A woman who is 39 weeks pregnant expresses fear about her impending labor and how she will manage. The nurse's best response is:
It's normal to be anxious about labor. Let's discuss what makes you afraid.'
A primigravida has just delivered a healthy infant girl. The nurse is about to administer erythromycin ointment in the infant's eyes when the mother asks, 'What is that medicine for?' The nurse responds:
Erythromycin is given prophylactically to prevent a gonorrheal infection.
An 18-year-old pregnant woman, gravida 1, is admitted to the labor and birth unit with moderate contractions every 5 minutes that last 40 seconds. The woman states, 'My contractions are so strong that I don't know what to do.' The nurse should:
Recognize that pain is personalized for each individual.
In planning for home care of a woman with preterm labor, the nurse needs to address what concern?
Prolonged bed rest may cause negative physiologic effects.
The early postpartum period is a time of emotional and physical vulnerability. Many mothers can easily become psychologically overwhelmed by the reality of their new parental responsibilities. Fatigue compounds these issues. Although the baby blues are a common occurrence in the postpartum period, about one-half million women in America experience a more severe syndrome known as postpartum depression (PPD). Which statement regarding PPD is essential for the nurse to be aware of when attempting to formulate a nursing diagnosis
PPD can easily go undetected
A multiparous woman has been in labor for 8 hours. Her membranes have just ruptured. The nurse's initial response would be to:
Assess the fetal heart rate and pattern
After giving birth to a healthy infant boy, a primiparous woman, 16, is admitted to the postpartum unit. An appropriate nursing diagnosis for her at this time is risk for impaired parenting related to deficient knowledge of newborn care. In planning for the woman's discharge, what should the nurse be certain to include in the plan of care?
Provide time for the woman to bathe her infant after she views an infant bath demonstration.
For a woman at 42 weeks of gestation, which finding would require more assessment by the nurse?
One fetal movement noted in 1 hour of assessment by the mother
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:
Infants can track their parent's eyes and prefer complex patterns.
A pregnant woman was admitted for induction of labor at 43 weeks of gestation with sure dates. A non-stress test (NST) in the obstetrician's office revealed a nonreactive tracing. On artificial rupture of membranes, thick, meconium-stained fluid was noted. The nurse caring for the infant after birth should anticipate:
Meconium aspiration, hypoglycemia, and dry, cracked skin.
A nurse is discussing the signs and symptoms of mastitis with a mother who is breastfeeding. What signs and symptoms should the nurse include in her discussion? Choose all that apply.
An area of redness on the breast often resembling the shape of a pie wedge
Fever and flulike symptoms
Warmth in the breast
A macrosomic infant is born after a difficult forceps-assisted delivery. After stabilization the infant is weighed, and the birth weight is 4550 g (9 pounds, 6 ounces). The nurse's most appropriate action is to:
Monitor blood glucose levels frequently and observe closely for signs of hypoglycemia
A client weighs 176 pounds. Heparin infusion 20,000 units in 1 L NS. Order: Bolus with heparin sodium at 80 units/kg, then initiate drip at 18 units/kg/hr. Calculate the bolus dosage in units.
Answer with a whole number
A woman who has recently given birth complains of pain and tenderness in her leg. On physical examination the nurse notices warmth and redness over an enlarged, hardened area. The nurse should suspect __________ and should confirm the diagnosis by ___________.
Thrombophlebitis; using real-time and color Doppler ultrasound
A woman in the active phase of the first stage of labor is using a shallow pattern of breathing, which is about twice the normal adult breathing rate. She starts to complain about feeling lightheaded and dizzy and states that her fingers are tingling. The nurse should:
Help her breathe into a paper bag or cupped hands
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?
I can store my breast milk in an ice chest for 2 days
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 10 liters oxygen via facemask, increase intravenous (IV) fluid, and perform a vaginal examination. The cervix has not changed. Five minutes have passed, and the fetal heart rate remains in the 80s. What additional nursing measures should you take?
Notify the care provider
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?
Cleanse the penis gently with water and put petroleum jelly around the glans after each diaper change
A new client and her partner arrive on the labor, delivery, recovery, and postpartum unit for the birth of their first child. You apply the electronic fetal monitor (EFM) to the woman. Her partner asks you to explain what is printing on the graph, referring to the EFM strip. He wants to know what the baby's heart rate should be. Your best response is:
'The top line graphs the baby's heart rate; it should be between 110 and 160. The heart rate will fluctuate in response to labor.
A client weighs 132 pounds. Heparin IV infusion: heparin sodium 25,000 units in 250 mL D5W. Order is to bolus with heparin sodium 80 units/kg, then initiate maintenance drip at 18 units/kg/hr.
At what rate will the nurse set the infusion pump in mL/hr for the maintenance dose.
Answer with a whole number.
At 1 minute after birth the nurse assesses the infant and notes: a heart rate of 80 beats/min, some flexion of extremities, a weak cry, grimacing, and a pink body but blue extremities. The nurse would calculate an Apgar score of:
New parents express concern that, because of the mother's emergency cesarean birth under general anesthesia, they did not have the opportunity to hold and bond with their daughter immediately after her birth. The nurse's response should convey to the parents that:
Bonding is a process that occurs over time and does not require early contact.
