The nurse evaluates a pattern on the fetal monitor that appears similar to early decelerations. The deceleration begins near the acme of the contraction and continues well beyond the end of the contraction. Which nursing action indicates the proper evaluation of this situation?

This deceleration pattern is associated with uteroplacental insufficiency. The nurse must act quickly to improve placental blood flow and fetal oxygen supply.

Which maternal condition should be considered a contraindication for the application of internal monitoring devices?

Unruptured membranes

The nurse is instructing a nursing student on the application of fetal monitoring devices. Which method of assessing the fetal heart rate requires the use of a gel?

Doppler

Proper placement of the tocotransducer for electronic fetal monitoring is

Over the uterine fundus

Which clinical finding can be determined only by electronic fetal monitoring?

Variability

Which method of intrapartum fetal monitoring is the most appropriate when a woman has a history of hypertension during pregnancy?

Continuous electronic fetal monitoring

Why is continuous electronic fetal monitoring generally used when oxytocin is administered?

Uteroplacental exchange may be compromised.

The nurse is concerned that a patient’s uterine activity is too intense and that her obesity is preventing accurate assessment of the actual intrauterine pressure. Based on this information, which action should the nurse take?

Obtain an order from the health care provider for an intrauterine pressure catheter.

f the position of a fetus in a cephalic presentation is right occiput anterior, the nurse should assess the fetal heart rate in which quadrant of the maternal abdomen

Right lower

In which situation would a baseline fetal heart rate of 160 to 170 bpm be considered a normal finding?

The fetus is at 30 weeks of gestation.

When the deceleration pattern of the fetal heart rate mirrors the uterine contraction, which nursing action is indicated?

Record this normal pattern.

When the mother’s membranes rupture during active labor, the fetal heart rate should be observed for the occurrence of which periodic pattern?

Variable decelerations

The fetal heart rate baseline increases 20 bpm after vibroacoustic stimulation. The best interpretation of this is that the fetus is showing

an expected response.

When a Category II pattern of the fetal heart rate is noted and the patient is lying on her left side, which nursing action is indicated?

Change her position to the right side.

Which nursing action is correct when initiating electronic fetal monitoring?

Securely apply the tocotransducer with a strap or belt

Which statement correctly describes the nurse’s responsibility related to electronic monitoring?

Teach the woman and her support person about the monitoring equipment and discuss any of their questions

Observation of a fetal heart rate pattern indicates an increase in heart rate from the prior baseline rate of 152 bpm. Which physiologic mechanisms would account for this situation?

Sympathetic stimulation

Which of the following therapeutic applications provides the most accurate information related to uterine contraction strength?

Intrauterine pressure catheter (IUPC)

What is the most likely cause for this fetal heart rate pattern?

Cord compression

The patient presenting at 38 weeks’ gestation, gravida 1, para 0, vaginal exam 4 cm, 100% effaced, +1 station vertex. What is the most likely intervention for this fetal heart rate pattern?

Change maternal position.

The physician has ordered an amnioinfusion for the laboring patient. Which data supports the use of this therapeutic procedure?

+4 meconium-stained amniotic fluid on artificial rupture of membranes (AROM)

Which of the following is the priority intervention for a supine patient whose monitor strip shows decelerations that begin after the peak of the contraction and return to the baseline after the contraction ends?

Reposition to left side-lying position.

Decelerations that mirror the contractions are present with each contraction on the monitor strip of a multipara who received epidural anesthesia 20 minutes ago. The nurse should

maintain the normal assessment routine.

To clarify the fetal condition when baseline variability is absent, the nurse should first

apply pressure to the fetal scalp with a glove finger using a circular motion.

Which patient is a candidate for internal monitoring with an intrauterine pressure catheter?

Obese patient whose contractions are 3 to 6 minutes apart, lasting 20 to 50 seconds

Which of the following is the priority intervention for the patient in a left side-lying position whose monitor strip shows a deceleration that extends beyond the end of the contraction

Administer O2 at 8 to 10 L/minute.

When a pattern of variable decelerations occur, the nurse should immediately

position patient in a knee-chest position.

The nurse is reviewing an electronic fetal monitor tracing from a patient in active labor and notes the fetal heart rate gradually drops to 20 beats per minute (bpm) below the baseline and returns to the baseline well after the completion of the patient’s contractions. How will the

nurse document these findings?

Late decelerations

A patient at 41 weeks’ gestation is undergoing an induction of labor with an IV administration of oxytocin (Pitocin). The fetal heart rate starts to demonstrate a recurrent pattern of late decelerations with moderate variability. What is the nurse’s priority action?

Stop the infusion of Pitocin

The nurse admits a laboring patient at term. On review of the prenatal record, the patient’s pregnancy has been unremarkable and she is considered low risk. In planning the patient’s care, at what interval will the nurse intermittently auscultate (IA) the fetal heart rate during the first stage of labor?

Every 30 minutes

The nurse is monitoring a patient in labor and notes this fetal heart rate pattern on the electronic fetal monitoring strip (see figure). Which is the most appropriate nursing action?

Administer oxygen with a face mask at 8 to 10 L/minute

The nurse is monitoring a patient in labor and notes this fetal heart rate pattern on the electronic fetal monitoring strip (see figure). Which is the most appropriate nursing action at this time?

Perform a vaginal exam to detect a prolapsed cord

Which clinical finding would be considered normal for a preterm fetus during the labor period?

Baseline tachycardia

Which medications could potentially cause hyperstimulation of the uterus during labor? (Select all that apply.

Oxytocin (Pitocin)

Misoprostol (Cytotec)

Dinoprostone (Cervidil)

Methylergonovine maleate (Methergine)

When evaluating the patient’s progress, the nurse knows that four of the five fetal factors that interact to regulate the heart rate are (Select all that apply.)

baroreceptors.

adrenal glands.

chemoreceptors.

autonomic nervous system.

The nurse recognizes that fetal scalp stimulation may be prescribed to evaluate the response of the fetus to tactile stimulation. Which conditions contrindicate the use of fetal scalp stimulation? (Select all that apply.)

Maternal fever

Placenta previa

Induction of labor

The nurse is preparing supplies for an amnioinfusion on a patient with intact membranes.Which supplies should the nurse gather? (Select all that apply.)

Extra underpads

Amniotic hook to perform an amniotomy

The nurse is preparing to perform Leopold’s maneuvers. Please select the rationale for the consistent use of these maneuvers by obstetric providers?

To determine the best location to assess the fetal heart rate

Which comfort measure should the nurse utilize in order to enable a laboring woman to relax?

Recommend frequent position changes.

Which assessment finding is an indication of hemorrhage in the recently delivered postpartum patient?

Elevated pulse rate

Which intervention is an essential part of nursing care for a laboring patient?

Helping the woman manage the pain

A patient at 40 weeks’ gestation should be instructed to go to a hospital or birth center for evaluation when she experiences

a trickle of fluid from the vagina

Which patient at term should proceed to the hospital or birth center the immediately after labor begins?

Gravida 3, para 2, whose longest previous labor was 4 hours

A woman who is gravida 3, para 2 enters the intrapartum unit. The most important nursing assessments include

fetal heart rate, maternal vital signs, and the woman’s nearness to birth.

A primigravida at 39 weeks of gestation is observed for two hours in the intrapartum unit The fetal heart rate has been normal. Contractions are 5 to 9 minutes apart, 20 to 30 seconds in duration, and of mild intensity. Cervical dilation is 1 to 2 cm and uneffaced (unchanged from admission). Membranes are intact. The nurse should expect the patient to be

discharged home to await the onset of true labor

The nurse auscultates the fetal heart rate and determines a rate of 152 bpm. Which nursing intervention is most appropriate at this time?

Inform the mother that the fetal heart rate is normal.

Which clinical finding would be an indication to the nurse that the fetus may be compromised?

Meconium-stained amniotic fluid

The nurse is caring for a low-risk patient in the active phase of labor. At which interval should the nurse assess the fetal heart rate?

Every 30 minutes

Which nursing assessment indicates that a patient who is in the second stage of labor is almost ready to give birth

The vulva bulges and encircles the fetal head

During labor a vaginal examination should be performed only when necessary because of the risk of

infection.

A 25-year-old primigravida patient is in the first stage of labor. She and her husband have been holding hands and breathing together through each contraction. Suddenly, the patient pushes her husband’s hand away and shouts, “Don’t touch me!” This behavior is most likely

common during the transition phase of labor.

At 1 minute after birth, the nurse assesses the newborn to assign an Apgar score. The apical heart rate is 110 bpm, and the infant is crying vigorously with the limbs flexed. The infant’s trunk is pink and the hands and feet are blue. The Apgar score for this infant is

9.

If a woman’s fundus is soft 30 minutes after birth, the nurse’s first action should be to

massage the fundus.

he nurse thoroughly dries the infant immediately after birth primarily to

reduce heat loss from evaporation

The nurse notes that a patient who has given birth 1 hour ago is touching her infant with her fingertips and talking to him softly in high-pitched tones. Based on this observation, which action should the nurse take?

Document this evidence of normal early maternal-infant attachment behavior.

Which nursing diagnosis would take priority in the care of a primipara patient with no visible support person in attendance? The patient has entered the second stage of labor after a first stage of labor lasting 4 hours.

Anxiety related to imminent birth process

Which of the following behaviors would be applicable to a nursing diagnosis of “risk for injury” in a patient who is in labor?

Patient has received an epidural for pain control during the labor process.

A nursing priority during admission of a laboring patient who has not had prenatal care is

identifying labor risk factors.

The patient in labor experiences a spontaneous rupture of membranes. Which information related to this event must the nurse include in the patient’s record?

Fetal heart rate

The nurse assesses the amniotic fluid. Which characteristic presents the lowest risk of fetal complications?

Clear with bits of vernix caseosa

The nurse is preparing to initiate intravenous (IV) access on a patient in the active phase of labor. Which size IV cannula is best for this patient?

18-gauge

The nurse is reviewing the cardinal maneuvers of labor and birth with a group of nursing students. Which maneuver will immediately follow the birth of the baby’s head?

Restitution

The nurse is performing Leopold’s maneuvers on her patient. Which figure depicts the Leopold’s maneuver that determines whether the fetal presenting part is engaged in the maternal pelvis? Refer to Figures A to D

C

After a forceps-assisted birth, the patient is observed to have continuous bright red lochia and a firm fundus. Which other data would indicate the presence of a potential vaginal wall hematoma?

Edema and discoloration of the labia and perineum

Which patient presentation is an acceptable indication for serial oxytocin induction of labor?

Past 42 weeks of gestation

The nurse is explaining the technique of internal version to a nursing orientee. Which statement best describes the technique of internal version?

Manipulation of the second twin from a transverse lie to a breech presentation during vaginal birth

A maternal indication for the use of vacuum extraction is

maternal exhaustion.

For which patient should the oxytocin (Pitocin) infusion be discontinued immediately?

A patient in transition with contractions every 2 minutes lasting 90 seconds each

Immediately following the forceps-assisted birth of an infant, which action should the nurse implement?

Assess the infant for signs of trauma.

While assisting with a vacuum extraction birth, which alteration should the nurse immediately report to the obstetric provider?

Persistent fetal bradycardia below 100 bpm

To monitor for potential hemorrhage in the patient who has just had a cesarean birth, which action should the recovery room nurse implement?

Assess the uterus for firmness every 15 minutes

The nurse is preparing to administer a vaginal prostaglandin preparation to ripen the cervix of her patient. With which patient should the nurse question the use of vaginal prostaglandin as a cervical ripening agent?

The patient who had previous surgery in the upper uterus

A patient who is receiving oxytocin (Pitocin) infusion for the augmentation of labor is experiencing a contraction pattern of more than eight contractions in a 10-minute period.Which intervention would be a priority?

Stop Pitocin infusion.

On vaginal exam, the patient’s cervix is anterior, soft, 70% effaced, dilated 2 cm, and the presenting part is at 0 station. The Bishop’s score for this patient is

9.

Which assessment would be important for a 6-hour-old infant who has bruising over the cheeks from a forceps birth?

Symmetry of facial movements

Which aspect of newborn assessment may be limited by the application of a vacuum extractor at birth?

Posterior fontanel

Which breech presentation should the nurse recognize as being favorable for an external cephalic version?

37-week gestation with fetal weight of 7 lb

Following an external cephalic version, which assessment finding indicates a complication?

Deceleration of FHR to 88 bpm

The pregnant patient expresses a desire to schedule birth during the baby’s father’s furlough from military service. The nurse explains that prior to induction of labor, it is essential to determine which clinical finding?

Fetal lung maturity

The labor nurse is developing a plan of care for a patient admitted in active labor with spontaneous rupture of the membranes 6 hours prior to admission with clear fluid. On admission, vital signs were as follows: maternal heart rate (HR) 92 bpm; fetal rate (FHR) baseline, 150 to 160 bpm; blood pressure, 124/76 mm Hg; temperature 37.2° C (99° F). What is the priority nursing action for this patient?

Assess temperature every 2 hours

A laboring patient is 10 cm dilated; however, she does not feel the urge to push. The nurse understands that according to laboring down the advantages of waiting until an urge to push are which of the following (Select all that apply.)

Less maternal fatigue

Less birth canal injuries

Decreased pushing time

Which interventions should be performed in the birth room to facilitate thermoregulation of the newborn? (Select all that apply

Dry the infant off with sterile towels.

Place stockinette cap on infant’s head.

Remove wet linen as needed.

When caring for a patient in labor who is considered to be at low risk, which assessments should be included in the plan of care? (Select all that apply)

Monitor and record vital signs frequently during the course of labor.

Document the FHR pattern, noting baseline and response to contraction patterns.

Indicate on the EFM tracing when maternal position changes are done.

The nurse is monitoring a patient in the active stage of labor. Which conditions associated with fetal compromise should the nurse monitor? (Select all that apply.)

Maternal hypotension

Meconium-stained amniotic fluid

Maternal fever—38°C (100.4°F) or higher

The nurse is caring for a patient in the fourth stage of labor. Which assessment findings should the nurse identify as a potential complication? (Select all that apply.)

Soft boggy uterus

High uterine fundus displaced to the right

Intense vaginal pain unrelieved by analgesics

Induction of labor is considered an acceptable obstetric procedure if it is a safe time to deliver the fetus. The charge nurse on the labor and birth unit is often asked to schedule patients for this procedure and therefore must be cognizant of the specific conditions appropriate for labor induction, including which of the following? (Select all that apply.)

Fetal death

Postterm pregnancy abirb.com/test

Rupture of membranes at or near term

Chorioamnionitis (inflammation of the amniotic sac)

Which pelvic shape is most conducive to vaginal labor and birth?

Gynecoid

Which action by the nurse prevents infection in the labor and birth area?

Keeping underpads and linens as dry as possible

A pregnant patient with premature rupture of membranes is at higher risk for postpartum infection. Which assessment data indicates a potential infection?

Cloudy amniotic fluid, with strong odor

A patient with polyhydramnios is admitted to a labor-birth-recovery-postpartum (LDRP)suite. Her membranes rupture and the fluid is clear and odorless; however, the fetal heart monitor indicates bradycardia and variable decelerations. Which action should be taken next?

Perform a vaginal examination.

Which technique is least effective for the patient with persistent occiput posterior position?

Lying supine and relaxing

Birth for the nulliparous patient with a fetus in a breech presentation is usually

cesarean birth.

Which patient situation presents the greatest risk for the occurrence of hypotonic dysfunction during labor

A multiparous patient at 39 weeks of gestation who is expecting twins

Which factor is most likely to result in fetal hypoxia during a dysfunctional labor?

Incomplete uterine relaxation

After a birth complicated by a shoulder dystocia, the infant’s Apgar scores were 7 at 1 minute and 9 at 5 minutes. The infant is now crying vigorously. The nurse in the birthing room should

palpate the infant’s clavicles.

A laboring patient in the latent phase is experiencing uncoordinated irregular contractions of low intensity. How should the nurse respond to complaints of constant cramping pain?

I have notified the doctor that you are having alot of discomfort Let me rub your back and see if that helps.”

Which nursing action should be initiated first when there is evidence of prolapsed cord?

Reposition the mother with her hips higher than her head

A patient who has had two previous cesarean births is in active labor when she suddenly complains of pain between her scapulae. Which should be the nurse’s priority action?

Notify the health care provider promptly.

Which factor should alert the nurse to the potential for a prolapsed umbilical cord?

Presenting part at a station of –3

The fetus in a breech presentation is often born by cesarean birth because

compression of the umbilical cord is more likely

A patient who is 32 weeks pregnant telephones the nurse at her obstetrician’s office and complains of constant backache. She asks what pain reliever is safe for her to take. The best nursing response is

You should come into the office and let the doctor check you.”

Which is the priority nursing assessment for the patient undergoing tocolytic therapy with terbutaline (Brethine)

Fetal heart rate, maternal pulse, and blood pressure

Which clinical finding during assessment indicates uterine rupture?

Contractions abruptly stop during labor.

Which intervention should be incorporated in the plan of care for a labor patient who is experiencing hypertonic labor? Vaginal exam is unchanged from prior exam—3 cm, 80%effaced, and 0 station presenting part vertex.

Preparing the patient for epidural administration as ordered by the physician

During the course of the birth process, the physician suspects that a shoulder dystocia is occurring and asks the nurse for assistance. Which priority action should be taken in response to this request?

Ask the physician if he or she would like you to prepare for a surgical method of birth

A pregnant patient who has had a prior obstetric history of preterm labors is pregnant with her third child. The physician has ordered a fetal fibronectin test. Which instructions should be given to the patient regarding this clinical test?

Patient should refrain from sexual activity prior to testing

An obstetric patient has been identified as being high risk. The patient has had activities restricted (placed on bed rest) until the end of the pregnancy currently , she is at 32 weeks’ gestation and has two other children at home, ages 3 and 6. The patient’s husband works at home. A nursing diagnosis of Impaired Home Maintenance is noted. Which statement potentially identifies a long-term goal?

The patient and husband will make arrangements for child care routine activity assistance for the rest of the pregnancy.

A labor patient has been diagnosed with cephalopelvic disproportion (CPD) following attempts at pushing for 2 hours with no progress. Based on this information, which birth method is most appropriate?

Cesarean section

A patient is diagnosed with anaphylactoid syndrome of pregnancy. Which therapeutic intervention does the nurse expect will be included in the plan of care?

Initiation of CPR and other life support measures

A 20-year-old gravida 1, para 0 woman, is evaluated to be at 42 weeks’ gestation on admission to the labor and birth unit. The patient is not in labor at the current time; however, she has been sent over by the physician to be admitted for the induction of labor. The patient indicates to you that she would rather go home and wait for natural labor to start. How should the nurse respond to the patient’s request?

Inform the patient that there are a number of serious concerns related to a postdate

Which presentation is least likely to occur with a hypotonic labor pattern?

Fetal distress

Which finding on vaginal examination would be a concern if a spontaneous rupture of the membranes has occurred

Presenting part at +3 station

Which intervention would be most effective if the fetal heart rate drops following a spontaneous rupture of the membranes?

Position the patient in the knee-chest position.

Which finding would be indicative of an adverse response to terbutaline (Brethine)?

Heart rate of 122 bpm

A dose of dexamethasone 12 mg was administered to a patient in preterm labor at 0830 hours on March 12. The nurse knows that the next dose must be scheduled for

0830 hours on March 13th.

When reviewing the prenatal record of a patient at 42 weeks’ gestation, the nurse recognizes that induction of labor is based upon which indication

reduced amniotic fluid volume.

Which assessment finding in the postpartum patient following a uterine inversion indicates normovolemia?

Urine output >30 mL/hour

Which assessment finding indicates a complication in the patient attempting a vaginal birth after cesarean (VBAC)?

Complaint of pain between the scapulae

The labor nurse is providing care to a multigravida waitbhirmb.ocdoemra/ttetsot strong contractions every 2 to 3 minutes, duration 45 to 60 seconds. On admission, her cervical assessment was 5 cm, 80%, and +2. An epidural was administered shortly thereafter. Two hours after admission, her contraction pattern remains the same and her cervical assessment pattern 5 cm, 90%, and +2. What is the nurse’s next action?

Palpate the patient’s bladder for fullness.

which patient is most at risk for a uterine rupture

A gravida 4 who had a classical cesarean incision

A pregnant woman develops hypertension. The nurse monitors the patient’s blood pressure closely at subsequent visits because the nurse is aware that hypertension is associated with which complication?

Reduced placental blood flow

After birth, the nurse monitors the mother for postpartum hemorrhage secondary to uterine atony. Which clinical finding would increase the nurse’s concern regarding this risk?

Prolonged use of oxytocin

Emergency measures used in the treatment of a prolapsed cord include which of the following? (Select all that apply.)

Administration of oxygen via face mask at 8 to 10 L/minute

Maternal change of position to knee-chest

Administration of tocolytic agent

Vaginal elevation

Which presentation is most likely to occur with a hypertonic labor pattern? (Select all that apply.)

Painful uterine contractions

Increased resting tone

Increased uterine pressure

Which patient would be most likely to have severe afterbirth pains and request a narcotic analgesic?

Gravida 5, para 5

Which maternal event is abnormal in the early postpartal period

Lochial color changes from rubra to alba

Which fundal assessment finding at 12 hours after birth requires further assessment?

The fundus is palpable two fingerbreadths above the umbilicus.

If the patient’s white blood cell (WBC) count is 25,000/mm3 on her second postpartum day, which action should the nurse take?

Document the finding.

Postpartal overdistention of the bladder and urinary retention can lead to which complication?

Postpartum hemorrhage and urinary tract infection

A postpartum patient asks, “Will these stretch marks ever go away?” Which is the nurse’s best response?

“They will fade to silvery lines but won’t disappear completely.”

A pregnant patient asks when the dark line on her abdomen (linea nigra) will go away. The nurse knows the pigmentation will fade after birth due to

decreased melanocyte-stimulating hormone.

Which clinical finding should the nurse suspect if the fundus is palpated on the right side of the abdomen above the expected level?

Distended bladder

Which situation would require the administration of Rho(D) immune globulin?

Mother Rh-negative, baby Rh-positive

If the rubella vaccine is indicated for a postpartum patient, which instructions should be provided?

Explanation of the risks of becoming pregnant within 28 days following injection

Which measure is optimal in order to prevent abdominal distention following cesarean birth?

Early and frequent ambulation

To assess fundal contraction 6 hours after cesarean birth, which technique should the nurse utilize?

Gently palpate, applying the same technique used for vaginal deliveries.

The nurse has completed a postpartum assessment on a patient who delivered 1 hour ago. Which amount of lochia consists of a moderate amount

10 to 15 cm (4- to 6-inch) stain on the peripad

The postpartum nurse has completed discharge teaching for a patient being discharged after an uncomplicated vaginal birth. Which statement by the patient indicates that further teaching is necessary?

“If I breastfeed and supplement with formula, I won’t need any birth control.”

The nurse is caring for a postpartum patient who delivered by the vaginal route 12 hours ago. Which assessment finding should the nurse report to the health care provider?

Firm fundus, but excessive lochia

To facilitate adequate urinary elimination during the postpartum period, the nurse should incorporate which intervention into the plan of care?

Teach the patient to perform pelvic floor exercises to combat potential stress incontinence.

When assessing the A of the acronym REEDA, the nurse should evaluate the

edges of the episiotomy.

Which assessment finding 24 hours after vaginal birth would indicate a need for further intervention?

Uterine fundus 2 cm above the umbilicus

The nurse is providing care to a patient who delivered a 3525-g infant 14 hours ago. The nurse palpates the fundus of the uterus as firm and at the umbilicus. What is the nurse’s priority action related to this finding?

Document the finding in the patient’s chart.

The nurse is providing care to a patient 2 hours after a cesarean birth. In the hand-off report, the preceding nurse indicated that the patient’s lochia was scant rubra. On initial assessment,the oncoming nurse notes the patient’s peripad is saturated with lochia rubra immediately after breastfeeding her infant. What is the nurse’s priority action with this finding?

Contact the health care provider.

The nurse includes the addition of ice sitz baths for the postpartum patient. Which assessment finding indicates the treatment has been effective?

No swelling or edema to the perineal area

Which description best explains the term reciprocal attachment behavior?

Positive feedback that the infant exhibits toward parents during the attachment process

The postpartum patient who continually repeats the story of her labor, birth, and recovery experiences is performing which of the following tasks

Making the birth experience “real”

During which stage of role attainment do the parents become acquainted with their baby and combine parenting activities with cues from the infant?

Formal

The nurse observes a patient on her first postpartum day sitting in bed while her newborn lies anticipatory stage begins during the pregnancy when the parents choose a physician and attend childbirth classes.awake in the bassinet. Which action is most appropriate for the nurse to take at this time?

Hand the baby to the woman.

The postpartum nurse is observing a patient holding the baby she delivered less than 24 hours ago. The partner is watching his wife and asking questions about newborn care. The 4-year-old big brother is punching his mother on the back what should the nurse do next?

No action; this is a normal family adjusting to family change

During which phase of maternal adjustment will the mother relinquish the baby of her fantasies and accept the real baby?

Letting-go

A new father calls the nurse’s station stating that his wife, who delivered last week, is happy one minute and crying the next. He states, “She was never like this before the baby was born.”How should the nurse best respond?

Reassure him that this behavior is normal.

To promote bonding and attachment immediately after birth, which action should the nurse take?

Assist the mother in assuming an en face position with her newborn.

Which patient is more likely to have less stress adjusting to her role as a mother?

A 26-year-old woman who is returning to work in 10 weeks

Which anticipatory guidance action by the nurse makes role transition to parenthood easier?

Helps the new parents identify resources.

Which action should the nurse take in order to provide support and encouragement to the new postpartum patient?

Praise the mother’s early attempts at infant care

Which should the nurse do to provide support to a patient who must return to full-time employment 6 weeks after a vaginal birth?

Allow her to express her positive and negative feelings freely

The postpartum nurse is reviewing dietary practices for an Asian patient. Which of the following should the nurse expect to observe as a dietary practice for this culture?

Special foods brought from home.

An example of binding in during the postpartum period is a

father looking at his newborn and stating that he looks like i did when I was a baby.”

Which of the following behaviors would be applicable to a nursing diagnosis of Risk for Impaired Parenting?

Mother states that she feels excessive fatigue as a result of the childbirth experience

A family is concerned about how their 2-year-old son is going to react to the new baby. Which intervention would help facilitate sibling attachment?

Include the son in helping to take care of the baby and reinforce the label of “big brother” as a special role.

The nurse is developing a plan of care for the patient’s fourth stage of labor. One nursing intervention is to promote bonding. Specifically, which nursing action will facilitate the bonding process?

Ask the patient if she wants her baby placed on her chest immediately after birth.

A postpartum patient calls the clinic and reports to the nurse feelings of fatigue, tearfulness, and anxiety. What is the nurse’s most appropriate response at this time?

“Are you able to get out of bed and provide care for your baby?”

Which vaccinations are indicated for the postpartum patient if she does not have immunity? (Select all that apply.)

Pertussis

Rubella

Diphtheria, tetanus (Tdap)

Varicella

The nurse is planning comfort measures to implement for a patient after a vaginal birth. Which measures should the nurse plan to include in the patient’s care plan? (Select all that apply.)

Sitz baths four times a day

Topical anesthetic spray after perineal care

Ice pack to the perineum for the first 24 hours

The nurse is teaching a non–breastfeeding patient measure to suppress lactation. Which information should the nurse include in the teaching session? (Select all that apply.)

Avoid massaging the breasts.

Ice packs or cabbage leaves can be applied to the breasts to relieve discomfort.

Wear a sports bra 24 hours a day until the breasts become soft.

The nurse is conducting discharge teaching for a patient going home after a cesarean birth. Which signs and symptoms should the patient be taught to report? (Select all that apply.)

Feeling of pelvic fullness

Lochia changing from red to pink in color

Frequency, urgency, or burning on urination

Which of the following are nursing measures that can promote parent-infant bonding and attachment? (Select all that apply.)

Provide comfort and ample time for rest.

Position the infant face to face with the mother.

Point out the characteristics of the infant in a positive way.

Which statement by a postpartum patient indicates that further teaching regarding thrombus formation is unnecessary?

“I’ll put my support stockings on every morning before rising.”

The nurse understands that late postpartum hemorrhage may be prevented by

inspecting the placenta after birth.

A multiparous patient is admitted to the postpartum unit after a rapid labor and birth of a 4000-g infant. Her fundus is boggy, lochia is heavy, and vital signs are unchanged. The nurse has the patient void and massages her fundus; however, the fundus remains difficult to find and the rubra lochia remains heavy. Which action should the nurse take next?

Notify the health care provider.

Early postpartum hemorrhage is defined as a blood loss greater than

750 mL within 24 hours after a vaginal birth

A steady trickle of bright red blood from the vagina in the presence of a firm fundus suggests

lacerations of the genital tract.

A postpartum patient would be at increased risk for postpartum hemorrhage if she delivered a(n)

6.5-lb infant after a 2-hour labor.

The nurse should expect medical intervention for subinvolution to include

oral methylergonovine maleate (Methergine) for 48 hours.

If nonsurgical treatment for subinvolution is ineffective, which surgical procedure is appropriate to correct the cause of this condition?

Dilation and curettage (D&C)

A positive sign of thrombophlebitis includes

local tenderness, heat, and swelling.

Which nursing measure would be most appropriate to prevent thrombophlebitis in the recovery period following a cesarean birth?

Assist the patient in performing leg exercises every 2 hours.

Which temperature indicates the presence of postpartum infection?

38.2°C (100.8°F) on the second and third postpartum days

A white blood cell (WBC) count of 35,000 cells/mm3 on the morning of the first postpartum day indicates

possible infection.

The patient who is being treated for endometritis is placed in the Fowler position because this position

facilitates drainage of lochia.

Nursing measures that help prevent postpartum urinary tract infection include

forcing fluids to at least 3000 mL/day.

Which measure may prevent mastitis in a breastfeeding patient?

Initiating early and frequent feedings

A patient with mastitis is concerned about breastfeeding while she has an active infection. Which is an appropriate response by the nurse?

Organisms that cause mastitis are not passed through the milk.

The nurse suspecting a uterine infection in a postpartum patient should assess the

odor of the lochia.

Following a difficult vaginal birth of a singleton pregnancy, the patient starts bleeding heavily. Clots are expressed and a Foley catheter is inserted to empty the bladder becausethe uterine fundus is soft and displaced laterally from midline. Vital signs are 37.6°C (99.8°F), pulse 90 beats/minute, respirations 20 breaths per minute, and BP 130/90 mm Hg.Which pharmacologic intervention is indicated?

Administration of prostaglandin analog

Following a vaginal birth, a patient has lost a significant amount of blood and is starting to experience signs of hypovolemic shock. Which clinical signs would be consistent with this diagnosis?

Compensatory response of tachycardia and decreased pulse pressure

A patient has been treated with oxytocin (Pitocin) for postpartum hemorrhage. Bleeding has stabilized and slowed down considerably. The peripad in place reveals a moderate amount of bright red blood, with no clots expelled when masbsiargbi.ncgomth/etefusnt dus. The patient now complains of having difficulty breathing. Auscultation of breath sounds reveals adventitious sounds. Based on this clinical presentation, the priority nursing action is to

initiate a rapid response intervention.

A postpartum patient has developed deep vein thrombosis and treatment with warfarin (Coumadin) has been initiated. Which dietary selection should be modified in view of this treatment regimen?

Lentils

To determine an adverse response to carboprost tromethamine (Hemabate), the nurse should on Coumadin therapy. Vitamin K is the antidote to Coumadin activity. frequently assess

breath sounds.

If the nurse suspects a complication of a low forceps birth labor, she should immediately

assess the perineal and vaginal areas.

Prior to ambulating the patient whose admission hemoglobin level was 10.2 g/dL to the bathroom, the nurse should

dangle her on the side of the bed.

If a late postpartum hemorrhage is documented on a patient who delivered 3 days ago, the nurse recognizes that this hemorrhage occurred

on the second postpartum day.

Which patient data received during report should the nurse recognize as being at risk for postpartum complications?

Gravida 5, para 5

Before administering methylergonovine (Methergine), the nurse checks the

blood pressure.

To evaluate the desired response of methylergonovainbeir, the nurse would assess the patient’s

uterine tone.

As you receive a report, which assessment finding should you recognize as an indication of a vaginal laceration?

Bright red continuous trickle of blood from vagina

The nurse observes the patient as she ambulates to the bathroom. Which clinical finding might indicate development of a DVT (deep vein tharboimrbb.ocsoims)?

Stiffness of right leg

If a DVT (deep vein thrombosis) is suspected, the nurse should

place the patient on bed rest, with the affected leg elevated

If the nurse suspects a pulmonary embolism in the patient who suddenly complains of chest pain, she or he should immediately

apply O2 via tight face mask at 8 to 10 L/minute.

To prevent infection of the reproductive tract, the nurse should instruct the patient to

cleanse the perineum from front to back.

The nurse notes that the fundus of a postpartum patient is boggy, shifted to the left of the midline, and 2 cm above the umbilicus. What is the nurse’s priority action?

Massage the fundus of the uterus.

Which information should the nurse recognize as contributing to mastitis in the breastfeeding mother? (Select all that apply.)

Insufficient emptying

Supplementing feedings

Blisters on both nipples

The visiting nurse must be aware that women who have had a postpartum hemorrhage are subject to a variety of complications after discharge from the hospital. These include which of the following? (Select all that apply.)

Anemia

Exhaustion

Postpartum infection

Failure to attach to her infant

A nursing student is helping the mother-baby nurse with morning vital signs. A baby born 10 hours ago via cesarean birth is found to have moist lung sounds. Which is the best interpretation of this information?

The lungs of a baby delivered by cesarean birth may sound moist for 24 hours after birth

Which of the following organs are nonfunctional during fetal life?

Lungs and liver

Which method of heat loss may occur if a newborn is placed on a cold scale or touched with cold hands?

Conduction

How can nurses prevent evaporative heat loss in the newborn?

Drying the baby after birth and wrapping the baby in a dry blanket

The nurse is explaining how a newly delivered baby initiates respirations. Which statement explains this process most accurately?

Chemical, thermal, and mechanical factors

During fetal circulation the pressure is greatest in the

right atrium.

The infant’s heat loss immediately at birth is predominantly from

evaporation.

The nurse is explaining the risk of hypothermia in the newborn to a group of nursing students. Which statement best describes the manifestations of hypothermia in the newborn?

Newborns have increased glucose demands.

Which infant has the lowest risk of developing high levels of bilirubin?

The infant who is breastfed during the first hour of life

The nurse is preparing to administer a vitamin K injection to the infant shortly after birth. Which statement is important to understand regarding the properties of vitamin K?

It is not initially synthesized because of a sterile bowel at birth.

A meconium stool can be differentiated from a transitional stool in the newborn because the meconium stool is

passed in the first 24 hours of life.

Which of the following is the most likely cause of regurgitation when a newborn is fed?

A relaxed cardiac sphincter

The process in which bilirubin is changed from a fat-soluble product to a water-soluble product is known as

conjugation of bilirubin.

A newborn is admitted to the special care nursery with hypothermia. Which complication should the nurse monitor for closely?

Metabolic acidosis

Which action by the nurse can result in hyperthermia in the newborn?

Placing the newborn in the radiant warmer without attaching the skin probe

A multiparous patient arrives to the labor unit and urgently states, “The baby is coming RIGHT NOW!” The nurse assists the patient into a comfortable position and delivers the infant. To prevent infant heat loss from conduction, what is the priority nursing action?

Place the baby on the patient’s abdomen after the cord is cut.

The nurse is planning to conduct the initial assessment of a full-term newborn. Included in the plan is providing a neutral thermal environment. To accomplish this plan, what is the desired environmental temperature to conduct the assessment

32 to 33.5°C (89.6 to 92.3°F

An infant at 39 weeks’ gestation was just delivered; included in the protocol for a term infant is an initial blood glucose assessment. The nurse obtains the blood sample and the reading is 58 mg/dL. What is the priority nursing action based upon this reading?

Document the finding in the newborn’s chart.

During the first few minutes after birth, which physiologic change occurs in the newborn as a response to vascular pressure changes in increased oxygen levels?

Dilation of pulmonary vessels

Which infant is at greater risk to develop cold stress?

36-week infant with an Apgar score of 7 to 9.

A reported hematocrit level for a newborn delivered by vaginal birth is 75%. Based on this lab value, which complication is the newborn least likely to develop?

Infection

In the newborn nursery, you are reviewing the maternal medication list to ascertain if there is any significant risk to the newborn. Which medications would pose a potential risk to the newborn in terms of clotting ability? (Select all that apply.)

Carbamazepine

Phenytoin (Dilantin)

Phenobarbital

INH (Isoniazid)

The nurse is teaching the postpartum patient about newborn transitional stools. Which should the nurse include in the teaching session with regard to transitional stools? (Select all that apply.)

They are a greenish brown color.

They are of a looser consistency

Which newborn is at higher risk for developing hypoglycemia? (Select all that apply.)

Post-term newborn

Small-for-gestational-age newborn

Large-for-gestational-age newborn