing a fetal heart rate (FHR) tracing, the nurse notes a decrease in the baseline rate from 155 to 110. The rate of 110 persists for more than 10 minutes. The nurse could attribute this decrease in baseline to: A. maternal hyperthyroidism. B. initiation of epidural anesthesia that resulted in maternal hypotension. C. maternal infection accompanied by fever. D. alteration in maternal position from semirecumbent to lateral. On review of a fetal monitor tracing, the nurse notes that for several contractions, the fetal heart rate decelerates as a contraction begins and returns to baseline just before it ends. The nurse should: A. describe the finding in the nurse's notes. B. reposition the woman onto her side. C. call the physician for instructions. D. administer oxygen at 8 to 10 L/min with a tight face mask. A. describe the finding in the nurse's notes Which finding meets the criteria of a reassuring fetal heart rate (FHR) pattern? A. FHR does not change as a result of fetal activity. B. Average baseline rate ranges between 100 and 140 beats/min. C. Mild late deceleration patterns occur with some contractions. D. Variability averages between 6 to 10 beats/min. Late deceleration patterns are noted when assessing the monitor tracing of a woman whose labor is being induced with an infusion of Pitocin. The woman is in a side-lying position, and her vital signs are stable and fall within a normal range. Contractions are intense, last 90 seconds, and occur every 1½ to 2 minutes. The nurse's IMMEDIATE action would be to: A. change the woman's position. B. stop the Pitocin. C. elevate the woman's legs. D. administer oxygen via a tight mask at 8 to 10 L/min. You are evaluating the fetal monitor tracing of your client, who is in active labor. Suddenly you see the fetal heart rate (FHR) drop from its baseline of 125 down to 80. You reposition the mother, provide oxygen, increase IV fluid, and perform a vaginal examination. The cervix has not changed. Five minutes have passed, and the FHR remains in the 80s. What additional nursing measures should you take? A. Notify nursery nurse of imminent delivery. B. Insert a Foley catheter. C. Start oxytocin (Pitocin). D. Notify the primary health care provider immediately (HCP). When using intermittent auscultation (IA) to assess uterine activity, nurses should be aware that: A. the examiner's hand should be placed over the fundus before, during, and after contractions. B. the frequency and duration of contractions are measured in seconds for consistency. C. contraction intensity is given a judgment number of 1 to 7 by the nurse and client together. D. the resting tone between contractions is described as either placid or turbulent. A nurse caring for a woman in labor understands that increased variability of the fetal heart rate might be caused by: A. narcotics. B. barbiturates. C. methamphetamines. D. tranquilizers. The nurse caring for a laboring woman is aware that maternal cardiac output can be increased by: A. change in position. B. oxytocin administration. C. regional anesthesia. D. intravenous analgesic. Fetal well-being during labor is assessed by: A. the response of the fetal heart rate (FHR) to uterine contractions (UCs). B. maternal pain control. C. accelerations in the FHR. D. an FHR greater than 110 beats/min. Which characteristic is associated with false labor contractions? A. Painless B. Decrease in intensity with ambulation C. Regular pattern of frequency established D. Progressive in terms of intensity and duration A pregnant couple has formulated a birth plan and is reviewing it with the nurse at an expectant parent's class. Which aspect of their birth plan would be considered unrealistic and require further discussion with the nurse? A. "My husband and I have agreed that my sister will be my coach since he becomes anxious with regard to medical procedures and blood. He will be nearby and check on me every so often to make sure everything is OK." B. "We plan to use the techniques taught in the Lamaze classes to reduce the pain experienced during labor." C. "We want the labor and birth to take place in a birthing room. My husband will come in the minute the baby is born." D. "We do not want the fetal monitor used during labor since it will interfere with movement and doing effleurage." The nurse should realize that the most common and potentially harmful maternal complication of epidural anesthesia is: A. severe postpartum headache. B. limited perception of bladder fullness. C. increase in respiratory rate. D. hypotension. When managing the care of a woman in the second stage of labor, the nurse uses various measures to enhance the progress of fetal descent. These measures include: A. encouraging the woman to try various upright positions, including squatting and standing. B. telling the woman to start pushing as soon as her cervix is fully dilated. C. continuing an epidural anesthetic so that pain is reduced and the woman can relax. D. coaching the woman to use sustained, 10- to 15-second, closed-glottis bearing-down efforts with each contraction. Evidence-based care practices designed to support normal labor and birth recommend which practice during the immediate newborn period? A. The healthy newborn should be taken to the nursery for a complete assessment. B. After drying, the infant should be given to the mother wrapped in a receiving blanket. C. Encourage skin-to-skin contact of mother and baby. D. The father or support person should be encouraged to hold the infant while awaiting delivery of the placenta. Which description of the phases of the second stage of labor is accurate? A. Latent phase: feels sleepy, fetal station is 2+ to 4+, duration is 30 to 45 minutes B. Active phase: overwhelmingly strong contractions, Ferguson reflux activated, duration is 5 to 15 minutes C. Descent phase: significant increase in contractions, Ferguson reflux activated, average duration varies Which test is performed to determine if membranes are ruptured? A. Urine analysis B. Fern test C. Leopold maneuvers D. Artificial Rupture of Membranes (AROM) A woman who is 39 weeks pregnant expresses fear about her impending labor and how she will manage. The nurse's best response is: A. "Don't worry about it. You'll do fine." B. "It's normal to be anxious about labor. Let's discuss what makes you afraid." C. "Labor is scary to think about, but the actual experience isn't." D. "You may have an epidural. You won't feel anything." Vaginal examinations should be performed by the nurse under which of these circumstances. (Select all that apply.) A. An admission to the hospital at the start of labor B. When accelerations of the fetal heart rate (FHR) are noted C. On maternal perception of perineal pressure or the urge to bear down D. When membranes rupture E. When bright, red bleeding is observed For the labor nurse, care of the expectant mother begins with which situations? (Select all that apply.) A. The onset of progressive, regular contractions B. The bloody, or pink, show C. The spontaneous rupture of membranes D. Formulation of the woman's plan of care for labor E. Moderately painful contractions A laboring woman's amniotic membranes have just ruptured. The immediate action of the nurse would be to: A. assess the fetal heart rate (FHR) pattern. B. perform a vaginal examination. C. inspect the characteristics of the fluid. D. assess maternal temperature. A woman is evaluated to be using an effective bearing-down effort if she: A. begins pushing as soon as she is told that her cervix is fully dilated and effaced. B. takes two deep, cleansing breaths at the onset of a uterine contraction and at the end of the contraction. C. uses the Valsalva maneuver by holding her breath and pushing vigorously for a count of 12. D. continues to push for short periods between uterine contractions throughout the second In planning for an expected cesarean birth for a woman who has given birth by cesarean previously and who has a fetus in the transverse presentation, the nurse includes which information? A. "Because this is a repeat procedure, you are at the lowest risk for complications." B. "Even though this is your second cesarean birth, you may wish to review the preoperative and postoperative procedures." C. "Because this is your second cesarean birth, you will recover faster." D. "You will not need preoperative teaching because this is your second cesarean birth." For a woman at 42 weeks of gestation, which finding requires more assessment by the nurse? A. Fetal heart rate of 116 beats/min B. Cervix dilated 2 cm and 50% effaced C. Score of 8 on the biophysical profile D. One fetal movement noted in 1 hour of assessment by the mother A pregnant woman's amniotic membranes rupture. Prolapsed cord is suspected. Which intervention is the nurse's top priority? A. Place the woman in the knee-chest position. B. Cover the cord in a sterile towel saturated with warm normal saline. C. Prepare the woman for a cesarean birth. D. Start oxygen by face mask. A nurse is caring for a client whose labor is being augmented with oxytocin. The nurse recognizes that the oxytocin should be discontinued immediately if there is evidence of: A. uterine contractions occurring every 8 to 10 minutes B. a fetal heart rate (FHR) of 180 with absence of variability C. the client needing to void D. rupture of the client's amniotic membranes With regard to the use of tocolytic therapy to suppress uterine activity, nurses should be aware that: A. the drugs can be given efficaciously up to the designated beginning of term at 37 weeks. B. there are no important maternal (as opposed to fetal) contraindications. C. its most important function is to afford the opportunity to administer antenatal glucocorticoids. D. if the client develops pulmonary edema while on tocolytics, IV fluids should be given. With regard to dysfunctional labor, nurses should be aware that: A. women who are underweight are more at risk. B. women experiencing precipitous labor are about the only "dysfunctionals" not to be exhausted. C. hypertonic uterine dysfunction is more common than hypotonic dysfunction. D. abnormal labor patterns are most common in older women. A nurse providing care to a woman in labor should be aware that cesarean birth: A. is declining in frequency in the United States. B. is more likely to be done for the poor in public hospitals who do not get the nurse counseling that wealthier clients do. C. is performed primarily for the benefit of the fetus. D. can be either elected or refused by women as their absolute legal right. Which statement is most likely to be associated with a breech presentation? A. Least common malpresentation B. Descent is rapid C. Diagnosis by ultrasound only D. High rate of neuromuscular disorders A woman at 26 weeks of gestation is being assessed to determine whether she is experiencing preterm labor. What findings indicate that preterm labor may be occurring? (Select all that apply.) A. Estriol is found in maternal saliva. B. Irregular, mild uterine contractions are occurring every 12 to 15 minutes. C. Fetal fibronectin is present in vaginal secretions. D. The cervix is effacing and dilated to 2 cm. E. Fetal heart rate of 150 beats/minute The labor and delivery nurse is admitting a woman complaining of being in labor. The nurse completes the admission database and notes that which factors may prohibit the woman from having a vaginal birth? (Select all that apply.) A. Unstable coronary artery disease B. Previous cesarean birth C. Placenta previa D. Initial blood pressure of 132/87 E. History of three spontaneous abortions Following the birth of her baby, a woman expresses concern about the weight she gained during pregnancy and how quickly she can lose it now that the baby is born. The nurse, in describing the expected pattern of weight loss, should begin by telling this woman that: A. return to pre-pregnant weight is usually achieved by the end of the postpartum period. B. fluid loss from diuresis, diaphoresis, and bleeding accounts for about a 3-lb weight loss. C. the expected weight loss immediately after birth averages about 11 to 13 lbs. D. lactation will inhibit weight loss since caloric intake must increase to support milk production. The breasts of a bottle-feeding woman are engorged. The nurse should tell her to: A. wear a snug, supportive bra. B. allow warm water to soothe the breasts during a shower. C. express milk from breasts occasionally to relieve discomfort. D. place absorbent pads with plastic liners into her bra to absorb leakage. A woman gave birth to a 7-lb, 3-oz boy 2 hours ago. The nurse determines that the woman's bladder is distended because her fundus is now 3 cm above the umbilicus and to the right of the midline. In the immediate postpartum period, the most serious consequence likely to occur from bladder distention is: A. urinary tract infection. B. excessive uterine bleeding. C. a ruptured bladder. D. bladder wall atony. What statement by a newly delivered woman indicates that she knows what to expect about her menstrual activity after childbirth? A. "My first menstrual cycle will be lighter than normal and then will get heavier every month thereafter." B. "My first menstrual cycle will be heavier than normal and will return to my prepregnant volume within three or four cycles." C. "I will not have a menstrual cycle for 6 months after childbirth." D. "My first menstrual cycle will be heavier than normal and then will be light for several months after." With regard to afterbirth pains, nurses should be aware that these pains are: A. caused by mild, continual contractions for the duration of the postpartum period. B. more common in first-time mothers. C. more noticeable in births in which the uterus was overdistended. D. alleviated somewhat when the mother breastfeeds. Postbirth uterine/vaginal discharge, called lochia: A. is similar to a light menstrual period for the first 6 to 12 hours. B. is usually greater after cesarean births. C. will usually decrease with ambulation and breastfeeding. D. should smell like normal menstrual flow unless an infection is present. Which description of postpartum restoration or healing times is accurate? A. The cervix shortens, becomes firm, and returns to form within a month postpartum. B. Rugae reappear within 3 to 4 weeks. C. Most episiotomies heal within a week. D. Hemorrhoids usually decrease in size within 2 weeks of childbirth. With regard to the condition and reconditioning of the urinary system after childbirth, nurses should be aware that: A. kidney function returns to normal a few days after birth. B. diastasis recti abdominis is a common condition that alters the voiding reflex. C. fluid loss through perspiration and increased urinary output account for a weight loss of more than 2 kg during the puerperium. D. with adequate emptying of the bladder, bladder tone usually is restored 2 to 3 weeks after childbirth. As part of the postpartum assessment, the nurse examines the breasts of a primiparous breastfeeding woman who is 1-day postpartum. Expected findings include: A. little if any change B. leakage of milk at let-down C. swollen, warm, and tender on palpation D. a few blisters and a bruise on each areola E. small amount of clear, yellow fluid expressed After completing a postpartum assessment on woman who delivered 20 hours ago, the nurse should report which assessment findings to the health care provider? (Select all that apply.) A. Temperature 100.0° F B. Pulse 110 beats/min C. Respiratory rate 12 breaths/min D. Blood pressure 125/78 E. Temperature 38° C When palpating the fundus of a woman 18 hours after birth, the nurse notes that it is firm, 2 fingerbreadths above the umbilicus, and deviated to the left of midline. The nurse should: A. massage the fundus. B. administer Methergine, 0.2 mg PO, that has been ordered prn. C. assist the woman to empty her bladder. D. recognize this as an expected finding during the first 24 hours following birth. The nurse examines a woman 1 hour after birth. The woman's fundus is boggy, midline, and 1 cm below the umbilicus. Her lochial flow is profuse, with two plum-sized clots. The nurse's initial action would be to: A. place her on a bedpan to empty her bladder. B. massage her fundus. C. call the physician. D. administer Methergine, 0.2 mg IM, which has been ordered prn. Perineal care is an important infection control measure. When evaluating a postpartum woman's perineal care technique, the nurse would recognize the need for further instruction if the woman: A. uses soap and warm water to wash the vulva and perineum. B. washes from the symphysis pubis back to the episiotomy. C, changes her perineal pad every 2 to 3 hours. D. uses the peribottle to rinse upward into her vagina. Which measure would be least effective in preventing postpartum hemorrhage? A. Administer Methergine, 0.2 mg every 6 hours for four doses, as ordered B. Encourage the woman to void every 2 hours C. Massage the fundus every hour for the first 24 hours following birth D. Teach the woman the importance of rest and nutrition to enhance healing On examining a woman who gave birth 5 hours ago, the nurse finds that the woman has completely saturated a perineal pad within 15 minutes. The nurse's first action is to: A. begin an IV infusion of Ringer's lactate solution. B. assess the woman's vital signs. C. call the woman's primary health care provider. D. massage the woman's fundus. Excessive blood loss after childbirth can have several causes; however, the most common is: A. vaginal or vulvar hematomas. B. unrepaired lacerations of the vagina or cervix. C. failure of the uterine muscle to contract firmly. D. retained placental fragments. Baby-friendly hospitals mandate that infants be put to breast within what time frame after birth? A. 1 hour B. 30 minutes C. 2 hours D. 4 hours Two hours after giving birth a primiparous woman becomes anxious and complains of intense perineal pain with a strong urge to have a bowel movement. Her fundus is firm at the umbilicus and midline. Her lochia is moderate rubra with no clots. The nurse suspects: A. bladder distention B. uterine atony C. constipation D. hematoma formation Which findings would be a source of concern if noted during the assessment of a woman who is 12 hours' postpartum? (Select all that apply.) A. Postural hypotension B. Temperature of 100.4° F C. Bradycardia—pulse rate of 55 beats/min D. Pain in left calf with dorsiflexion of left foot E. Lochia rubra with foul odor A postpartum woman preparing for discharge asks the nurse about resuming sexual activity. Which information is appropriate to include in the patient teaching? (Select all that apply.) A. Do not perform Kegel exercises to decrease pelvic floor muscle healing time. B. If breastfeeding, sexual interest may be delayed. C. Fatigue may affect interest in sexual activity. D. Sexual activity can usually be safely resumed by 5 to 6 weeks after birth. E. Water-soluble lubrication may increase comfort. F. The female-on-top position may be more comfortable than other positions. When making a visit to the home of a postpartum woman 1 week after birth, the nurse should recognize that the woman would characteristically: A. express a strong need to review events and her behavior during the process of labor and birth. B. exhibit a reduced attention span, limiting readiness to learn. C. vacillate between the desire to have her own nurturing needs met and the need to take charge of her own care and that of her newborn. D. have reestablished her role as a spouse/partner. Four hours after a difficult labor and birth, a primiparous woman refuses to feed her baby, stating that she is too tired and just wants to sleep. The nurse should: A. tell the woman she can rest after she feeds her baby. B. recognize this as a behavior of the taking-hold stage. C. record the behavior as ineffective maternal-newborn attachment. D. take the baby back to the nursery, reassuring the woman that her rest is a priority at this time. Parents can facilitate the adjustment of their other children to a new baby by: A. having the children choose or make a gift to give to the new baby on its arrival home. B. emphasizing activities that keep the new baby and other children together. C, having the mother carry the new baby into the home so she can show him or her to the other children. D, reducing stress on other children by limiting their involvement in the care of the new baby. A primiparous woman is in the taking-in stage of psychosocial recovery and adjustment following birth. Recognizing the needs of women during this stage, the nurse should: A. foster an active role in the baby's care. B. provide time for the mother to reflect on the events of and her behavior during childbirth. C. recognize the woman's limited attention span by giving her written materials to read when she gets home rather than doing a teaching session now. D. promote maternal independence by encouraging her to meet her own hygiene and comfort needs. The nurse observes several interactions between a postpartum woman and her new son. What behavior, if exhibited by this woman, does the nurse identify as a possible maladaptive behavior regarding parent-infant attachment? A. Talks and coos to her son B. Seldom makes eye contact with her son C. Cuddles her son close to her D. Tells visitors how well her son is feeding In follow-up appointments or visits with parents and their new baby, it may be useful if the nurse can identify parental behaviors that can either facilitate or inhibit attachment. What is a facilitating behavior? A. The parents have difficulty naming the infant. B. The parents hover around the infant, directing attention to and pointing at the infant. C. The parents make no effort to interpret the actions or needs of the infant. D. The parents do not move from fingertip touch to palmar contact and holding. Which statement regarding postpartum depression (PPD) is essential for the nurse to be aware of when attempting to formulate a plan of care? A. PPD symptoms are consistently severe. B. This syndrome affects only new mothers. C. PPD can easily go undetected. D. Only mental health professionals should teach new parents about this condition. When working with parents who have some form of sensory impairment, nurses should consider which information when writing a plan of care? A. One of the major difficulties visually impaired parents experience is the skepticism of health care professionals B. Visually impaired mothers cannot overcome the infant's need for eye-to- eye contact C. The best approach for the nurse is to assess the parents' capabilities rather than focusing on their disabilities D. Technologic advances, including the Internet, can provide deaf parents with a full range of parenting activities and information E. Childbirth education and other materials are available in Braille. The maternity nurse promoting parental-infant attachment should incorporate which appropriate cultural beliefs into the plan of care? (Select all that apply.) A. Asian mothers are encouraged to return to work as soon as possible. B. Jordanian mothers have a 40-day lying-in after birth. C. Japanese mothers rest for the first 2 months after childbirth. D. Encourage Hispanics to eat plenty of fish and pork to increase vitamin intake. E. Encourage Vietnamese mothers to cuddle with the newborn. When helping a woman cope with postpartum blues, the nurse should offer what appropriate suggestions? (Select all that apply.) A. The father should take over care of the baby, because postpartum blues are exclusively a female problem. B. Get plenty of rest. C. Plan to get out of the house occasionally. D. Asking for help will not foster independence. E. Use La Leche League or community mental health centers. Postpartum women experience an increased risk for urinary tract infection. A prevention measure the nurse could teach the postpartum woman would be to: A. acidify the urine by drinking three glasses of orange juice each day. B. maintain a fluid intake of 1 to 2 L/day. C. empty her bladder every 4 hours throughout the day. D. perform perineal care on a regular basis. D. perform perineal care on a regular basis. The first and most important nursing intervention when a nurse observes profuse postpartum bleeding is to: A. call the woman's primary health care provider B. administer the standing order for an oxytocic C. palpate the uterus and massage it if it is boggy D. assess maternal blood pressure and pulse for signs of hypovolemic shock Which postpartum conditions are considered medical emergencies that require immediate treatment? A. Inversion of the uterus and hypovolemic shock B. Hypotonic uterus and coagulopathies C. Subinvolution of the uterus and idiopathic thrombocytopenic purpura D. Uterine atony and disseminated intravascular coagulation (DIC) Which postpartum infection is most often contracted by first-time mothers who are breastfeeding? A. Endometritis B. Wound infections C. Mastitis D. Urinary tract infections (UTIs) Despite popular belief, there is a rare type of hemophilia that affects women of childbearing age. von Willebrand disease is the most common of the hereditary bleeding disorders and can affect males and females alike. It results from a factor VIII deficiency and platelet dysfunction. Although factor VIII levels increase naturally during pregnancy, there is an increased risk for postpartum hemorrhage from birth until 4 weeks postpartum as levels of von Willebrand factor (vWf) and factor VIII decrease. The treatment that should be considered first for the client with von Willebrand disease who experiences a postpartum hemorrhage is: A. cryoprecipitate B. factor VIII and vWf C. desmopressin D. Hemabate Herbal remedies have been used with some success to control PPH after initial management. Some herbs have homeostatic actions, whereas others work as oxytocic agents to contract the uterus. What herbal remedy is a commonly used oxytocic agent? A. Witch hazel B. Lady's mantel C. Blue cohosh D. Yarrow The priority nursing intervention for a woman who suffered a perineal laceration is to: A. apply a cold compress. B. establish hemostasis. C. administer analgesia. D. administer a stool softener. Thromboembolic conditions that are of concern during the postpartum period include (Select all that apply.) A. Amniotic fluid embolism (AFE) B. Superficial venous thrombosis C. Deep vein thrombosis D. Pulmonary embolism E. Disseminate intravascular coagulation (DIC) Nursing care management for mothers and fathers suffering grief from the loss of their baby includes: (Select all that apply.) A. using therapeutic communication and caring techniques. B. listening as parents tell their story of loss and grief. C. avoiding asking any questions about the loss of parents. D. giving advice from personal experiences. E. insisting parents name the baby in order to be remembered. What would be a warning sign of ineffective adaptation to extrauterine life if noted when assessing a 24-hour-old breastfed newborn before discharge? A. Apical heart rate of 90 beats/min, slightly irregular, when awake and active B. Acrocyanosis C. Harlequin color sign When caring for a newborn, the nurse must be alert for signs of cold stress, including: A. decreased activity level. B. increased respiratory rate. C. hyperglycemia. D. shivering. The nurse helps a breastfeeding mother change the diaper of her 16-hour-old newborn after the first bowel movement. The mother expresses concern since the large amount of thick, sticky stool is very dark green, almost black in color. She asks the nurse if something is wrong. The nurse should respond to this mother's concern by: A. telling the mother not to worry since all breastfed babies have this type of stool. B. explaining to the mother that the stool is called meconium and is expected of all newborns for the first few bowel movements. C. asking the mother what she ate at her last meal. D. suggesting that the mother ask her pediatrician to explain newborn stool patterns to her. When weighing a newborn, the nurse should: A. leave its diaper on for comfort. B. place a sterile scale paper on the scale for infection control. C. keep hand on the newborn's abdomen for safety. D. weigh the newborn at the same time each day for accuracy. Vitamin K is given to the newborn to: A. reduce bilirubin levels. B. increase the production of red blood cells. C. enhance ability of blood to clot. D. stimulate the formation of surfactant. The nurse notes that, when placed on the scale, the newborn immediately abducts and extends the arms, and the fingers fan out with the thumb and forefinger forming a "C." This response is known as a: A. tonic neck reflex. B. Moro reflex. C. cremasteric reflex. D. Babinski reflex. A newborn male, estimated to be 39 weeks of gestation, would exhibit: A. extended posture when at rest. B. testes descended into scrotum. C. abundant lanugo over his entire body. D. ability to move his elbow past his sternum. A nurse caring for a newborn should be aware that the sensory system least mature at the time of birth is: A. vision. B. hearing. C. smell. D. taste. An examiner who discovers unequal movement or uneven gluteal skinfolds during the Ortolani maneuver: A. tells the parents that one leg may be longer than the other, but they will equal out by the time the infant is walking. B. alerts the physician that the infant has a dislocated hip. C. informs the parents and physician that molding has not taken place. D. suggests that if the condition does not change, surgery to correct vision problems might be needed. The newborn's nurse should alert the health care provider when which newborn reflex assessment findings are seen? (Select all that apply.) A. Newborn turns head toward stimulus when eliciting rooting reflex. B. Newborn's fingers fan out when palmar reflex checked. C. Newborn forces tongue outward when tongue touched. D. Newborn exhibits symmetric abduction and extension of arms, and fingers form "C" when Moro reflex elicited. E. Newborn's toes hyperextend with dorsiflexion of big toe when sole of foot stroked upward along lateral aspect. The nurse must administer erythromycin ophthalmic ointment to a newborn after birth. The nurse should: A. instill within 15 minutes of birth for maximum effectiveness. B. cleanse eyes from inner to outer canthus before administration. C. apply directly over the cornea. D. flush eyes 10 minutes after instillation to reduce irritation. Newborns are at high risk for injury if appropriate safety precautions are not implemented. Parents should be taught to: A. place the newborn on the abdomen (prone) after feeding and for sleep. B. avoid use of pacifiers. C. use a rear-facing car seat. D. use a crib with side rail slats that are no more than 3 inches apart. Following circumcision of a newborn, the nurse provides instructions to his or her parents regarding post circumcision care. The nurse should tell the parents to: A. apply topical anesthetics with each diaper change. B. expect a yellowish exudate to cover the glans after the first 24 hours. C. change the diaper every 2 hours and cleanse the site with soap and water or baby wipes. D. apply constant pressure to the site if bleeding occurs and call the physician. When placing a newborn under a radiant heat warmer to stabilize the temperature after birth, the nurse should: A. place the thermistor probe on the left side of the chest. B. cover the probe with a non-reflective material. C. recheck the temperature by periodically taking a rectal temperature. D. prewarm the radiant heat warmer and place the undressed newborn under it. With regard to umbilical cord care, nurses should be aware that: A. the stump can easily become infected. B. a nurse noting bleeding from the vessels of the cord should immediately call for assistance. C. the cord clamp is removed at cord separation. D. the average cord separation time is 5 to 7 days. A 3.8-kg infant was delivered vaginally at 39 weeks after a 30-minute second stage. There was a nuchal cord. After birth the infant is noted to have petechiae over the face and upper back. Information given to the infant's parents should be based on the knowledge that petechiae: A. are benign if they disappear within 48 hours of birth B. result from increased blood volume C. should always be further investigated D. usually occur with forceps delivery A mother expresses fear about changing her infant's diaper after he is circumcised. What does the woman need to be taught to take care of the infant when she gets home? A. Cleanse the penis with prepackaged diaper wipes every 3 to 4 hours. B. Apply constant, firm pressure by squeezing the penis with the fingers for at least 5 minutes if bleeding occurs. C. Cleanse the penis gently with water and put petroleum jelly around the glans after each diaper change. D. Wash off the yellow exudate that forms on the glans at least once every day to prevent Which of these statements are helpful and accurate nursing advice concerning bathing the new baby. (Select all that apply.) A. Newborns should be bathed every day, for the bonding as well as the cleaning B. Tub baths may be given before the infant's umbilical cord falls of f and the umbilicus is healed. C. Only plain warm water can be used to preserve the skin's acid mantle. D. Powders are not recommended because the infant can inhale powder. E. Bathe immediately after feeding while baby is calm and relaxed. As part of their teaching function at discharge, nurses should tell parents that the baby's respiratory status should be protected by the following procedures: (Select all that apply.) A. Prevent exposure to people with upper respiratory tract infections B. Keep the infant away from secondhand smoke C. Avoid loose bedding, waterbeds, and beanbag chairs D. Do not let the infant sleep on his or her back E. Keep a bulb suction available at home. At 1 minute following birth, the newborn exhibited the following: heart rate of 155; loud, vigorous crying with active movement of all extremities; sneezing when nose is stimulated with a catheter; hands and feet bluish and cool to the touch. The Apgar score of this newborn should be recorded as 9 . 9 - The newborn receives 2 points each for a heart rate over 100 beats/min, a vigorous cry, active movement, and sneezing as a response to nasal stimulation. The newborn receives 1 point for color since he exhibits acrocyanosis. A vaginal examination during labor reveals the following information: LOA, -1, 75%, 3 cm. An accurate interpretation of this data would include which of the following? (Circle all that apply) A. Attitude : Flexed B. Station : 3 cm below the ischial spines C. Presentation : cephalic D. Lie : longitudinal E. Effacement : 75% complete F. Dilation : 9 cm more to reach full dilation Changes occur as a woman progresses through labor. Which of the following maternal adaptations would be expected during labor? (Circle all that apply) A. Increase in both systolic and diastolic blood pressure during uterine contractions in the first stage of labor. B. Decrease in white blood cell count. C. Slight increase in heart rate during the first and second stages of labor. D. Decrease in gastric motility leading to nausea and vomiting during the first stage of labor. E. Hypoglycemia F. Proteinuria up to 1 + With regard to primary and secondary powers, the maternity nurse should understand that: A. Primary powers are responsible for effacement and dilation of the cervix. B. Effacement generally is well ahead of dilation in women giving birth for the first time; they are more together in subsequent pregnancies. C. Scarring of the cervix caused by a previous infection or surgery may make the delivery a bit more painful, but it should not slow or inhibit dilation. D. Pushing in the second stage of labor is more effective if the woman can breathe deeply and control some of her involuntary needs to push, as the nurse directs. Which sign does not precede the onset of labor? A. A return of urinary frequency as a result of increased bladder pressure B. Persistent low backache from relaxed pelvic joints C. Stronger and more frequent uterine (Braxton Hicks) contractions D. A decline in energy, as the body stores up for labor In order to accurately assess the health of the mother accurately during labor, the nurse should be aware that: A. The woman’s blood pressure increases during contractions and falls back to prelabor normal between contractions. B. Use of the Valsalva maneuver is encouraged during the second stage of labor to relieve fetal hypoxia. C. Having the woman point her toes reduces leg cramps. D. The endogenous endorphins released during labor raise the woman’s pain threshold and produce sedation. The nurse knows that the second stage of labor, the descent phase, has begun when: A. The amniotic membranes rupture. B. The cervix cannot be felt during a vaginal examination. C. The woman experiences a strong urge to bear down D. The presenting part is below the ischial spines. Which statement is inaccurate with regard to normal labor? A. A single fetus presents by vertex. B. It is completed within 8 hours. C. A regular progression of contractions, effacement, dilation, and descent occurs. D. No complications are involved. Which position would the nurse suggest for second-stage labor if the pelvic outlet needs to be increased? A. Semirecumbent B. Sitting C. Squatting D. Side-lying Fetal circulation can be affected by many factors during labor. Accurate assessment of the laboring woman and fetus requires knowledge of these expected adaptations. Which factor will not affect fetal circulation during labor? A. Fetal position B. Uterine contractions C. Blood pressure D. Umbilical cord blood flow Concerning the third stage of labor, nurses should be aware that: A. The placenta eventually detaches itself from a flaccid uterus. B. The duration of the third stage may be as short as 3 to 5 minutes. C. It is important that the dark, roughened maternal surface of the placenta appear before the shiny fetal surface. D. The major risk for women during the third stage is a rapid heart rate. Which of the following findings would be a cause for concern for a nurse who is monitoring an obstetric patient who is in early labor? (Select all that apply.) A. Biparietal diameter of less than 9.25 cm B. Vertex presenting part C. Transverse lie D. General flexion attitude E. Android pelvis A woman in active labor receives an opioid agonist analgesic. Which medication relieves severe, persistent, or recurrent pain, creates a sense of well-being, overcomes inhibitory factors, and may even relax the cervix but should be used cautiously in women with cardiac disease? A. Meperidine (Demerol) B. Promethazine (Phenergan) C. Butorphanol tartrate (Stadol) D. Nalbuphine (Nubain) In the current practice of childbirth preparation, emphasis is placed on: A. The Dick-Read (natural) childbirth method. B. The Lamaze (psychoprophylactic) method. C. The Bradley (husband-coached) method. D. Encouraging expectant parents to attend childbirth preparation in any or no specific method. With regard to breathing techniques during labor, maternity nurses should be aware that: A. Breathing techniques in the first stage of labor are designed to increase the size of the abdominal cavity to reduce friction. B. By the time labor has begun, it is too late for instruction in breathing and relaxation. C. Controlled breathing techniques are most difficult near the end of the second stage of labor. D. The patterned-paced breathing technique can help prevent hyperventilation. With regard to spinal and epidural (block) anesthesia, nurses should know that: A. This type of anesthesia is commonly used for cesarean births but is not suitable for vaginal births. B. A high incidence of post birth headache is seen with spinal blocks. C. Epidural blocks allow the woman to move freely. D. Spinal and epidural blocks are never used together. After change of shift report, the nurse assumes care of a multiparous client in labor. The woman is complaining of pain that radiates to her abdominal wall, lower back, and buttocks, and down her thighs. Before implementing a plan of care, the nurse should understand that this type of pain is: A. Visceral B. Referred C. Somatic D. After-pain The breasts of a woman who is bottle feeding her baby are engorged. The nurse should instruct her to: A. Wear a snug, supportive bra B. Allow warm water to soothe the breasts during a shower. C. Express milk from breasts occasionally to relieve discomfort. D. Place absorbent pads with plastic liners into her bra to absorb leakage. A woman gave birth to a 7-lb, 3-oz boy 2 hours ago. The nurse determines that the woman’s bladder is distended because her fundus is now 3 cm above the umbilicus and to the right of the midline. In the immediate postpartum period, the most serious likely consequence of bladder distention is: A. Urinary tract infection. B. Excessive uterine bleeding. C. A ruptured bladder. D. Bladder wall atony. Which of the following findings would raise concern for the nurse who is monitoring a postpartum patient who had a spontaneous vaginal delivery (SVD) of a 10-lb baby boy? A. Lochia rubra with minimal clots expressed on fundal massage B. Fundus midline and firm with nonpalpable bladder C. Fundus midline and firm with spurts of bright red blood upon fundal massage D. Patient report of mild to moderate cramping and request for pain medication A woman gave birth to an infant boy 10 hours ago. Where would the nurse expect to locate this woman's fundus? A. One centimeter above the umbilicus B. Two centimeters below the umbilicus C. Midway between the umbilicus and the symphysis pubis D. Nonpalpable abdominally A woman gave birth to a healthy infant boy 5 days ago. What type of lochia would the nurse expect to find when assessing this woman? A. Lochia rubra B. Lochia sangra C. Lochia alba D. Lochia serosa Two days ago, a woman gave birth to a full-term infant. Last night, she awakened several times to urinate and noted that her gown and bedding were wet from profuse diaphoresis. One mechanism for the diaphoresis and diuresis that this woman is experiencing during the early postpartum period is: A. Elevated temperature caused by postpartum infection B. Increased basal metabolic rate after giving birth C. Loss of increased blood volume associated with pregnancy D. Increased venous pressure in the lower extremities The nurse caring for the postpartum woman understands that breast engorgement is caused by: A. Overproduction of colostrum B. Accumulation of milk in the lactiferous ducts C. Hyperplasia of mammary tissue D. Congestion of veins and lymphatics A woman gave birth to a 7-pound, 6-ounce infant girl 1 hour ago. The birth was vaginal and the estimated blood loss (EBL) was approximately 1500 ml. When assessing the woman's vital signs, the nurse would be concerned to see: A. Temperature 37.9° C, heart rate 120, respirations 20, blood pressure 90/50 B. Temperature 37.4°C, heart rate 88, respirations 36, blood pressure 126/68 C. Temperature 38° C, heart rate 80, respirations 16, blood pressure 110/80 D. Temperature 36.8° C, heart rate 60, respirations 18, blood pressure 140/90 To provide optimum care for the postpartum woman, the nurse understands that the most common causes of subinvolution are: A. Postpartum hemorrhage and infection B. Multiple gestation and postpartum hemorrhage C. Uterine tetany and overproduction of oxytocin D. Retained placental fragments and infection Which woman is most likely to experience strong afterpains? A. A woman who experienced oligohydramnios B. A woman who is a gravida 4, para 4-0-0-4 C. A woman who is bottle feeding her infant D. A woman whose infant weighed 5 pounds, 3 ounces Which of the following changes are consistent with metabolic function during the postpartum period? (Select all that apply.) A. Moderate hyperglycemia B. Increased BMR in the immediate postpartum period C. Secretion of insulinase D. Mildly increased T3 and T4 levels for the first several weeks postpartum E. Decrease in estrogen and cortisol levels The interval between the birth of the newborn and the return of the reproductive organs to their normal nonpregnant state is called the: A. Involutionary period because of what happens to the uterus B. Lochia period because of the nature of the vaginal discharge C. Mini-tri period because it lasts only 3 to 6 weeks D. Puerperium, or fourth trimester of pregnancy A nurse in the postpartum unit is assessing a newborn infant for signs of breastfeeding problems. Which of the following indicates a problem? Select all that apply. 1 The infant exhibits dimpling of the cheeks. 2 The infant makes smacking or clicking sounds. 3 The mother's breast gets softer during a feeding. 4 Milk drips from the mother's breast occasionally. 5 The infant falls asleep after feeding less than 5 minutes. 6 The infant can be heard swallowing frequently during a feeding. It has been 12 hours since the client's delivery of a newborn. The nurse assesses the client for the process of involution and documents that it is progressing normally when palpation of the client's fundus is noted: 1 At the level of the umbilicus 2 One finger breadth below the umbilicus 3 Two finger breadths below the umbilicus 4 Midway between the umbilicus and the symphysis pubis A nurse teaches a postpartum client about observation of lochia. The nurse determines the client's understanding when the client says that on the second day postpartum, the lochia should be: 1 Red 2 Pink 3 White 4 Yellow A physician has written a prescription to administer methylergonovine maleate (Methergine) to a postpartum client with uterine atony. The nurse would contact the physician to verify the prescription if which of the following conditions were present in the mother? 1 Hypertension 2 Excessive lochia 3 Difficulty locating the uterine fundus 4 Excessive bleeding and saturation of more than one peripad per hour After delivery, the postpartum nurse instructs the client with known cardiac disease to call for the nurse when she needs to get out of bed or when she plans to care for her newborn infant. The nurse informs the client that this is necessary to: 1 Help the mother assume the parenting role. 2 Minimize the potential of postpartum hemorrhage. 3 Provide an opportunity for the nurse to teach newborn infant care techniques. 4 Avoid maternal or infant injury caused by the potential for syncope or overexertion. The self-destruction of excess hypertrophied tissue in the uterus is called: A. Autolysis B. Subinvolution C. Afterpain D. Diastasis With regard to the postpartum uterus, nurses should be aware that: A. At the end of the third stage of labor, it weighs approximately 500 g. B. After 2 weeks postpartum, it should not be palpable abdominally. C. After 2 weeks postpartum, it weighs 100 g. D. It returns to its original (prepregnancy) size by 6 weeks postpartum A nurse provides instructions to a new mother who is about to breast-feed her newborn infant. The nurse observes the new mother as she breast-feeds for the first time and intervenes if the new mother: 1 Turns the newborn infant on his side, facing the mother 2 Tilts up the nipple or squeezes the areola, pushing it into the newborn's mouth 3 Draws the newborn the rest of the way onto the breast when the newborn opens his mouth 4 Places a clean finger in the side of the newborn's mouth to break the suction before removing the newborn from the breast A postpartum nurse has instructed a new mother regarding how to bathe her newborn infant. The nurse demonstrates the procedure to the mother and, on the following day, asks the mother to perform the procedure. Which observation by the nurse indicates that the mother is performing the procedure correctly? 1 The mother cleans the ears and then moves to the eyes and the face. 2 The mother begins to wash the newborn infant by starting with the eyes and face. 3 The mother washes the arms, chest, and back followed by the neck, arms, and face. 4 The mother washes the entire newborn infant's body and then washes the eyes, face, and scalp. A nurse is teaching umbilical cord care to a new mother. The nurse tells the mother that: 1 Alcohol is the only agent to use to clean the cord. 2 Cord care is done only at birth to control bleeding. 3 It takes at least 21 days for the cord to dry up and fall off. 4 The process of keeping the cord clean and dry will decrease bacterial growth. A nurse teaches the mother of a newly circumcised infant about post circumcision care. Which statement by the mother indicates an understanding of the care required? 1 " I need to clean the penis every hour with baby wipes." 2 "I need to check for bleeding every hour for the first 12 hours." 3 "My baby will not urinate for the next 24 hours because of swelling." 4 " I need to wrap the penis completely in dry sterile gauze, making sure that it is dry when I change his diaper." A nurse is preparing to care for the mother of a preterm infant. The nurse plans to begin discharge planning: 1 When the mother is in labor 2 When the discharge date is set 3 After stabilization of the infant during the early stages of hospitalization 4 When the parents feel comfortable with and can demonstrate adequate care of the infant A postpartum client with gestational diabetes is scheduled for discharge. During the discharge teaching, the client asks the nurse, "Do I have to worry about this diabetes anymore?" Which of the following is the appropriate response by the nurse? 1 "Your blood glucose level is within normal limits now, so you will be all right." 2 "You will only have to worry about the diabetes if you become pregnant again." 3 "You will be at risk for developing gestational diabetes with your next pregnancy and also for developing diabetes mellitus." 4 "When you have gestational diabetes, you have diabetes forever, and you must be treated with medication for the rest of your life." A nurse determines that a client is beginning to experience shock and hemorrhage as a result of a partial inversion of the uterus. The nurse pages the obstetrician to come immediately and calls for assistance. The client asks in an apprehensive voice, "What is happening to me? I feel so funny, and I know I'm bleeding. Am I dying?" The nurse responds to the client, knowing that the client is feeling: 1 Panic as a result of shock 2 Anticipatory grieving related to the fear of dying 3 Depression related to postpartum hormonal changes 4 Fear and anxiety related to unexpected and ambiguous sensations A client has just given birth to a newborn who has a cleft lip and palate. When planning to talk to the client, the nurse recognizes that the client needs to work through which emotion before maternal bonding can occur? 1 Guilt 2 Grief 3 Anger 4 Depression A nurse is caring for a postpartum client with thromboembolytic disease. When planning care to prevent the complication of pulmonary embolism, the nurse plans specifically to: 1 Enforce bedrest. 2 Monitor the vital signs frequently. 3 Assess the breath sounds frequently. 4 Administer and monitor anticoagulant therapy as prescribed. A mother who is breast-feeding her newborn infant is experiencing nipple soreness, and the nurse provides instructions regarding measures to relieve the soreness. Which statement by the mother indicates an understanding of the instructions? 1 "I need to avoid rotating breast-feeding positions so that the nipple will toughen." 2 "I need to stop nursing during the period of nipple soreness to allow the nipples to heal." 3 "I need to nurse less frequently and substitute a bottle feeding until the nipples become less sore." 4 "I need to position my infant with her ear, shoulder, and hip in straight alignment and place her stomach against me." A nurse in the postpartum unit is caring for a mother after vaginal delivery of a healthy newborn infant. The client received epidural anesthesia for the delivery. One-half hour after admission to the postpartum unit, the nurse checks the client and suspects the presence of a vaginal hematoma. Which finding would be the best indicator of the presence of this type of hematoma? 1 Changes in vital signs 2 Signs of vaginal bruising 3 Client complaints of a tearing sensation 4 Client complaints of intense vaginal pressure Methylergonovine (Methergine) is prescribed for a woman who has just delivered a healthy newborn infant . The priority assessment before administering the medication is to check the client's: 1 Lochia 2 Uterine tone 3 Blood pressure 4 Deep tendon reflexes A new breast -feeding mother is seen in the clinic with complaints of breast discomfort . The nurse determines that the mother is experiencing breast engorgement and provides the mother with instructions regarding care for the condition. Which statement by the mother indicates an understanding of the measures that will provide comfort for the engorgement? 1 "I will breast -feed using only one breast." 2 "I will apply cold compresses to my breasts." 3 "I will avoid the use of a bra while my breasts are engorged." 4 "I will massage my breasts before feeding to stimulate letdown." The first and most important nursing intervention when a nurse observes profuse postpartum bleeding is to: A. Call the woman's primary health care provider B. Administer the standing order for an oxytocic C. Palpate the uterus and massage it if it is boggy D. Assess maternal blood pressure and pulse for signs of hypovolemic shock Which PPH conditions are considered medical emergencies that require immediate treatment? A. Inversion of the uterus and hypovolemic shock B. Hypotonic uterus and coagulopathies C. Subinvolution of the uterus and idiopathic thrombocytopenic purpura D. Uterine atony and disseminated intravascular coagulation (DIC) A thrombosis results from the formation of a blood clot or clots inside a blood vessel and is caused by inflammation or partial obstruction of the vessel. Three thromboembolic conditions are of concern during the postpartum period and include all except: A. Amniotic fluid embolism (AFE) B. Superficial venous thrombosis C. Deep vein thrombosis D. Pulmonary embolism Nursing care management for mothers and fathers suffering grief from the loss of their baby includes: (Select all that apply.) A. using therapeutic communication and caring techniques. B. listening as parents tell their story of loss and grief. C. avoiding asking any questions about the loss of parents. D. giving advice from personal experiences. E. insisting parents name the baby in order to be remembered. What would be a warning sign of ineffective adaptation to extrauterine life if noted when assessing a 24-hour-old breastfed newborn before discharge? A. Apical heart rate of 90 beats/min, slightly irregular, when awake and active B. Acrocyanosis C.Harlequin color sign D.Weight loss representing 5% of the newborn's birth weight In most healthy newborns, blood glucose levels stabilize at mg/dL during the first hours after birth: Correct Responses• 50 to 60 A new mother recalls from prenatal class that she should try to feed her newborn daughter when she exhibits feeding readiness cues rather than waiting until her infant is crying frantically. On the basis of this information, this woman should feed her infant about every 2.5 to 3 hours when she: A. Waves her arms in the air B. makes sucking motions C. Has hiccups. D. Stretches her legs out straight. A new father is ready to take his wife and newborn son home. He proudly tells the nurse who is discharging them that within the next week he plans to start feeding the infant cereal between breastfeeding sessions. The nurse can explain to him that beginning solid foods before 4 to 6 months may: a. Decrease the infant's intake of sufficient calories. b. Lead to early cessation of breastfeeding. c. Help the infant sleep through the night. d. Limit the infant's growth A pregnant woman wants to breastfeed her infant, but her husband is not convinced that there are any scientific reasons to do so. The nurse can give the couple printed information comparing breastfeeding and bottle-feeding. What statement is true? Bottle-feeding using commercially prepared infant formulas: a. Increases the risk that the infant will develop allergies. b. Helps the infant sleep through the night. c. Ensures that the infant is getting iron in a form that is easily absorbed. d. Requires that multivitamin supplements be given to the infant. A postpartum woman telephones about her 4-day-old infant. She is not scheduled for a weight check until the infant is 10 days old, and she is worried about whether breastfeeding is going well. Effective breastfeeding is indicated by the newborn who: a. Sleeps for 6 hours at a time between feedings. b. Has at least one breast milk stool every 24 hours. c. Gains 1 to 2 ounces per week. d. Has at least six to eight wet diapers per day. A primiparous woman is delighted with her newborn son and wants to begin breastfeeding as soon as possible. The nurse can facilitate the infant's correct latch-on by helping the woman hold the infant: a. With his arms folded together over his chest. b. Curled up in a fetal position. c. With his head cupped in her hand. d. With his head and body in alignment. A breastfeeding woman develops engorged breasts at 3 days' postpartum. What action would help this woman achieve her goal of reducing the engorgement? The woman: a. Skips feedings to let her sore breasts rest. b. Avoids using a breast pump. c. Breastfeeds her infant every 2 hours. d. Reduces her fluid intake for 24 hours. At a 2-month well-baby examination, it was discovered that a breastfed infant had only gained 10 ounces in the past 4 weeks. The mother and the nurse agree that, to gain weight faster, the infant needs to: a. Begin solid foods. b. Have a bottle of formula after every feeding. c. Add at least one extra breastfeeding session every 24 hours. d. Start iron supplements. A new mother wants to be sure that she is meeting her daughter's needs while feeding her commercially prepared infant formula. The nurse should evaluate the mother's knowledge about appropriate infant care. The mother meets her child's needs when she: a. Adds rice cereal to her formula at 2 weeks of age to ensure adequate nutrition. b. Warms the bottles using a microwave oven. c. Burps her infant during and after the feeding as needed. d. Refrigerates any leftover formula for the next feeding. The nurse is discussing storage of breast milk with a mother whose infant is preterm and in the special care unit. What statement would indicate that the mother needs additional teaching? a. "I can store my breast milk in the refrigerator for 3 months." b. "I can store my breast milk in the freezer for 3 months." c. "I can store my breast milk at room temperature for 8 hours." d. "I can store my breast milk in the refrigerator for 3 to 5 days." According to the recommendations of the American Academy of Pediatrics on infant nutrition: a. Infants should be given only human milk for the first 6 months of life. b. Infants fed on formula should be started on solid food sooner than breastfed infants. c. If infants are weaned from breast milk before 12 months, they should receive cow's milk, not formula. d. After 6 months mothers should shift from breast milk to cow's milk. According to demographic research, the woman least likely to breastfeed and therefore most likely to need education regarding the benefits and proper techniques of breastfeeding would be: a. A woman who is 30 to 35 years of age, Caucasian, and employed part time outside the home. b. A woman who is younger than 25 years of age, Hispanic, and unemployed. c. A woman who is younger than 25 years of age, African-American, and employed full time outside the home. d. A woman who is 35 years of age or older, Caucasian, and employed full time at home. What statement concerning the benefits or limitations of breastfeeding is NOT accurate? a. Breast milk changes over time to meet changing needs as infants grow. b. Long-term studies have shown that the benefits of breast milk continue after the infant is weaned. c. Breast milk/breastfeeding may enhance cognitive development. d. Breastfeeding increases the risk of childhood obesity. Benefits to the mother associated with breastfeeding include all except: a. They have a decreased risk of breast cancer. b. It is an effective method of birth control. c. It increases bone density. d. It may enhance postpartum weight loss. All of these statements indicate impacts of breastfeeding on the family or society at large except: a. Breastfeeding requires fewer supplies and less cumbersome equipment. b. Breastfeeding saves families money. c. Breastfeeding costs employers in terms of time lost from work. d. Breastfeeding benefits the environment. With regard to the nutrient needs of breastfed and formula-fed infants, nurses should be aware that: a. Breastfed infants need extra water in hot climates. b. During the first 3 months breastfed infants consume more energy than formula-fed infants. c. Breastfeeding infants should receive oral vitamin D drops daily at least during the first 2 months. d. Vitamin K injections at birth are not needed for infants fed on specially enriched formula. The maternity nurse must be cognizant that cultural practices have significant influence on infant feeding methods. A new mother who recently emigrated from South Africa insists on feeding her newborn a watery porridge. This new mother believes that this first food will: a. Clear the infant's throat. b. Clear the infant's bowel of meconium. c. Remove the fluids of the womb ingested by the newborn during birth. d. Teach the baby to learn how to taste. During a phone follow-up conversation with a woman who is 4 days postpartum, the woman tells the nurse, "I don't know what's wrong. I love my son, but I feel so let down. I seem to cry for no reason!" The nurse would recognize that the woman is experiencing: A. Taking-in B. Postpartum depression (PPD) C. Postpartum blues D. Attachment difficulty The nurse can help a father in his transition to parenthood by: A. Pointing out that the infant turned at the sound of his voice B. Encouraging him to go home to get some sleep C. Telling him to tape the infant's diaper a different way D. Suggesting that he let the infant sleep in the bassinet The nurse notes that a Vietnamese woman does not cuddle or interact with her newborn other than to feed him, change his diapers or soiled clothes, and put him to bed. In evaluating the woman's behavior with her infant, the nurse realizes that: A. What appears to be a lack of interest in the newborn is in fact the Vietnamese way of demonstrating intense love by attempting to ward of f evil spirits. B. The woman is inexperienced in caring for newborns. C. The woman needs a referral to a social worker for further evaluation of her parenting behaviors once she goes home with the newborn. D. Extra time needs to be planned for assisting the woman in bonding with her newborn. With regard to parents' early and extended contact with their infant and the relationships built, nurses should be aware that: A. Immediate contact is essential for the parent-child relationship. B. Skin-to-skin contact is preferable to contact with the body totally wrapped in a blanket. C. Extended contact is especially important for adolescents and low-income women because they are at risk for parenting inadequacies. D. Mothers need to take precedence over their partners and other family matters. In the United States, the en face position is preferred immediately after birth. Nurses can facilitate this process by all of these actions except: A. Washing both the infant's face and the mother's face B. Placing the infant on the mother's abdomen or breast with their heads on the same plane C. Dimming the lights D. Delaying the instillation of prophylactic antibiotic ointment in the infant's eyes After birth, a crying infant may be soothed by being held in a position in which the newborn can hear the mother's heartbeat. This phenomenon is known as: A. Entrainment B. Reciprocity C. Synchrony D. Biorhythmicity A woman gave birth to a healthy 7-pound, 13-ounce infant girl. The nurse suggests that the woman place the infant to her breast within 15 minutes after birth. The nurse knows that breastfeeding is effective during the first 30 minutes after birth because this is the: a. Transition period. b. First period of reactivity. c. Organizational stage. d. Second period of reactivity. Part of the health assessment of a newborn is observing the infant's breathing pattern. A full-term newborn's breathing pattern is predominantly: a. Abdominal with synchronous chest movements. b. Chest breathing with nasal flaring. c. Diaphragmatic with chest retraction. d. Deep with a regular rhythm. The nurse assessing a newborn knows that the most critical physiologic change required of the newborn is: a. Closure of fetal shunts in the circulatory system. b. Full function of the immune defense system at birth. c. Maintenance of a stable temperature. d. Initiation and maintenance of respirations. The parents of a newborn ask the nurse how much the newborn can see. The parents specifically want to know what type of visual stimuli they should provide for their newborn. The nurse responds to the parents by telling them: a. "Infants can see very little until about 3 months of age." b. "Infants can track their parent's eyes and distinguish patterns; they prefer complex patterns." c. "The infant's eyes must be protected. Infants enjoy looking at brightly colored stripes." d. "It's important to shield the newborn's eyes. Overhead lights help them see better." A client is warm and asks for a fan in her room for her comfort. The nurse enters the room to assess the mother and her infant and finds the infant unwrapped in his crib with the fan blowing over him on "high." The nurse instructs the mother that the fan should not be directed toward the newborn and the newborn should be wrapped in a blanket. The mother asks why. The nurse's best response is: a. "Your baby may lose heat by convection, which means that he will lose heat from his body to the cooler ambient air. You should keep him wrapped and prevent cool air from blowing on him." b. "Your baby may lose heat by conduction, which means that he will lose heat from his body to the cooler ambient air. You should keep him wrapped and prevent cool air from blowing on him." c. "Your baby may lose heat by evaporation, which means that he will lose heat from his body to the cooler ambient air. You should keep him wrapped and prevent cool air from blowing on him." d. "Your baby will get cold stressed easily and needs to be bundled up at all times." The transition period between intrauterine and extrauterine existence for the newborn: a. Consists of four phases, two reactive and two of decreased responses. b. Lasts from birth to day 28 of life. c. Applies to full-term births only. d. Varies by socioeconomic status and the mother's age. Which statement describing the first phase of the transition period is inaccurate? a. It lasts no longer than 30 minutes. b. It is marked by spontaneous tremors, crying, and head movements. c. It includes the passage of meconium. d. It may involve the infant's suddenly sleeping briefly. By knowing about variations in infants' blood count, nurses can explain to their clients that: a. A somewhat lower than expected red blood cell count could be the result of delay in clamping the umbilical cord. b. The early high white blood cell (WBC) count is normal at birth and should decrease rapidly. c. Platelet counts are higher than in adults for a few months. d. Even a modest vitamin K deficiency means a problem with the ability of the blood to clot properly. What infant response to cool environmental conditions is either not effective or not available to them? a. Constriction of peripheral blood vessels b. Metabolism of brown fat c. Increased respiratory rates d. Unflexing from the normal position Which statement describing physiologic jaundice is incorrect? a. Neonatal jaundice is common, but kernicterus is rare. b. The appearance of jaundice during the first 24 hours or beyond day 7 indicates a pathologic process. c. Because jaundice may not appear before discharge, parents need instruction on how to assess it and when to call for medical help. d. Breastfed babies have a lower incidence of jaundice. One reason the brain is vulnerable to nutritional deficiencies and trauma in early infancy is the: a. Incompletely developed neuromuscular system. b. Primitive reflex system. c. Presence of various sleep-wake states. d. Cerebellum growth spurt. A collection of blood between the skull bone and its periosteum is known as a cephalhematoma. To reassure the new parents whose infant develops such a soft bulge, it is important that the nurse be aware that this condition: a. May occur with spontaneous vaginal birth. b. Happens only as the result of a forceps or vacuum delivery. c. Is present immediately after birth. d. Will gradually absorb over the first few months of life. A nursing student is helping the nursery nurses with morning vital signs. A baby born 10 hours ago by cesarean section is found to have moist lung sounds. What is the best interpretation of these data? a. The nurse should notify the pediatrician stat for this emergency situation. b. The neonate must have aspirated surfactant. c. If this baby was born vaginally, it could indicate a pneumothorax. d. The lungs of a baby delivered by cesarean section may sound moist for 24 hours after birth. Cardiovascular changes that cause the foramen ovale to close at birth are a direct result of: a. Increased pressure in the right atrium. b. Increased pressure in the left atrium. c. Decreased blood flow to the left ventricle. d. Changes in the hepatic blood flow. In administering vitamin K to the infant shortly after birth, the nurse understands that vitamin K is: a. Important in the production of red blood cells. b. Necessary in the production of platelets. c. Not initially synthesized because of a sterile bowel at birth. d. Responsible for the breakdown of bilirubin and prevention of jaundice. Infants in whom cephalhematomas develop are at increased risk for: a. Infection. b. Jaundice. c. Caput succedaneum. d. Erythema toxicum. The nurse providing care for the laboring woman understands that accelerations with fetal movement: a) Are reassuring b) Are caused by umbilical cord compression c) Warrant close observation d) Are caused by uteroplacental insufficiency The most common cause of decreased variability in the FHR that lasts 30 minutes or less is: a) Altered cerebral blood flow b) Fetal hypoxemia c) Umbilical cord compression d) Fetal sleep cycles You are evaluating the fetal monitor tracing of your client, who is in active labor. Suddenly you see the fetal heart rate (FHR) drop from its baseline of 125 down to 80. You reposition the mother, provide oxygen, increase IV fluid, and perform a vaginal exam. The cervix has not changed. Five minutes have passed, and the FHR remains in the 80s. What additional nursing measures should you take? a) Call for help b) Insert a foley catheter c) Start oxytocin (Pitocin) d) Notify the primary health care provider immediately When using intermittent auscultation to assess uterine activity, nurses should be aware that: a) The examiner's hand should be placed over the fundus before, during, and after contractions b) The frequency and duration of contractions are measured in seconds for consistency c) Contraction intensity is given a judgment number of 1 to 7 by the nurse and client together d) The resting tone between contractions is described as either placid or turbulent In documenting labor experiences, nurses should know that a uterine contraction is described according to all of these characteristics except: a) Frequency (how often contractions occur) b) Intensity (the strength of the contraction at its peak) c) Resting tone (The tension in the uterine muscle) d) Appearance (shape and height) A group of fetal monitoring experts (National Institute of Child Health and Human Development, 2008) recommends that fetal heart rate (FHR) tracings demonstrate certain characteristics to be described as reassuring or normal (category I). This includes: a) Bradycardia not accompanied by baseline variability b) Early decelerations, either present or absent c) Sinusoidal pattern d) Tachycardia When assessing a woman in labor, the nurse is aware that the relationship of the fetal body parts to one another is called fetal: A) Lie. B) Position. C) Presentation. D) Attitude. When assessing the fetus using Leopold maneuvers, the nurse feels a round, hard, movable fetal part just above the symphysis and a long, smooth surface in the mother's left side close to midline. In the fundus, there is a prominence- when pushed the whole body seems to follow. What is the likely position of the fetus? A) RSA B) ROA C) LSP D) LOA With regard to fetal positioning during labor, nurses should be aware that: A) Birth is imminent when the presenting part is at +4 to +5 cm, below the spine. B) Engagement is the term used to describe the beginning of labor. C) The largest transverse diameter of the presenting part is the suboccipitobregmatic diameter. D) Position is a measure of the degree of descent of the presenting part of the fetus through the birth canal. A client is admitted to the labor and delivery unit with contractions that are 3-5 minutes apart, lasting 60-70 seconds. She reports that she is leaking fluid. A vaginal exam reveals that her cervix is 80 percent effaced and 4 cm dilated and a -1 station. The nurse knows that the client is in which phase and stage of labor? A) Latent phase, First Stage B) Active Phase of First Stage C) Latent phase of Second Stage D) Transition While evaluating an external monitor tracing of a woman in active labor, the nurse notes that the fetal heart rate (FHR) for five sequential contractions begins to decelerate late in the contraction, with the nadir of the decelerations occurring after the peak of the contraction. The nurse's first priority is to: A) Notify the care provider. B) Assist with amnioinfusion C) Change the woman's position D) Insert a scalp electrode. During labor a fetus with an average heart rate of 175 beats/min over a 15- minute period would be considered to have: A) A normal baseline heart rate. B) Bradycardia. C) Hypoxia. D) Tachycardia. As a perinatal nurse you realize that a fetal heart rate that is tachycardic, is bradycardic, or has late decelerations with loss of variability is nonreassuring and is associated with A) Cord compression B) Hypotension C) Hypoxemia/acidemia D) Maternal drug use. The nurse providing care for the laboring woman should understand that amnioinfusion is used to treat: A) Fetal tachycardia. B) Fetal bradycardia. C) Variable decelerations D) Late decelerations. The most common cause of decreased variability in the fetal heart rate (FHR) that lasts 30 minutes or less is: A) Fetal hypoxemia B) Fetal sleep cycles C) Altered cerebral blood flow. D) Umbilical cord compression. What three measures should the nurse implement to provide intrauterine resuscitation? Select the response that best indicates the priority of actions that should be taken. A) Reposition the mother, increase intravenous (IV) fluid, and provide oxygen via face mask. B) Perform a vaginal examination, reposition the mother, and provide oxygen via face mask. C) Administer oxygen to the mother, increase IV fluid, and notify the care provider. D) Call the provider, reposition the mother, and perform a vaginal examination The nurse providing care for the laboring woman should understand that late fetal heart rate (FHR) decelerations are caused by: A) Altered cerebral blood flow B) Spontaneous rupture of membranes C) Uteroplacental insufficiency D) Umbilical cord compression The nurse caring for the woman in labor should understand that maternal hypotension can result in: A) Uteroplacental insufficiency. B) Spontaneous rupture of membranes C) Fetal dysrhythmias. D) Early decelerations. The nurse providing care for the laboring woman should understand that accelerations with fetal movement: A) Are caused by umbilical cord compression B) Are caused by uteroplacental insufficiency C) Warrant close observation D) Are reassuring. A woman has requested an epidural for her pain. She is 5 cm dilated and 100% effaced. The baby is in a vertex position and is engaged. The nurse increases the woman's intravenous fluid for a preprocedural bolus. She reviews her laboratory values and notes that the woman's hemoglobin is 12 g/dl, hematocrit is 38%, platelets are 67,000, and white blood cells (WBCs) are 12,000/mm3. Which factor would contraindicate an epidural for the woman? A) She is too far dilated B) She is anemic. C) She has thrombocytopenia D) She is septic Maternal hypotension is a potential side effect of regional anesthesia and analgesia. What nursing interventions could you use to raise the client's blood pressure? Choose all that apply. A) Place the woman in a supine position. B) Place the woman in a lateral position. C) Increase intravenous (IV) fluids. D) Continuous Fetal Monitor E) Administer ephedrine per MD order Nursing care measures are commonly offered to women in labor. Which nursing measure reflects application of the gate-control theory? A) Massaging the woman's back B) Changing the woman's position C) Giving the prescribed medication D) Encouraging the woman to rest between contractions Your patient is a nulliparous woman, requesting pain relief. You examine her and she is 8 cm. What is the best option for pain relief at this point? A) Demerol B) Spinal C) Epidural D) Stadol Which of the following is NOT a reason to come to labor and birth. A) The patient is 39 weeks with second baby. She has been having contractions for 2 hours. Contractions are getting longer and stronger and closer together. B) The patients says she has noticed greenish fluid leaking from her vagina. She is 41.5 weeks pregnant and not having contractions. C) The patient is 40 weeks and has contractions that are 8-10 minutes apart, 30 seconds long and been that way for 8 hours. D) The patient has not felt the baby move for 8 hours, despite drinking cold fluids, and nudging the baby with her hand. Through vaginal examination the nurse determines that a woman is 4 cm dilated, and the external fetal monitor shows uterine contractions every 3.5 to 4 minutes. The nurse would report this as: A) First stage, latent phase B) First stage, active phase C) First stage, transition phase D) Second stage, latent phase When assessing a multiparous woman who has just given birth to an 8-pound boy, the nurse notes that the woman's fundus is firm and has become globular in shape. A gush of dark red blood comes from her vagina. The nurse concludes that: A) The placenta has separated. B) A cervical tear occurred during the birth C) The woman is beginning to hemorrhage. D) Clots have formed in the upper uterine segment. Which of the following is true about placenta previa. A) The bleeding from placenta previa usually occurs late in pregnancy at term. B) In evaluating the bleeding, a vaginal exam would be done to determine the cause of the bleeding. C) Symptoms of placenta previa are painful frequent contractions and bright red vaginal bleeding D) Once placenta previa is diagnosed by a 20 week ultrasound, it is very likely the placenta previa will resolve in the third trimester. A woman arrive in the admission area of L&D. She is complaining of severe abdominal pain which she thinks are contractions and vaginal bleeding. You notice the sheet on the bed is about 1/3 covered with port wine fluid. You would do all of the following EXCEPT: A) Take a complete medical history and measure her vital signs. B) Position on her side and give her oxygen if the fetal heart rate was category II. C) NOtify the charge nurse and patient's provider. D) Start an IV E) Put her on the monitor A woman in preterm labor at 30 weeks of gestation receives two 12-mg doses of betamethasone intramuscularly. The purpose of this pharmacologic treatment is to: A) Suppress uterine contractions. B) Maintain adequate maternal respiratory effort and ventilation during magnesium sulfate therapy. C) Stimulate fetal surfactant production. D) Reduce maternal and fetal tachycardia associated with ritodrine administration Which of the following is true about labor dystocia. A) Labor dystocia would be defined if it took longer than an hour to dilate 1 cm during active labor in a first time laboring woman. B) In a nulliparous women with an arrest of labor, the use of pitocin will only help about 25% of women achieve a vaginal birth. C) second stage is abnormally long if it takes longer than 1 hour in a first time mother. D) When a woman has weak and infrequent contractions it is an indication that the baby is too large and she needs to have a Cesarean soon. Your client has been on magnesium sulfate for 20 hours for treatment of preeclampsia. She just delivered a viable infant girl 30 minutes ago. What uterine findings would you expect to observe/assess in this client? A) Absence of uterine bleeding in the postpartum period B) A fundus firm below the level of the umbilicus C) Scant lochia flow D) A boggy uterus with heavy lochia flow A woman with severe preeclampsia has been receiving magnesium sulfate by intravenous infusion for 8 hours. The nurse assesses the woman and documents the following findings: temperature of 37.1° C, pulse rate of 96 beats/min, respiratory rate of 24 breaths/min, blood pressure (BP) of 175/112 mm Hg, 3+ deep tendon reflexes, and no ankle clonus. The nurse calls the physician, anticipating an order for: A) Hydralazine. B) Magnesium sulfate bolus. C) Diazepam. D) Calcium gluconate. [Show More]

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