A newborn is jaundiced and receiving phototherapy via ultraviolet bank lights. An appropriate nursing intervention when caring for an infant with hyperbilirubinemia and receiving phototherapy by this method would be to:
Place eye shields over the newborn's closed eyes
Order: Heparin 1800 units/hr IV. Available: 25,000 units heparin in 250 mL D5W.
What rate in mL/hr will deliver 1800 units/hr?
Answer with a whole number only.
The nurse who performs vaginal examinations to assess a woman's progress in labor should:
Discuss the findings with the woman and her partner
During a prenatal examination, the woman reports having two cats at home. The nurse informs her that she should not be cleaning the litter box while she is pregnant. When the woman asks why, the nurse's best response would be:
'Your cats could be carrying toxoplasmosis that can infect you and have severe effects on your unborn child.
When preparing to administer a hepatitis B vaccine to a newborn, the nurse should:
Obtain a syringe with a 25-gauge, 5/8-inch needle
A pregnant woman's amniotic membranes rupture. Prolapsed cord is suspected and the physician is notified. What intervention would be the top priority
Placing the woman in the McRobert's (knee-chest)position
An infant at 26 weeks of gestation arrives from the delivery room intubated. The nurse weighs the infant, places him under the radiant warmer, and attaches him to the ventilator at the prescribed settings. A pulse oximeter and cardiorespiratory monitor are placed. The pulse oximeter is recording oxygen saturations of 80%. The prescribed saturations are 92%. The nurse's most appropriate action would be to:
Listen to breath sounds and ensure the patency of the endotracheal tube, increase oxygen, and notify a physician.
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:
Massage the woman's fundus
A client weighs 154 pounds. Heparin IV infusion: heparin sodium 200,000 units in 1000 mL D5W. The hospital protocol is to bolus the client with 80 units /kg and start a maintenance drip at 14 units /kg/hr. What is the infusion rate for the maintenance drip in units/hr.
Answer with a whole number
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?
She has thrombocytopenia
A plan of care for an infant experiencing symptoms of drug withdrawal should include:
Swaddling the infant snugly and holding the baby tightly
What woman is at greatest risk for early postpartum hemorrhage (PPH)?
A woman with severe preeclampsia on magnesium sulfate whose labor is being induced
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:
Change the woman's position.
The first and most important nursing intervention when a nurse observes profuse postpartum bleeding is to:
Palpate the uterus and massage it if it is boggy
The nurse recognizes that uterine hyperstimulation with oxytocin requires emergency interventions. What clinical cues would alert the nurse that the woman is experiencing uterine hyperstimulation? Choose all that apply.
Uterine tone >20 mm Hg
Increased uterine activity accompanied by a nonreassuring fetal heart rate (FHR) and pattern
Uterine contractions lasting >90 seconds and occurring <2 minutes in frequency
Order: Heparin 40,000 units in 500 mL D5W and infuse at 30 mL/hr.
Calculate the hourly heparin dosage in units/hr.
Answer with a whole number.
A woman gave birth 48 hours ago to a healthy infant girl. She has decided to bottle-feed. During your assessment you notice that both of her breasts are swollen, warm, and tender on palpation. The woman should be advised that this condition can best be treated by:
Applying ice to the breasts for comfort.
While evaluating an external monitor tracing of a woman in active labor whose labor is being induced, the nurse notes that the fetal heart rate (FHR) begins to decelerate at the onset of several contractions and returns to baseline before each contraction ends. The nurse should:
Document the finding in the client's record.
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:
Increases the risk that the infant will develop allergies.
The nurse is caring for a client whose labor is being augmented with oxytocin. He or she recognizes that the oxytocin should be discontinued immediately if there is evidence of:
A fetal heart rate (FHR) of 180 with absence of variability
The nurse teaches a pregnant woman about the characteristics of true labor contractions. The nurse evaluates the woman's understanding of the instructions when she states, 'True labor contractions will:
Continue and get stronger even if I relax and take a shower.
The nurse providing care for a woman with preterm labor on terbutaline would include which intervention to identify side effects of the drug?
Assessing for dyspnea and crackles
What position would be least effective when gravity is desired to assist in fetal descent?
A woman in labor has just received an epidural block. The most important nursing intervention is to:
Monitor the maternal blood pressure for possible hypotension.
A primigravida at 40 weeks of gestation is having uterine contractions every 1.5 to 2 minutes and says that they are very painful. Her cervix is dilated 2 cm and has not changed in 3 hours. The woman is crying and wants an epidural. What is the likely status of this woman's labor?
She is exhibiting hypertonic uterine dysfunction.
While assessing the integument of a 24-hour-old newborn, the nurse notes a pink, papular rash with vesicles superimposed on the thorax, back, and abdomen. The nurse should:
Document the finding as erythema toxicum
In evaluating the effectiveness of oxytocin induction, the nurse would expect:
Contractions lasting 40 to 90 seconds, 2 to 3 minutes apart, promoting dilation and effacement.
A 25-year-old gravida 2, para 2-0-0-2 gave birth 4 hours ago to a 9-pound, 7-ounce boy after augmentation of labor with Pitocin. She puts on her call light and asks for her nurse right away, stating, 'I'm bleeding a lot.' The most likely cause of postpartum hemorrhage in this woman is: