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302 GSRN Exam 3
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The nurse who is evaluating the client for potential abuse should be aware that intimate partner violence includes (choose all that apply): >>Physical abuse AND Sexual abuse AND Emotional abuse AND Psychologic abuse AND Economic abuseSome other stupid answer
A thorough abuse assessment screen should be done on all clients. This screen includes (choose all that apply): >>Asking the client if she has ever been slapped, kicked, punched, or physically hurt by her partner. AND Asking the client if she is afraid of her partner. AND Asking the client if she has been forced to perform sexual acts. AND Diagramming the client's current injuries on a body map.Asking the client what she did wrong to elicit the abuse.
One purpose of preconception care is to: Ensure that pregnancy complications do not occur.Identify women who should not become pregnant.>>Encourage healthy lifestyles for families desiring pregnancy.Ensure that women know about prenatal care.
The nurse who provides preconception care understands that it: Is designed for women who have never been pregnant.Includes risk factor assessments for potential medical and psychologic problems but by law cannot consider finances or workplace conditions.Avoids teaching about safe sex to avoid political controversy.>>Could include interventions to reduce substance use and abuse.
Concerning the use and abuse of legal drugs or substances, nurses should be aware that: Although cigarette smoking causes a number of health problems, it has little direct effect on maternity-related health.>>Women ages 21 to 34 have the highest rates of specific alcohol-related problems.Coffee is a stimulant that can interrupt body functions and has been related to birth defects.Prescription psychotherapeutic drugs taken by the mother do not affect the fetus; otherwise they would not have been prescribed.
The use of methamphetamine (meth) has been described as the number one drug problem in America. To provide adequate nursing care to this client population the nurse must be cognizant that methamphetamine: Is used only by those of a higher socioeconomic status because of the expense.>>Uses amphetamine, a central nervous system stimulant, as the active ingredient.Manifests a response similar to marijuana when smoked.Decreases sexual activity when used among fertile women.
What opiate causes euphoria, relaxation, drowsiness, and detachment from reality and has possible effects on the pregnancy, including preeclampsia, intrauterine growth restriction, and premature rupture of membranes? >>HeroinPCPAlcoholCocaine
As a powerful central nervous system stimulant, which of these substances can lead to miscarriage, preterm labor, premature separation of the placenta, and stillbirth? HeroinPCPAlcohol>>Cocaine
_____ use/abuse during pregnancy causes vasoconstriction and decreased placental perfusion, resulting in maternal and neonatal complications. Alcohol>>TobaccoCaffeineChocolate
Kegel exercises, or pelvic muscle exercises: >>Were developed to control or reduce incontinent urine loss.Are the best exercises for a pregnant woman because they are so pleasurable.Help to manage stress.Are ineffective without sufficient calcium in the diet.
During the past 20 years the prevalence of obesity has doubled in the United States, with 25% of women older than 20 years of age being obese. Body mass index is defined as the measure of an adult's weight in relation to his or her height. This is currently the most accurate measure of weight. It is an important part of the health screening process because obesity is closely associated with: The non-Hispanic Caucasian population.>>A large number of chronic conditions.Mostly acute illnesses.Improved mental well-being.
The modern woman faces increasing levels of stress on a daily basis. As a result she is prone to a variety of increased complaints and illness. The nurse is most likely aware of the psychologic symptoms of stress such as anxiety and depression; however, a number of physiologic symptoms may also occur. To best assist her client in managing these symptoms the nurse is aware that stress may also result in: Decreased heart rate and blood pressure.Rapid digestion resulting in heartburn.Decrease in hormone levels.>>Flare-ups of arthritis and asthma.
The nurse's best measure when evaluating the care of a woman in an abusive situation is based on the: Woman's decision to leave her partner.>>Woman's declaration of a safety plan.Couple's follow-through on a referral for counseling.Woman's gratitude to the nurse for the helpful information.
Intervention for the sexual abuse survivor often is not attempted by maternity and women's health nurses because of the concern about increasing the woman's distress and the lack of expertise in counseling. What initial intervention is appropriate and most important in facilitating the woman's care? Initiating a referral to an expert counselorSetting limits on what the client discloses>>Listening and encouraging therapeutic communication skillsAcknowledging the nurse's discomfort to the client as an expression of empathy
Sexual assault is: Limited to rape.>>An act of force in which an unwanted and uncomfortable sexual act occurs.A legal term for sexual violence.An act of violence in which the partner is unknown.
During a health history interview, a woman tells the nurse that her husband physically abuses her. The nurse's first response should be to: >>Advise the woman of mandatory state reporting laws pertaining to abuse and confidentiality.Reassure the woman that the abuse is not her fault.Give the woman referrals to local agencies and shelters where she can obtain help.Formulate an escape plan for the woman that she can use the next time her husband abuses her.
With regard to violence against women, intimate partner violence (IPV) nurses should be aware that: Relationship violence usually consists of a single episode that the couple can put behind them.Violence often declines or ends with pregnancy.>>Economic coercion is considered part of IPV.Battered women generally are poorly educated and come from a deprived social background.
Intrauterine growth restriction is associated with what pregnancy-related risk factors? Choose all that apply. >>Poor nutrition AND Maternal collagen disease AND Gestational hypertension AND SmokingPremature rupture of membranes
MSAFP levels have been used as a screening tool for ________________ in pregnancy. >>Neural tube defectsSome other stupid test
A woman arrives at the clinic seeking confirmation that she is pregnant. The following information is obtained: She is 24 years old with a body mass index (BMI) of 17.5. She admits to having used cocaine ""several times"" during the past year and drinks alcohol occasionally. Her blood pressure (BP) is 108/70 mm Hg, her pulse rate is 72 beats/min, and her respiratory rate is 16 breaths/min. The family history is positive for diabetes mellitus and cancer. Her sister recently gave birth to an infant with a neural tube defect (NTD). Which characteristics place the woman in a high risk category? Blood pressure, age, BMIDrug/alcohol use, age, family historyFamily history, blood pressure, BMI>>Family history, BMI, drug/alcohol abuse
A 39-year-old primigravida thinks that she is about 8 weeks pregnant, although she has had irregular menstrual periods all her life. She has a history of smoking approximately one pack of cigarettes a day, but she tells you that she is trying to cut down. Her laboratory data are within normal limits. What diagnostic technique could be used with this pregnant woman at this time? >>Ultrasound examinationMaternal serum alpha-fetoprotein screening (MSAFP)AmniocentesisNonstress test (NST)
The nurse sees a woman for the first time when she is 30 weeks pregnant. The woman has smoked throughout the pregnancy, and fundal height measurements now are suggestive of growth restriction in the fetus. In addition to ultrasound to measure fetal size, what would be another tool useful in confirming the diagnosis? >>Doppler blood flow analysisAmniocentesisContraction stress test (CST)Daily fetal movement counts
A 41-week pregnant multigravida presents in the labor and delivery unit after a nonstress test indicated that her fetus could be experiencing some difficulties in utero. Which diagnostic tool would yield more detailed information about the fetus? Ultrasound for fetal anomalies>>Biophysical profile (BPP)Maternal serum alpha-fetoprotein screening (MSAFP)Percutaneous umbilical blood sampling (PUBS)
At 35 weeks of pregnancy a woman experiences preterm labor. Although tocolytics are administered and she is placed on bed rest, she continues to experience regular uterine contractions, and her cervix is beginning to dilate and efface. What would be an important test for fetal well-being at this time? Percutaneous umbilical blood sampling (PUBS)Ultrasound for fetal size>>Amniocentesis for fetal lung maturityNonstress test
A 40-year-old woman is 10 weeks pregnant. Which diagnostic tool would be appropriate to suggest to her at this time? Biophysical profileAmniocentesisMaternal serum alpha-fetoprotein (MSAFP)>>Transvaginal ultrasound
A maternal serum alpha-fetoprotein (AFP) test indicates an elevated level. It is repeated and again is reported as higher than normal. What would be the next step in the assessment sequence to determine the well-being of the fetus? Percutaneous umbilical blood sampling (PUBS)>>Ultrasound for fetal anomaliesBiophysical profile (BPP) for fetal well-beingAmniocentesis for genetic anomalies
A client asks her nurse, ""My doctor told me that he is concerned with the grade of my placenta because I am overdue. What does that mean?"" The best response by the nurse is: >>""Your placenta changes as your pregnancy progresses, and it is given a score that indicates the amount of calcium deposits it has. The more calcium deposits, the higher the grade, or number, that is assigned to the placenta. It also means that less blood and oxygen can be delivered to your baby.""Your placenta isn't working properly, and your baby is in danger.This means that we will need to perform an amniocentesis to detect if you have any placental damage.Don't worry about it. Everything is fine.
A woman is undergoing a nipple-stimulated contraction stress test (CST). She is having contractions that occur every 3 minutes. The fetal heart rate (FHR) has a baseline of approximately 120 beats/min without any decelerations. The interpretation of this test is said to be: >>Negative.Satisfactory.Positive.Unsatisfactory.
In the United States today: More than 20% of pregnancies meet the definition of high risk to either the mother or the infant.>>Other than biophysical criteria, the chief factor in high risk pregnancies is the number of women who have no access to prenatal care.High risk pregnancy status extends from first confirmation of pregnancy to birth.High risk pregnancy is less critical a medical concern because of the reduction in family size and the decrease in unwanted pregnancies.
When nurses help their expectant mothers assess the daily fetal movement counts, they should be aware that: Alcohol or cigarette smoke can irritate the fetus into greater activity.Kick counts should be taken every half hour and averaged every 6 hours, with every other 6-hour stretch off.>>The fetal alarm signal should go off when fetal movements stop entirely for 12 hours.Obese mothers familiar with their bodies can assess fetal movement as well as average-size women.
In comparing the abdominal and transvaginal methods of ultrasound examination, nurses should explain to their clients that: Both require the woman to have a full bladder.The abdominal examination is more useful in the first trimester.Initially the transvaginal examination can be painful.>>The transvaginal examination allows pelvic anatomy to be evaluated in greater detail.
In the first trimester, ultrasonography can be used to gain information on: Amniotic fluid volume.>>The presence and location of an intrauterine contraceptive device.Placental location and maturity.Cervical length.
Nurses should be aware that the biophysical profile (BPP): >>Is an accurate indicator of impending fetal death.Is a compilation of health risk factors of the mother during the later stages of pregnancy.Consists of a Doppler blood flow analysis and an amniotic fluid index.Involves an invasive form of ultrasonic examination.
With regard to amniocentesis, nurses should be aware that: Because of new imaging techniques, it is now possible in the first trimester.Despite the use of ultrasonography, complications still occur in the mother or infant in 5% to 10% of cases.>>The shake test, or bubble stability test, is a quick means of determining fetal maturity.The presence of meconium in the amniotic fluid is always cause for concern.
Nurses should be aware of the strengths and limitations of various biochemical assessments during pregnancy, including that: Chorionic villus sampling (CVS) is becoming more popular because it provides early diagnosis.Screening for maternal serum alpha-fetoprotein (MSAFP) levels is recommended only for women at risk for neural tube defects.Percutaneous umbilical blood sampling (PUBS) is one of the triple-marker tests for Down syndrome.>>MSAFP is a screening tool only; it identifies candidates for more definitive procedures.
In comparison to contraction stress tests (CSTs), the nonstress test (NST) for antepartum fetal assessment: >>Has no known contraindications.Has fewer false-positive results.Is more sensitive in detecting fetal compromise.Is slightly more expensive.
The nurse providing care for the antepartum woman should understand that the contraction stress test (CST): Sometimes uses vibroacoustic stimulation.Is an invasive test; however, contractions are stimulated.>>Is considered negative if no late decelerations are observed with the contractions.Is more effective than the nonstress test (NST) if the membranes have already been ruptured.
A woman has been diagnosed with a high risk pregnancy. She and her husband come into the office in a very anxious state. She seems to be coping by withdrawing from the discussion, showing declining interest. The nurse can best help the couple by: Telling her that the physician will isolate the problem with more tests.>>Encouraging her and urging her to continue with childbirth classes.Becoming assertive and laying out the decisions the couple needs to make.Downplaying her risks by citing success rate studies.
In the past factors to determine whether a woman was likely to develop a high risk pregnancy were evaluated primarily from a medical point of view. A broader, more comprehensive approach to high risk pregnancy has been adopted today. There are now four categories based on threats to the health of the woman and the outcome of pregnancy. These categories include all of these except: Biophysical.>>Geographic.Psychosocial.Environmental.
Risk factors tend to be interrelated and cumulative in their effect. While planning the care for a laboring client with diabetes mellitus, the nurse is aware that he or she is at a greater risk for: Oligohydramnios.Postterm pregnancy.>>Polyhydramnios.Chromosomal abnormalities.
A client who has undergone a dilation and curettage for early pregnancy loss is likely to be discharged the same day. The nurse must ensure that vital signs are stable, bleeding has been controlled, and the woman has adequately recovered from the administration of anesthesia. To promote an optimal recovery, discharge teaching should include (choose all that apply): >>Iron supplementation. AND Referral to a support group if necessary. AND Emphasizing the need for rest.Resumption of intercourse at 6 weeks following the procedure.Expectation of heavy bleeding for at least 2 weeks.
The condition in which the placenta is implanted in the lower uterine segment near or over the internal cervical os is _________________________. >>Placenta previaSome other stupid answer
_________________________ is responsible for 9% of all maternal mortality and is the leading cause of infertility. >>Ectopic pregnancySome other stupid answer
The antidote administered to reverse magnesium toxicity is _____________________. >>Calcium gluconateSome other stupid answer
Women with hyperemesis gravidarum: Are a majority, because 70% of all pregnant women suffer from it at some time.>>Have vomiting severe and persistent enough to cause weight loss, dehydration, and electrolyte imbalance.Need intravenous (IV) fluid and nutrition for most of their pregnancy.Often inspire similar, milder symptoms in their male partners and mothers.
Because pregnant women may need surgery during pregnancy, nurses should be aware that: >>The diagnosis of appendicitis may be difficult, because the normal signs and symptoms mimic some normal changes in pregnancy.Rupture of the appendix is less likely in pregnant women because of the close monitoring.Surgery for intestinal obstructions should be delayed as long as possible because it usually affects the pregnancy.When pregnancy takes over, a woman is less likely to have ovarian problems that require invasive responses.
What laboratory marker is indicative of disseminated intravascular coagulation (DIC)? Bleeding time of 10 minutesThrombocytopenia>>Presence of fibrin split productsHyperfibrinogenemia
In caring for an immediate postpartum client, you note petechiae and oozing from her IV site. You would monitor her closely for the clotting disorder: >>Disseminated intravascular coagulation (DIC)Amniotic fluid embolism (AFE)HemorrhageHELLP syndrome
In caring for the woman with disseminated intravascular coagulation (DIC), what order should the nurse anticipate? >>Administration of bloodPreparation of the client for invasive hemodynamic monitoringRestriction of intravascular fluidsAdministration of steroids
A primigravida is being monitored in her prenatal clinic for preeclampsia. What finding should concern her nurse? Blood pressure (BP) increase to 138/86 mm HgWeight gain of 0.5 kg during the past 2 weeks>>A dipstick value of 3+ for protein in her urinePitting pedal edema at the end of the day
The labor of a pregnant woman with preeclampsia is going to be induced. Before initiating the Pitocin infusion, the nurse reviews the woman's latest laboratory test findings, which reveal a platelet count of 90,000, an elevated aspartate transaminase (AST) level, and a falling hematocrit. The nurse notifies the physician because the laboratory results are indicative of: Eclampsia.Disseminated intravascular coagulation (DIC).>>HELLP syndrome.Idiopathic thrombocytopenia.
A woman with preeclampsia has a seizure. The nurse's primary duty during the seizure is to: Insert an oral airway.Suction the mouth to prevent aspiration.Administer oxygen by mask.>>Stay with the client and call for help.
A pregnant woman has been receiving a magnesium sulfate infusion for treatment of severe preeclampsia for 24 hours. On assessment the nurse finds the following vital signs: temperature of 37.3° C, pulse rate of 88 beats/min, respiratory rate of 10 breaths/min, blood pressure (BP) of 148/90 mm Hg, absent deep tendon reflexes, and no ankle clonus. The client complains, ""I'm so thirsty and warm."" The nurse: Calls for a stat magnesium sulfate level.Administers oxygen.>>Discontinues the magnesium sulfate infusion.Prepares to administer hydralazine.
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 155/112 mm Hg, 3+ deep tendon reflexes, and no ankle clonus. The nurse calls the physician, anticipating an order for: >>Hydralazine.Diazepam.Magnesium sulfate bolus.Calcium gluconate.
A woman at 39 weeks of gestation with a history of preeclampsia is admitted to the labor and birth unit. She suddenly experiences increased contraction frequency of every 1 to 2 minutes; dark red vaginal bleeding; and a tense, painful abdomen. The nurse suspects the onset of: Eclamptic seizure.Placenta previa.Rupture of the uterus.>>Placental abruption.
A woman with severe preeclampsia is receiving a magnesium sulfate infusion. The nurse becomes concerned after assessment when the woman exhibits: A sleepy, sedated affect.Deep tendon reflexes of 2.>>A respiratory rate of 10 breaths/min.Absent ankle clonus.
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? Absence of uterine bleeding in the postpartum periodA fundus firm below the level of the umbilicusScant lochia flow>>A boggy uterus with heavy lochia flow
Your client is being induced because of her worsening preeclampsia. She is also receiving magnesium sulfate. It appears that her labor has not become active despite several hours of oxytocin administration. She asks the nurse, ""Why is it taking so long?"" The most appropriate response by the nurse would be: >>""The magnesium is relaxing your uterus and competing with the oxytocin. It may increase the duration of your labor.""I don't know why it is taking so long.The length of labor varies for different women.Your baby is just being stubborn.
What nursing diagnosis would be the most appropriate for a woman experiencing severe preeclampsia? >>Risk for injury to the fetus related to uteroplacental insufficiencyRisk for eclampsiaRisk for deficient fluid volume related to increased sodium retention secondary to administration of MgSO4Risk for increased cardiac output related to use of antihypertensive drugs
The nurse caring for pregnant women must be aware that the most common medical complication of pregnancy is: >>Hypertension.Hemorrhagic complications.Hyperemesis gravidarum.Infections.
Nurses should be aware that HELLP syndrome: Is a mild form of preeclampsia.Can be diagnosed by a nurse alert to its symptoms.>>Is characterized by hemolysis, elevated liver enzymes, and low platelets.Is associated with preterm labor but not perinatal mortality.
Nurses should be aware that chronic hypertension: Is defined as hypertension that begins during pregnancy and lasts for the duration of pregnancy.Is considered severe when the systolic blood pressure (BP) is greater than 140 mm Hg or the diastolic BP is greater than 90 mm Hg.Is general hypertension plus proteinuria.>>Can occur independently of or simultaneously with gestational hypertension.
In planning care for women with preeclampsia, nurses should be aware that: >>Induction of labor is likely, as near term as possible.If at home, the woman should be confined to her bed, even with mild preeclampsia.A special diet low in protein and salt should be initiated.Vaginal birth is still an option, even in severe cases.
Magnesium sulfate is given to women with preeclampsia and eclampsia to: Improve patellar reflexes and increase respiratory efficiency.Shorten the duration of labor.>>Prevent and treat convulsions.Prevent a boggy uterus and lessen lochial flow.
Preeclampsia is a unique disease process related only to human pregnancy. The exact cause of this condition continues to elude researchers. The American College of Obstetricians and Gynecologists has developed a comprehensive list of risk factors associated with the development of preeclampsia. Which client exhibits the greatest number of these risk factors? A 30-year-old obese Caucasian with her third pregnancyA 41-year-old Caucasian primigravida>>An African-American client who is 19 years old and pregnant with twinsA 25-year-old Asian-American, whose pregnancy is the result of donor insemination
A woman presents to the emergency department complaining of bleeding and cramping. The initial nursing history is significant for a last menstrual period 6 weeks ago. On sterile speculum examination, the primary care provider finds that the cervix is closed. The anticipated plan of care for this woman would be based on a probable diagnosis of which type of spontaneous abortion? Incomplete>>ThreatenedInevitableSeptic
The perinatal nurse is giving discharge instructions to a woman, status postsuction curettage secondary to a hydatidiform mole. The woman asks why she must take oral contraceptives for the next 12 months. The best response from the nurse would be: If you get pregnant within 1 year, the chance of a successful pregnancy is very small. Therefore, if you desire a future pregnancy, it would be better for you to use the most reliable method of contraception available.>>""The major risk to you after a molar pregnancy is a type of cancer that can be diagnosed only by measuring the same hormone that your body produces during pregnancy. If you were to get pregnant, it would make the diagnosis of this cancer more difficult.""If you can avoid a pregnancy for the next year, the chance of developing a second molar pregnancy is rare. Therefore, to improve your chance of a successful pregnancy, it is better not to get pregnant at this time.Oral contraceptives are the only form of birth control that will prevent a recurrence of a molar pregnancy.
The most prevalent clinical manifestation of abruptio placentae (as opposed to placenta previa) is: Bleeding.Uterine activity.>>Intense abdominal pain.Cramping.
Methotrexate is recommended as part of the treatment plan for which obstetric complication? Complete hydatidiform mole>>Unruptured ectopic pregnancyMissed abortionAbruptio placentae
A 26-year-old pregnant woman, gravida 2, para 1-0-0-1 is 28 weeks pregnant when she experiences bright red, painless vaginal bleeding. On her arrival at the hospital, what would be an expected diagnostic procedure? Amniocentesis for fetal lung maturityContraction stress test (CST)>>Ultrasound for placental locationInternal fetal monitoring
A laboring woman with no known risk factors suddenly experiences spontaneous rupture of membranes (ROM). The fluid consists of bright red blood. Her contractions are consistent with her current stage of labor. There is no change in uterine resting tone. The fetal heart rate begins to decline rapidly after the ROM. The nurse should suspect the possibility of: Placenta previa.>>Vasa previa.Severe abruptio placentae.Disseminated intravascular coagulation (DIC).
A woman arrives for evaluation of her symptoms, which include a missed period, adnexal fullness, tenderness, and dark red vaginal bleeding. On examination the nurse notices an ecchymotic blueness around the woman's umbilicus and recognizes this assessment finding as: Normal integumentary changes associated with pregnancy.Turner's sign associated with appendicitis.>>Cullen's sign associated with a ruptured ectopic pregnancy.Chadwick's sign associated with early pregnancy.
With regard to miscarriage, nurses should be aware that: It is a natural pregnancy loss before labor begins.It occurs in fewer than 5% of all clinically recognized pregnancies.It often can be attributed to careless maternal behavior such as poor nutrition or excessive exercise.>>If it occurs before the twelfth week of pregnancy, it may present only as moderate discomfort and blood loss.
Bleeding disorders in late pregnancy include all of these except: Placenta previa.>>Spontaneous abortion.Abruptio placentae.Cord insertion.
External fetal monitoring cannot detect the ____________________ of uterine contractions. >>IntensitySome other stupid answer
Fetal bradycardia is most common during: Intraamniotic infection.Fetal anemia.>>Prolonged umbilical cord compression.Tocolytic treatment using ritodrine.
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.Assist with amnioinfusion.Notify the care provider.Insert a scalp electrode.
The nurse caring for the laboring woman should understand that early decelerations are caused by: >>Altered fetal cerebral blood flow.Uteroplacental insufficiency.Umbilical cord compression.Spontaneous rupture of membranes.
The nurse providing care for the laboring woman should understand that accelerations with fetal movement: >>Are reassuring.Are caused by umbilical cord compression.Warrant close observation.Are caused by uteroplacental insufficiency.
The nurse providing care for the laboring woman should understand that variable fetal heart rate (FHR) decelerations are caused by: Altered fetal cerebral blood flow.Uteroplacental insufficiency.>>Umbilical cord compression.Fetal hypoxemia.
The nurse providing care for the laboring woman should understand that late fetal heart rate (FHR) decelerations are caused by: Altered cerebral blood flow.>>Uteroplacental insufficiency.Umbilical cord compression.Meconium fluid.
The nurse providing care for the laboring woman should understand that amnioinfusion is used to treat: >>Variable decelerations.Fetal bradycardia.Late decelerations.Fetal tachycardia.
The nurse caring for the woman in labor should understand that maternal hypotension can result in: Early decelerations.>>Uteroplacental insufficiency.Fetal dysrhythmias.Spontaneous rupture of membranes.
The nurse caring for a laboring woman is aware that maternal cardiac output can be increased by: >>Change in position.Regional anesthesia.Oxytocin administration.Intravenous analgesic.
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: Change the woman's position.Discontinue the oxytocin infusion.Insert an internal monitor.>>Document the finding in the client's record.
Which fetal heart rate (FHR) finding would concern the nurse during labor? Accelerations with fetal movementAn average FHR of 126 beats/minEarly decelerations>>Late decelerations
The most common cause of decreased variability in the fetal heart rate (FHR) that lasts 30 minutes or less is: Altered cerebral blood flow.Umbilical cord compression.Fetal hypoxemia.>>Fetal sleep cycles.
Fetal well-being during labor is assessed by: >>The response of the fetal heart rate (FHR) to uterine contractions (UCs).Maternal pain control.Accelerations in the FHR.An FHR above 110 beats/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 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? Scream for help.Start pitocin.Insert a Foley catheter.>>Notify the care provider immediately.
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. Call the provider, reposition the mother, and perform a vaginal examination.>>Reposition the mother, increase intravenous (IV) fluid, and provide oxygen via face mask.Administer oxygen to the mother, increase IV fluid, and notify the care provider.Perform a vaginal examination, reposition the mother, and provide oxygen via face mask.
Perinatal nurses are legally responsible for: >>Correctly interpreting fetal heart rate (FHR) patterns, initiating appropriate nursing interventions, and documenting the outcomes.Greeting the client on arrival, assessing her, and starting an intravenous line.Applying the external fetal monitor and notifying the care provider.Making sure that the woman is comfortable.
As a perinatal nurse you realize that a fetal heart rate that is tachycardic, is bradycardic, or has late decelerations or loss of variability is nonreassuring and is associated with: Hypotension.Maternal drug use.Cord compression.>>Hypoxemia.
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: Don't worry about that machine; that's my job.>>""The top line graphs the baby's heart rate. Generally the heart rate is between 110 and 160. The heart rate will fluctuate in response to what is happening during labor.""The top line graphs the baby's heart rate, and the bottom line lets me know how strong the contractions are.Your doctor will explain all of that later.
A normal uterine activity pattern in labor is characterized by: >>Contractions every 2 to 5 minutes.Contractions lasting about 2 minutes.Contractions about 1 minute apart.A contraction intensity of about 1000 mm Hg with relaxation at 50 mm Hg.
According to standard professional thinking, nurses should auscultate the fetal heart rate (FHR): Every 15 minutes in the active phase of the first stage of labor in the absence of risk factors.Every 20 minutes in the second stage, regardless of whether risk factors are present.>>Before and after ambulation and rupture of membranes.More often in a woman's first pregnancy.
When using intermittent auscultation (IA) for fetal heart rate, nurses should be aware that: They can be expected to cover only two or three clients when IA is the primary method of fetal assessment.The best course is to use the descriptive terms associated with electronic fetal monitoring (EFM) when documenting results.If the heartbeat cannot be found immediately, a shift must be made to EFM.>>Ultrasound can be used to find the fetal heartbeat and reassure the mother if initial difficulty was a factor.
When using intermittent auscultation (IA) to assess uterine activity, nurses should be aware that: >>The examiner's hand should be placed over the fundus before, during, and after contractions.The frequency and duration of contractions is measured in seconds for consistency.Contraction intensity is given a judgment number of 1 to 7 by the nurse and client together.The resting tone between contractions is described as either placid or turbulent.
What is an advantage of external electronic fetal monitoring? The ultrasound transducer can accurately measure short-term variability and beat-to-beat changes in the fetal heart rate.The tocotransducer can measure and record the frequency, regularity, intensity, and approximate duration of uterine contractions (UCs).>>The tocotransducer is especially valuable for measuring uterine activity during the first stage of labor.Once correctly applied by the nurse, the transducer need not be repositioned even when the woman changes positions.
When assessing the relative advantages and disadvantages of internal and external electronic fetal monitoring, nurses should be aware that both: Can be used when membranes are intact.Measure the frequency, duration, and intensity of uterine contractions.May need to rely on the woman to indicate when uterine activity (UA) is occurring.>>Can be used during the antepartum and intrapartum periods.
During labor a fetus with an average heart rate of 135 beats/min over a 10-minute period would be considered to have: Bradycardia.Tachycardia.>>A normal baseline heart rate.Hypoxia.
The nurse caring for the woman in labor should understand that increased variability of the fetal heart rate might be caused by: Narcotics.>>Methamphetamines.Barbiturates.Tranquilizers.
Nurses should be aware that accelerations in the fetal heart rate: Are indications of fetal well-being when they are periodic.Are greater and longer in preterm gestations.Are usually seen with breech presentations when they are episodic.>>May visibly resemble the shape of the uterine contraction.
Which deceleration of the fetal heart rate would NOT require the nurse to change the maternal position? >>Early decelerationsLate decelerationsVariable decelerationsIt is always a good idea to change the woman's position.
What correctly matches the type of deceleration with its likely cause? Early deceleration—umbilical cord compression>>Late deceleration—uteroplacental inefficiencyVariable deceleration—head compressionProlonged deceleration—cause unknown
The nurse caring for a woman in labor understands that prolonged decelerations: Are a continuing pattern of benign decelerations that do not require intervention.Constitute a baseline change when they last longer than 5 minutes.>>Usually are isolated events that end spontaneously.Require the usual fetal monitoring by the nurse.
A nurse might be called on to stimulate the fetal scalp: As part of fetal scalp blood sampling.In response to tocolysis.In preparation for fetal oxygen saturation monitoring.>>To elicit an acceleration in the fetal heart rate (FHR).
In assisting with the two factors that have an effect on fetal status (i.e., pushing and positioning), nurses should: >>Encourage the woman's cooperation in avoiding the supine position.Advise the woman to avoid the semi-Fowler position.Encourage the woman to hold her breath and tighten her abdominal muscles to produce a vaginal response.Instruct the woman to open her mouth and close her glottis, letting air escape after the push.
A number of methods to assist in the assessment of fetal well-being have been developed for use in conjunction with electronic fetal monitoring. These various technologies assist in supporting interventions for a nonreassuring fetal heart rate pattern when necessary. The labor and delivery nurse should be aware that one of these modalities, fetal oxygen saturation monitoring, includes the use of: A fetal acoustic stimulator.>>Fetal pulse oximetry.Fetal blood sampling.Umbilical cord acid-base determination.
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 contractions lasting <90 seconds and occurring >2 minutes in frequency>>Uterine contractions lasting >90 seconds and occurring <2 minutes in frequency AND Uterine tone >20 mm Hg AND Increased uterine activity accompanied by a nonreassuring fetal heart rate (FHR) and patternUterine tone <20 mm Hg
Complications and risks associated with cesarean births include (choose all that apply): >>Pulmonary edema. AND Wound dehiscence. AND Hemorrhage. AND Urinary tract infections. AND Fetal injuries.Some other stupid answer
____________________ is defined as long, difficult, or abnormal labor. It is caused by various conditions associated with the five factors affecting labor. >>DystociaSome other stupid answer
A nurse is caring for a client in the active phase of labor. The woman's bag of waters spontaneously ruptures. Suddenly the woman complains of dyspnea and appears restless and cyanotic. In addition, she becomes hypotensive and tachycardic. The nurse immediately suspects the presence of:__________________________________. >>An amniotic fluid embolismSome other stupid answer
Approximately 50% of all women who give birth prematurely have no identifiable risk factors, and about 50% of preterm births could not be prevented. >>TRUEFALSE
In planning for home care of a woman with preterm labor, the nurse needs to address what concern? Nursing assessments will be different from those done in the hospital setting.Restricted activity and medications will be necessary to prevent recurrence of preterm labor.>>Prolonged bed rest may cause negative physiologic effects.Home health care providers will be necessary.
The nurse providing care for a woman with preterm labor on terbutaline would include which intervention to identify side effects of the drug? Assessing deep tendon reflexes (DTRs)>>Assessing for dyspnea and cracklesAssessing for bradycardiaAssessing for hypoglycemia
In evaluating the effectiveness of magnesium sulfate for the treatment of preterm labor, what finding would alert the nurse to possible side effects? Urine output of 160 ml in 4 hoursDeep tendon reflexes 2+ and no clonusRespiratory rate of 16 breaths/min>>Serum magnesium level of 10 mg/dl
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: >>Stimulate fetal surfactant production.Reduce maternal and fetal tachycardia associated with ritodrine administration.Suppress uterine contractions.Maintain adequate maternal respiratory effort and ventilation during magnesium sulfate therapy.
A woman at 26 weeks of gestation is being assessed to determine whether she is experiencing preterm labor. What finding indicates that preterm labor is occurring? Estriol is not found in maternal saliva.Irregular, mild uterine contractions are occurring every 12 to 15 minutes.Fetal fibronectin is present in vaginal secretions.>>The cervix is effacing and dilated to 2 cm.
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 hypotonic uterine dysfunction.She is experiencing a normal latent stage.>>She is exhibiting hypertonic uterine dysfunction.She is experiencing pelvic dystocia.
What assessment is least likely to be associated with a breech presentation? Meconium-stained amniotic fluidFetal heart tones heard at or above the maternal umbilicusPreterm labor and birth>>Postterm gestation
A woman is having her first child. She has been in labor for 15 hours. Two hours ago her vaginal examination revealed the cervix to be dilated to 5 cm and 100% effaced, and the presenting part was at station 0. Five minutes ago her vaginal examination indicated that there had been no change. What abnormal labor pattern is associated with this description? Prolonged latent phase>>Arrest of active phaseProtracted active phaseProtracted descent
In evaluating the effectiveness of oxytocin induction, the nurse would expect: >>Contractions lasting 40 to 90 seconds, 2 to 3 minutes apart.The intensity of contractions to be at least 110 to 130 mm Hg.Labor to progress at least 2 cm/hr dilation.At least 30 mU/min of oxytocin will be needed to achieve cervical dilation.
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 would include what information? Because this is a repeat procedure, you are at the lowest risk for complications.>>""Even though this is your second cesarean birth, you may wish to review the preoperative and postoperative procedures.""Because this is your second cesarean birth, you will recover faster.You will not need preoperative teaching because this is your second cesarean birth.
For a woman at 42 weeks of gestation, which finding would require more assessment by the nurse? Fetal heart rate of 116 beats/minCervix dilated 2 cm and 50% effacedScore of 8 on the biophysical profile>>One fetal movement noted in 1 hour of assessment by the mother
A pregnant woman's amniotic membranes rupture. Prolapsed cord is suspected. What intervention would be the top priority? >>Placing the woman in the knee-chest positionCovering the cord in sterile gauze soaked in salinePreparing the woman for a cesarean birthStarting oxygen by face mask
Prepidil (prostaglandin gel) has been ordered for a pregnant woman at 43 weeks of gestation. The nurse recognizes that this medication will be administered to: Enhance uteroplacental perfusion in an aging placenta.Increase amniotic fluid volume.>>Ripen the cervix in preparation for labor induction.Stimulate the amniotic membranes to rupture.
A pregnant woman at 29 weeks of gestation has been diagnosed with preterm labor. Her labor is being controlled with tocolytic medications. She asks when she might be able to go home. What response by the nurse is most accurate? After the baby is born.>>""When we can stabilize your preterm labor and arrange home health visits.""Whenever the doctor says that it is okay.It depends on what kind of insurance coverage you have.
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: Uterine contractions occurring every 8 to 10 minutes.>>A fetal heart rate (FHR) of 180 with absence of variability.The client needing to void.Rupture of the client's amniotic membranes.
Nurses should know some basic definitions concerning preterm birth, preterm labor, and low birth weight. For instance: The terms preterm birth and low birth weight can be used interchangeably.>>Preterm labor is defined as cervical changes and uterine contractions occurring between 20 and 37 weeks of pregnancy.Low birth weight is anything below 3.7 pounds.In the United States early in this century, preterm birth accounted for 18% to 20% of all births.
With regard to the care management of preterm labor, nurses should be aware that: Because all women must be considered at risk for preterm labor and prediction is so hit-and-miss, teaching pregnant women the symptoms probably causes more harm through false alarms.Braxton Hicks contractions often signal the onset of preterm labor.Because preterm labor is likely to be the start of an extended labor, a woman with symptoms can wait several hours before contacting the primary caregiver.>>The diagnosis of preterm labor is based on gestational age, uterine activity, and progressive cervical change.
With regard to the use of tocolytic therapy to suppress uterine activity, nurses should be aware that: The drugs can be given efficaciously up to the designated beginning of term at 37 weeks.There are no important maternal (as opposed to fetal) contraindications.>>Its most important function is to afford the opportunity to administer antenatal glucocorticoids.If the client develops pulmonary edema while on tocolytics, intravenous (IV) fluids should be given.
With regard to dysfunctional labor, nurses should be aware that: Women who are underweight are more at risk.>>Women experiencing precipitous labor are about the only ""dysfunctionals"" not to be exhausted.Hypertonic uterine dysfunction is more common than hypotonic dysfunction.Abnormal labor patterns are most common in older women.
The least common cause of long, difficult, or abnormal labor (dystocia) is: Midplane contracture of the pelvis.Compromised bearing-down efforts as a result of pain medication.>>Disproportion of the pelvis.Low-lying placenta.
Nurses should be aware that the induction of labor: Can be achieved by external and internal version techniques.Is also known as a trial of labor (TOL).Is almost always done for medical reasons.>>Is rated for viability by a Bishop score.
With regard to the process of inducing labor, nurses should be aware that: Ripening the cervix usually results in a decreased success rate for induction.>>Labor sometimes can be induced with balloon catheters or laminaria tents.Oxytocin is less expensive than prostaglandins and more effective but creates greater health risks.Amniotomy can be used to make the cervix more favorable for labor.
With regard to the process of augmentation of labor, the nurse should be aware that it: >>Is part of the active management of labor that is instituted when the labor process is unsatisfactory.Relies on more invasive methods when oxytocin and amniotomy have failed.Is a modern management term to cover up the negative connotations of forceps-assisted birth.Uses vacuum cups.
The nurse providing care to a woman in labor should be aware that cesarean birth: Is declining in frequency in the twenty-first century in the United States.Is more likely to be done for the poor in public hospitals who do not get the nurse counseling that wealthier clients do.>>Is performed primarily for the benefit of the fetus.Can be either elected or refused by women as their absolute legal right.
With regard to the psychologic complications and risks of forced cesarean births, nurses should be aware that: A family's worries about extra cost are unfounded; vaginal birth and unscheduled cesarean births cost about the same.Most women relate to their newborns as quickly and are as likely to breastfeed as those who went through vaginal birth.The psychologic outcomes are the same as for women who go through scheduled cesarean births.>>Some couples (and individuals) have sexual worries; the women worry about sexual attractiveness, and the men worry about hurting their partners.
The exact cause of preterm labor is unknown and believed to be multifactorial. Infection is thought to be a major factor in many preterm labors. Select the type of infection that has not been linked to preterm births: >>ViralCervicalPeriodontalUrinary tract
Medications used to manage postpartum hemorrhage (PPH) include (choose all that apply): >>Pitocin. AND Methergine. AND Hemabate.Terbutaline.Magnesium sulfate.
Possible alternative and complementary therapies for postpartum depression (PPD) for breastfeeding mothers include (choose all that apply): >>Acupressure. AND Aromatherapy. AND Yoga.St. John's wort.Wine consumption.
____________________ is the most common postpartum infection. >>EndometritisSome other stupid answer
_________________________ refers to the grief response that occurs with reminders of loss. This typically happens on special anniversary dates of the loss. >>Bittersweet griefSome other stupid answer
The perinatal nurse is caring for a woman in the immediate postbirth period. Assessment reveals that the woman is experiencing profuse bleeding. The most likely etiology for the bleeding is: >>Uterine atony.Vaginal hematoma.Uterine inversion.Vaginal laceration.
A primary nursing responsibility when caring for a woman experiencing an obstetric hemorrhage associated with uterine atony is to: Establish venous access.>>Perform fundal massage.Prepare the woman for surgical intervention.Catheterize the bladder.
The perinatal nurse caring for the postpartum woman understands that late postpartum hemorrhage (PPH) is most likely caused by: >>Subinvolution of the placental site.Cervical lacerations.Defective vascularity of the decidua.Coagulation disorders.
What woman is at greatest risk for early postpartum hemorrhage (PPH)? A primiparous woman (G 2 P 1 0 0 1) being prepared for an emergency cesarean birth for fetal distress>>A woman with severe preeclampsia on magnesium sulfate whose labor is being inducedA multiparous woman (G 3 P 2 0 0 2) with an 8-hour laborA primigravida in spontaneous labor with preterm twins
The first and most important nursing intervention when a nurse observes profuse postpartum bleeding is to: Call the woman's primary health care provider.Administer the standing order for an oxytocic.>>Palpate the uterus and massage it if it is boggy.Assess maternal blood pressure and pulse for signs of hypovolemic shock.
When caring for a postpartum woman experiencing hemorrhagic shock, the nurse recognizes that the most objective and least invasive assessment of adequate organ perfusion and oxygenation is: Absence of cyanosis in the buccal mucosa.Cool, dry skin.Diminished restlessness.>>Urinary output of at least 30 ml/hr.
One of the first symptoms of puerperal infection to assess for in the postpartum woman is: Fatigue continuing for longer than 1 week.Pain with voiding.Profuse vaginal bleeding with ambulation.>>Temperature of 38° C (100.4° F) or higher on 2 successive days starting 24 hours after birth.
The perinatal nurse assisting with establishing lactation is aware that acute mastitis can be minimized by: Washing the nipples and breasts with mild soap and water once a day.>>Using proper breastfeeding techniques.Wearing a nipple shield for the first few days of breastfeeding.Wearing a supportive bra 24 hours a day.
Nurses need to know the basic definitions and incidence data about postpartum hemorrhage (PPH). For instance: PPH is easy to recognize early; after all, the woman is bleeding.Traditionally it takes more than 1000 ml of blood after vaginal birth and 2500 ml after cesarean birth to define the condition as PPH.If anything, nurses and doctors tend to overestimate the amount of blood loss.>>Traditionally PPH has been classified as early or late with respect to birth.
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 ___________. Disseminated intravascular coagulation; asking for laboratory testsvon Willebrand disease; noting whether bleeding times have been extended>>Thrombophlebitis; using real-time and color Doppler ultrasoundCoagulopathies; drawing blood for laboratory analysis
What PPH conditions are considered medical emergencies that require immediate treatment? >>Inversion of the uterus and hypovolemic shockHypotonic uterus and coagulopathiesSubinvolution of the uterus and idiopathic thrombocytopenic purpuraUterine atony and disseminated intravascular coagulation
What infection is contracted mostly by first-time mothers who are breastfeeding? Endometritis>>MastitisWound infectionsUrinary tract infections
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 after delivery 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: Cryoprecipitate.>>Desmopressin.Factor VIII and vWf.Hemabate.
The nurse should be aware that a pessary would be most effective in the treatment of what disorder? CystoceleRectocele>>Uterine prolapseStress urinary incontinence
A mother in late middle age who is certain she is not pregnant tells the nurse during an office visit that she has urinary problems and sensations of bearing down and of something in her vagina. The nurse would realize that the client most likely is suffering from: Pelvic relaxation.Uterine displacement.>>Cystoceles and/or rectoceles.Genital fistulas.
The prevalence of urinary incontinence (UI) increases as women age, with more than one third of women in the United States suffering from some form of this disorder. The symptoms of mild-to-moderate UI can be successfully decreased by a number of strategies. Which of these should the nurse instruct the client to use first? Pelvic floor support devices>>Bladder training and pelvic muscle exercisesSurgeryMedications
When a woman is diagnosed with postpartum depression (PPD) with psychotic features, one of the main concerns is that she may: Have outbursts of anger.>>Harm her infant.Neglect her hygiene.Lose interest in her husband.
According to Beck's studies, what risk factor for postpartum depression is likely to have the greatest effect on the woman's condition? >>Prenatal depressionLow socioeconomic statusSingle-mother statusUnplanned or unwanted pregnancy
To provide adequate postpartum care, the nurse should be aware that postpartum depression (PPD) without psychotic features: Means that the woman is experiencing the baby blues. In addition she has a visit with a counselor or psychologist.Is more common among older, Caucasian women because they have higher expectations.>>Is distinguished by irritability, severe anxiety, and panic attacks.Will disappear on its own without outside help.
To provide adequate postpartum care, the nurse should be aware that postpartum depression (PPD) with psychotic features: Is more likely to occur in women with more than two children.Is rarely delusional and then usually about someone trying to harm her (the mother).Although serious, is not likely to need psychiatric hospitalization.>>May include bipolar disorder (formerly called ""manic depression"").
With shortened hospital stays, new mothers are often discharged before they begin to experience symptoms of the baby blues or postpartum depression. As part of the discharge teaching, the nurse can prepare the mother for this adjustment to her new role by instructing her regarding self-care activities to help prevent postpartum depression. The most accurate statement as related to these activities is to: Stay home and avoid outside activities to ensure adequate rest.Be certain that you are the only caregiver for your baby to facilitate infant attachment.Keep feelings of sadness and adjustment to your new role to yourself.>>Realize that this is a common occurrence that affects many women.
A family is visiting two surviving triplets. The third triplet died 2 days ago. What action would indicate that the family had begun to grieve for the dead infant? They refer to the two live infants as twins.They ask about the dead triplet's current status.They bring in play clothes for all three infants.>>They refer to the dead infant in the past tense.
A newborn in the neonatal intensive care unit (NICU) is dying as a result of a massive infection. The parents speak to the neonatologist, who informs them of their son's prognosis. When the father sees his son, he says, ""He looks just fine to me. I can't understand what all this is about."" The most appropriate response by the nurse would be: Didn't the doctor tell you about your son's problems?>>""This must be a difficult time for you. Tell me how you're doing.""To stand beside him quietly.You'll have to face up to the fact that he is going to die sooner or later.
The most appropriate statement that the nurse can make to bereaved parents is: You have an angel in heaven.I understand how you must feel.You're young and can have other children.>>""I'm sorry.""
After giving birth to a stillborn infant, the woman turns to the nurse and says, ""I just finished painting the baby's room. Do you think that caused my baby to die?"" The nurse's best response to this woman is: That's an old wives' tale; lots of women are around paint during pregnancy, and this doesn't happen to them.That's not likely. Paint is associated with elevated pediatric lead levels.Silence.>>""I can understand your need to find an answer to what caused this. What else are you thinking about?""
What options for saying goodbye would the nurse want to discuss with a woman who is diagnosed with having a stillborn girl? The nurse shouldn't discuss any options at this time; there is plenty of time after the baby is born.Would you like a picture taken of your baby after birth?>>""When your baby is born, would you like to see and hold her?""What funeral home do you want notified after the baby is born?
A woman experienced a miscarriage at 10 weeks of gestation and had a dilation and curettage (D&C). She states that she is just fine and wants to go home as soon as possible. While you are assessing her responses to her loss, she tells you that she had purchased some baby things and had picked out a name. On the basis of your assessment of her responses, what nursing intervention would you use first? Ready her for discharge.Notify pastoral care to offer her a blessing.Ask her if she would like to see what was obtained from her D&C.>>Ask her what name she had picked out for her baby.
A woman is diagnosed with having a stillborn. At first, she appears stunned by the news, cries a little, and then asks you to call her mother. The phase of bereavement the woman is experiencing is called: Anticipatory grief.Intense grief.>>Acute distress.Reorganization.
During the initial acute distress phase of grieving, parents still must make unexpected and unwanted decisions about funeral arrangements and even naming the baby. The nurse's role should be to: Take over as much as possible to relieve the pressure.Encourage grandparents to take over.>>Make sure the parents themselves approve the final decisions.Let them alone to work things out.
During a follow-up visit, if parents have progressed to the second stage or phase of grieving, the nurse should not expect to see: Guilt, particularly in the mother.>>Numbness or lack of response.Bitterness or irritability.Fear and anxiety, especially about getting pregnant again.
The nurse would conclude that grieving parents had progressed to the reorganization/recovery phase during a follow-up visit a year later if: The parents say they feel no pain.>>The parents are discussing sex and a future pregnancy, even if they have not sorted out their feelings yet.The parents have abandoned those moments of bittersweet grief.The parents' questions have progressed from ""Why?"" to ""Why us?""
The nurse caring for a family during a loss might notice that survival guilt sometimes is felt at the death of an infant by the child's: Siblings.Father.Mother.>>Grandparents.
When helping the mother, father, and other family members actualize the loss of the infant, nurses should: Use the words lost or gone rather than dead or died.Make sure that the family understands that it is important to name the baby.>>If the parents choose to visit with the baby, apply powder and lotion to the baby and wrap the infant in a pretty blanket.Set a firm time for ending the visit with the baby so the parents know when to let go.
Nurses who want to help parents with their decision making about an autopsy or who may be required to be involved in seeking consent for autopsies should be aware that: >>Autopsies not specifically covered by insurance or done under the jurisdiction of the medical examiner's office can be very expensive.Autopsies must be done within a few hours after delivery.In the current litigious society more autopsies are performed than in the past.Most parents who refuse the examination regret it later.
With regard to organ donation after an infant's death, nurses should be aware that: Federal law requires medical staff to ask the parents about organ donation and then to contact their state's organ procurement organization (OPO) to handle the procedure if the parents agree.>>Organ donation can aid grieving by giving the family an opportunity to see something positive about the experience.The most common donation is the infant's kidneys.Corneas can be donated if the infant was either stillborn or alive, as long as the pregnancy went full term.
Complicated bereavement: Occurs when, in multiple births, one child dies, and the other or others live.Is a state in which the parents are ambivalent, as with an abortion.>>Is an extremely intense grief reaction that persists for a long time.Is felt by the family of adolescent mothers who lose their babies.
In helping bereaved parents cope and move on, nurses should keep in mind that: >>A perinatal or parental grief support group is more likely to be helpful if the needs of the parents are matched with the focus of the group.When pictures of the infant are taken for keepsakes, no close-ups should be taken of any congenital anomalies.No significant differences exist in grieving individuals from various cultures, ethnic groups, and religions.In emergency situations nurses who are so disposed must resist the temptation to baptize the infant in the absence of a priest or minister.
Pain should be assessed regularly in all newborn infants. If the infant is displaying physiologic or behavioral cues indicating pain, measures should be taken to manage the pain. Examples of nonpharmacologic pain management techniques include (choose all that apply): >>Swaddling. AND Nonnutritive sucking. AND Skin-to-skin contact with the mother. AND Sucrose.Acetaminophen.
The nurse is discussing infant care as part of the mother-infant's couplet discharge planning. The mother asks the nurse, ""When will my baby's cord fall off?"" The nurse responds, ""Your baby's cord should fall off by ____________________ (weeks/days) after birth."" >>10-14 daysSome other stupid answer
The nurse is performing a blood glucose test every 4 hours on an infant born to a diabetic mother. This is to assess the infant's risk of hypoglycemia. The nurse becomes concerned if the infant's blood glucose concentration falls below _____ mg/dl. >>36Some other stupid answer
An infant boy was born just a few minutes ago. The nurse is conducting the initial assessment. Part of the assessment includes the Apgar score. The Apgar assessment is performed: Only if the newborn is in obvious distress.Once by the obstetrician, just after the birth.>>At least twice, 1 minute and 5 minutes after birth.Every 15 minutes during the newborn's first hour after birth.
A new father wants to know what medication was put into his infant's eyes and why it is needed. The nurse explains to the father that the purpose of the Ilotycin ophthalmic ointment is to: Destroy an infectious exudate caused by Staphylococcus that could make the infant blind.>>Prevent gonorrheal and chlamydial infection of the infant's eyes potentially acquired from the birth canal.Prevent potentially harmful exudate from invading the tear ducts of the infant's eyes, leading to dry eyes.Prevent the infant's eyelids from sticking together and help the infant see.
The nurse is using the Ballard scale to determine the gestational age of a newborn. Which assessment finding is consistent with a gestational age of 40 weeks? >>Flexed postureAbundant lanugoSmooth, pink skin with visible veinsFaint red marks on the soles of the feet
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: >>Are benign if they disappear within 48 hours of birth.Result from increased blood volume.Should always be further investigated.Usually occur with forceps delivery.
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: Apply an oil-based lotion to the newborn's skin to prevent dying and cracking.Limit the newborn's intake of milk to prevent nausea, vomiting, and diarrhea.>>Place eye shields over the newborn's closed eyes.Change the newborn's position every 4 hours.
Early this morning, an infant boy was circumcised using the PlastiBell method. The nurse tells the mother that she and the infant can be discharged after: The bleeding stops completely.The PlastiBell rim falls off.Yellow exudate forms over the glans.>>The infant voids.
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 with prepackaged diaper wipes every 3 to 4 hours.Apply constant, firm pressure by squeezing the penis with the fingers for at least 5 minutes if bleeding occurs.>>Cleanse the penis gently with water and put petroleum jelly around the glans after each diaper change.Wash off the yellow exudate that forms on the glans at least once every day to prevent infection.
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.Confirm that the newborn's mother has been infected with the hepatitis B virus.Assess the dorsogluteal muscle as the preferred site for injection.Confirm that the newborn is at least 24 hours old.
The nurse is performing a gestational age and physical assessment on the newborn. The infant appears to have an excessive amount of saliva. The nurse recognizes that this finding: Is normal.Indicates that the infant is hungry.>>May indicate that the infant has a tracheoesophageal fistula or esophageal atresia.May indicate that the infant has a diaphragmatic hernia.
As part of Standard Precautions, nurses wear gloves when handling the newborn. The chief reason is: To protect the baby from infection.That it is part of the Apgar protocol.>>To protect the nurse from contamination by the newborn.Because the nurse has primary responsibility for the baby during the first 2 hours.
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: 46>>5.7
An Apgar score of 10 at 1 minute after birth would indicate a(n): Infant having no difficulty adjusting to extrauterine life and needing no further testing.Infant in severe distress that needs resuscitation.Prediction of a future free of neurologic problems.>>Infant having no difficulty adjusting to extrauterine life but who should be assessed again at 5 minutes after birth.
With regard to umbilical cord care, nurses should be aware that: >>The stump can easily become infected.A nurse noting bleeding from the vessels of the cord should immediately call for assistance.The cord clamp is removed at cord separation.The average cord separation time is 5 to 7 days.
In the classification of newborns by gestational age and birth weight, the appropriate for gestational age (AGA) weight would: Fall between the 25th and 75th percentiles for the infant's age.Depend on the infant's length and the size of the head.>>Fall between the 10th and 90th percentiles for the infant's age.Be modified to consider intrauterine growth restriction (IUGR).
During the complete physical examination 24 hours after birth: The parents are excused to reduce their normal anxiety.>>The nurse can gauge the neonate's maturity level by assessing its general appearance.Once often neglected, blood pressure is now routinely checked.When the nurse listens to the heart, the S1 and S2 sounds can be heard; the first sound is somewhat higher in pitch and sharper than the second.
With regard to laboratory tests and diagnostic tests in the hospital after birth, nurses should be aware that: All states test for phenylketonuria (PKU), hypothyroidism, cystic fibrosis, and sickle cell diseases.Federal law prohibits newborn genetic testing without parental consent.>>If genetic screening is done before the infant is 24 hours old, it should be repeated at age 1 to 2 weeks.Hearing screening is now mandated by federal law.
Nurses can help parents deal with the issue and fact of circumcision if they explain: >>The pros and cons of the procedure during the prenatal period.That the American Academy of Pediatrics (AAP) recommends that all newborn males be routinely circumcised.That circumcision is rarely painful and any discomfort can be managed without medication.That the infant will likely be alert and hungry shortly after the procedure.
As part of their teaching function at discharge, nurses should tell parents that the baby's respiration should be protected by all of the following procedures except: Preventing exposure to people with upper respiratory tract infections.Keeping the infant away from secondhand smoke.Avoiding loose bedding, water beds, and beanbag chairs.>>Not letting the infant sleep on his or her back.
The normal term infant has little difficulty clearing its airway after birth. Most secretions are brought up to the oropharynx by the cough reflex. However, if the infant has excess secretions, the mouth and nasal passages can be cleared easily with a bulb syringe. When instructing parents on the correct use of this piece of equipment, it is important that the nurse teach them to: Avoid suctioning the nares.Insert the compressed bulb into the center of the mouth.>>Suction the mouth first.Remove the bulb syringe from the crib when finished.
Risk factors associated with necrotizing enterocolitis (NEC) include (choose all that apply): >>Polycythemia. AND Anemia. AND Congenital heart disease.Bronchopulmonary dysphasia.Retinopathy.
The corrected age of an infant who was born at 25 1/7 weeks and is preparing for discharge 124 days past delivery is ____________________. >>42 6/7 weeksSome other stupid answer
As with all aspects of care, strict handwashing is the single most important measure to prevent nosocomial infections. >>TRUEFALSE
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: Leave the infant in the room with the mother.Take the infant immediately to the nursery.Perform a gestational age assessment to determine whether the infant is large for gestational age.>>Monitor blood glucose levels frequently and observe closely for signs of hypoglycemia.
Infants of mothers with diabetes are at higher risk for developing: Anemia.>>Respiratory distress syndrome.Hyponatremia.Sepsis.
An infant was born 2 hours ago at 37 weeks of gestation, weighing 4.1 kg. The infant appears chubby with a flushed complexion and is very tremulous. The tremors are most likely the result of: Birth injury.>>Hypoglycemia.Hypocalcemia.Seizures.
An infant at 36 weeks of gestation has increasing respirations (80 to 100 breaths/min with marked substernal retractions). The infant is given oxygen by continuous nasal positive airway pressure. Which arterial oxygen level would indicate hypoxia? PaO2 of 67>>PaO2 of 45PaO2 of 89PaO2 of 73
On day 3 of life, a newborn continues to require 100% oxygen by nasal cannula. The parents ask if they can hold their infant during his next gavage feeding. Given that this newborn is physiologically stable, what response would the nurse give? Parents are not allowed to hold infants who depend on oxygen.You may only hold your baby's hand during the feeding.Feedings cause more physiologic stress, so the baby must be closely monitored. Therefore, I don't think you should hold the baby.>>""You may hold your baby during the feeding.""
A premature infant with respiratory distress syndrome receives artificial surfactant. How would the nurse explain surfactant therapy to the parents? >>""Surfactant improves the ability of your baby's lungs to exchange oxygen and carbon dioxide.""The drug keeps your baby from requiring too much sedation.Surfactant is used to reduce episodes of periodic apnea.Your baby needs this medication to fight a possible respiratory tract infection.
When providing an infant with a gavage feeding, which of the following should be documented each time? The infant's abdominal circumference after the feedingThe infant's heart rate and respirationsThe infant's suck and swallow coordination>>The infant's response to the feeding
An infant is to receive gastrostomy feedings. What intervention should the nurse institute to prevent bloating, gastrointestinal reflux into the esophagus, vomiting, and respiratory compromise? Rapid bolusing of the entire amount in 15 minutesWarm cloths to the abdomen for the first 10 minutes>>Slow, small, warm bolus feedings over 30 minutesCold, medium bolus feedings over 20 minutes
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.Continue to observe and make no changes until the saturations are 75%.Continue with the admission process to ensure that a thorough assessment is completed.Notify the parents that their infant is not doing well.
A newborn was admitted to the neonatal intensive care unit after being delivered at 29 weeks of gestation to a 28-year-old multiparous, married, Caucasian female whose pregnancy was uncomplicated until premature rupture of membranes and preterm birth. The newborn's parents arrive for their first visit after the birth. The parents walk toward the bedside but remain approximately 5 feet away from the bed. The nurse's most appropriate action would be to: Wait quietly at the newborn's bedside until the parents come closer.>>Go to the parents, introduce himself or herself, and gently encourage them to come meet their infant; explain the equipment first, and then focus on the newborn.Leave the parents at the bedside while they are visiting so they can have some privacy.Tell the parents only about the newborn's physical condition and caution them to avoid touching their baby.
Necrotizing enterocolitis (NEC) is an inflammatory disease of the gastrointestinal mucosa. The signs of NEC are nonspecific. Some generalized signs include: Hypertonia, tachycardia, and metabolic alkalosis.>>Abdominal distention, temperature instability, and grossly bloody stools.Hypertension, absence of apnea, and ruddy skin color.Scaphoid abdomen, no residual with feedings, and increased urinary output.
An infant is being discharged from the neonatal intensive care unit after 70 days of hospitalization. The infant was born at 30 weeks of gestation with several conditions associated with prematurity, including respiratory distress syndrome, mild bronchopulmonary dysplasia, and retinopathy of prematurity requiring surgical treatment. During discharge teaching the infant's mother asks the nurse if her baby will meet developmental milestones on time, as did her son who was born at term. The nurse's most appropriate response is: Your baby will develop exactly like your first child did.Your baby does not appear to have any problems at the present time.>>""Your baby will need to be corrected for prematurity. Your baby is currently 40 weeks of postconceptional age and can be expected to be doing what a 40-week-old infant would be doing.""Your baby will need to be followed very closely.
A pregnant woman was admitted for induction of labor at 43 weeks of gestation with sure dates. A nonstress 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.Excessive vernix caseosa covering the skin, lethargy, and respiratory distress syndrome.Golden yellow- to green stained–skin and nails, absence of scalp hair, and an increased amount of subcutaneous fat.Hyperglycemia, hyperthermia, and an alert, wide-eyed appearance.
For diagnostic and treatment purposes nurses should know the birth weight classifications of high risk infants. For example, extremely low birth weight (ELBW) is the designation for an infant whose weight is: Less than 1500 g.Less than 2000 g.>>Less than 1000 g.Dependent on the gestational age.
In the continuing assessment of a preterm infant, the nurse notices continued respiratory distress even though oxygen and ventilation have been provided. The nurse should suspect: >>Hypovolemia and/or shock.Central nervous system injury.A nonneutral thermal environment.Pending renal failure.
Premature infants who exhibit 5 to 10 seconds of respiratory pauses followed by 10 to 15 seconds of compensatory rapid respiration are: Suffering from sleep or wakeful apnea.Experiencing severe swings in blood pressure.Trying to maintain a neutral thermal environment.>>Breathing in a respiratory pattern common to premature infants.
In appraising the growth and development potential of a preterm infant, nurses should: Tell parents their child won't catch up until about age 10 (girls) to 12 (boys).>>Correct for milestones such as motor competencies and vocalizations until the child is approximately 3 years of age.Know that the greatest catch-up period is between 9 and 15 months postconceptual age.Know that the length and breadth of the trunk is the first part of the infant to experience catch-up growth.
The nurse practicing in the perinatal setting should promote kangaroo care regardless of an infant's gestational age. This intervention: Is adopted from classical British nursing traditions.Helps infants with motor and central nervous system impairment.>>Helps infants to interact directly with their parents and enhances their temperature regulation.Gets infants ready for breastfeeding.
For clinical purposes preterm and postterm infants are defined as: Preterm before 34 weeks if appropriate for gestational age (AGA); before 37 weeks if small for gestational age (SGA).Postterm after 40 weeks if large for gestational age (LGA); beyond 42 weeks if AGA.>>Preterm before 37 weeks, postterm beyond 42 weeks, no matter the size for gestational age at birth.Preterm, SGA before 38 to 40 weeks; postterm, LGA beyond 40 to 42 weeks.
With regard to small for gestational age (SGA) infants and intrauterine growth restrictions (IUGR), nurses should be aware that: In the first trimester diseases or abnormalities result in asymmetric IUGR.>>Infants with asymmetric IUGR have the potential for normal growth and development.In asymmetric IUGR weight will be slightly more than SGA, whereas length and head circumference will be somewhat less than SGA.Symmetric IUGR occurs in the later stages of pregnancy.
With regard to eventual discharge of the high risk newborn or transfer to a different facility, nurses and families should be aware that: Infants will stay in the neonatal intensive care unit (NICU) until they are ready to go home.Once discharged to home, the high risk infant should be treated like any healthy term newborn.>>Parents of high risk infants need special support and detailed contact information.If a high risk infant and mother need transfer to a specialized regional center, it is better to wait until after birth and the infant is stabilized.
Necrotizing enterocolitis (NEC) is an acute inflammatory disease of the gastrointestinal mucosa that can progress to perforation of the bowel. Approximately 2% to 5% of premature infants succumb to this fatal disease. Care is supportive; however, there are known interventions that may decrease the risk of NEC. To develop an optimal plan of care for this infant, the nurse must understand that which intervention has the greatest effect on lowering the risk of NEC? Early enteral feedingsExchange transfusion>>BreastfeedingProphylactic probiotics
As a result of large body surface in relation to weight, the preterm infant is at high risk for heat loss and cold stress. By understanding the four mechanisms of heat transfer (convection, conduction, radiation, and evaporation), the nurse can create an environment for the infant that prevents temperature instability. While evaluating the plan that has been implemented, the nurse knows that the infant is experiencing cold stress when he or she exhibits: Decreased respiratory rate.Bradycardia followed by an increased heart rate.>>Mottled skin with acrocyanosis.Increased physical activity.
Cleft lip or palate is a common congenital midline fissure, or opening, in the lip or palate resulting from failure of the primary palate to fuse. Multiple genetic and to a lesser extent environmental factors may lead to the development of a cleft lip or palate. Such factors include (choose all that apply): >>Alcohol consumption. AND Use of some antiepileptics. AND Maternal cigarette smoking.Female gender.Antibiotic use in pregnancy.
Many common drugs of abuse cause significant physiologic and behavioral problems in infants who are breastfed by mothers currently using (choose all that apply): >>Amphetamine. AND Heroin. AND Nicotine. AND PCP.Morphine.
____________________ is a condition in which the ventricles of the brain are enlarged as a result of an imbalance between the production and absorption of the cerebrospinal fluid (CSF). An infant with this condition initially has a bulging anterior fontanel and a head circumference that increases at an abnormal rate, resulting from the increase in CSF pressure. >>HydrocephalusAnother stupid answer
_____________________, a synthetic opiate, has been the therapy of choice for heroin addiction. It crosses the placenta, leading to significant neonatal abstinence syndrome after birth. >>MethadoneAnother stupid answer
A pregnant woman at 37 weeks of gestation has had ruptured membranes for 26 hours. A cesarean section is performed for failure to progress. The fetal heart rate (FHR) before birth is 180 beats/min with limited variability. At birth the newborn has Apgar scores of 6 and 7 at 1 and 5 minutes and is noted to be pale and tachypneic. On the basis of the maternal history, the cause of this newborn's distress is most likely to be: Hypoglycemia.Respiratory distress syndrome.Phrenic nerve injury.>>Sepsis.
The most important nursing action in preventing neonatal infection is: >>Good handwashing.Separate gown technique.Isolation of infected infants.Standard Precautions.
A pregnant woman presents in labor at term, having had no prenatal care. After birth her infant is noted to be small for gestational age with small eyes and a thin upper lip. The infant also is microcephalic. On the basis of her infant's physical findings, this woman should be questioned about her use of which substance during pregnancy? >>AlcoholHeroinCocaineMarijuana
A plan of care for an infant experiencing symptoms of drug withdrawal should include: Administering chloral hydrate for sedation.Feeding every 4 to 6 hours to allow extra rest.>>Swaddling the infant snugly and holding the baby tightly.Playing soft music during feeding.
Human immunodeficiency virus (HIV) may be perinatally transmitted: Only in the third trimester from the maternal circulation.By a needlestick injury at birth from unsterile instruments.Only through the ingestion of amniotic fluid.>>Through the ingestion of breast milk from an infected mother.
The abuse of which of the following substances during pregnancy is the leading cause of cognitive impairment in the United States? >>AlcoholMarijuanaTobaccoHeroin
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. This is a zoonotic parasite that can infect you and have severe effects on your unborn child.""You and your baby can be exposed to the human immunodeficiency virus (HIV) in your cats' feces.It's just gross. You should make your husband clean the litter boxes.Cat feces are known to carry Escherichia coli, which can cause a severe infection in both you and your baby.
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: It is an eye ointment to help your baby see you better.It is to protect your baby from contracting herpes from your vaginal tract.>>""Erythromycin is given prophylactically to prevent a gonorrheal infection.""This medicine will protect your baby's eyes from drying out over the next few days.
With regard to skeletal injuries sustained by a neonate during labor or birth, nurses should be aware that: A newborn's skull is still forming and fractures fairly easily.>>Unless a blood vessel is involved, linear skull fractures heal without special treatment.Clavicle fractures often need to be set with an inserted pin for stability.Other than the skull, the most common skeletal injuries are to leg bones.
With regard to injuries to the infant's plexus during labor and birth, nurses should be aware that: >>If the nerves are stretched with no avulsion, they should recover completely in 3 to 6 months.Erb palsy is damage to the lower plexus.Parents of children with brachial palsy are taught to pick up the child from under the axillae.Breastfeeding is not recommended for infants with facial nerve paralysis until the condition resolves.
With regard to central nervous system injuries to the infant during labor and birth, nurses should be aware that: Intracranial hemorrhage (ICH) as a result of birth trauma is more likely to occur in the preterm, low-birth-weight infant.Subarachnoid hemorrhage (the most common form of ICH) occurs in term infants as a result of hypoxia.>>In many infants signs of hemorrhage in a full-term infant are absent and diagnosed only through laboratory tests.Spinal cord injuries almost always result from forceps-assisted deliveries.
With regard to the classification of neonatal bacterial infection, nurses should be aware that: Congenital infection progresses slower than nosocomial infection.>>Nosocomial infection can be prevented by effective handwashing; early-onset infections cannot.Infections occur with about the same frequency in boy and girl infants, although female mortality is higher.The clinical sign of a rapid, high fever makes infection easier to diagnose.
Near the end of the first week of life an infant who has not been treated for any infection develops a copper-colored, maculopapular rash on the palms and around the mouth and anus. The newborn is showing signs of: Gonorrhea.>>Congenital syphilis.Herpes simplex virus infection.Human immunodeficiency virus.
What bacterial infection is definitely decreasing because of effective drug treatment? Escherichia coli infectionCandidiasisTuberculosis>>Group B streptococcal infection
In caring for the mother who has abused (or is abusing) alcohol and for her infant, nurses should be aware that: The pattern of growth restriction of the fetus begun in prenatal life is halted after birth, and normal growth takes over.Two thirds of newborns with fetal alcohol syndrome (FAS) are boys.>>Alcohol-related neurodevelopmental disorders not sufficient to meet FAS criteria (learning disabilities, speech and language problems) are often not detected until the child goes to school.Both the distinctive facial features of the FAS infant and the diminished mental capacities tend toward normal over time.
A careful review of the literature on the various recreational and illicit drugs reveals that: >>More longer-term studies are needed to assess the lasting effects on infants when mothers have taken or are taking illegal drugs.Heroin and methadone cross the placenta; marijuana, cocaine, and phencyclidine (PCP) do not.Mothers should get off heroin (detox) any time they can during pregnancy.Methadone withdrawal for infants is less severe and shorter than heroin withdrawal.
With regard to the understanding and treatment of infants born to mothers who are substance abusers, nurses should be aware that: Infants born to addicted mothers are also addicted.>>Mothers who abuse one substance likely will use or abuse another, compounding the infant's difficulties.The NICU Network Neurobehavioral Scale (NNNS) is designed to assess the damage the mother has done to herself.No laboratory procedures are available that can identify the intrauterine drug exposure of the infant.
Providing care for the neonate born to a mother who abuses substances can present a challenge for the health care team. Nursing care for this infant requires a multisystem approach. The first step in the provision of this care is: Pharmacologic treatment.Reduction of environmental stimuli.>>Neonatal abstinence syndrome scoring.Adequate nutrition and maintenance of fluid and electrolyte balance.
While completing a newborn assessment, the nurse should be aware that the most common birth injury is: To the soft tissues.Caused by forceps gripping the head on delivery.Fracture of the humerus and femur.>>Fracture of the clavicle.
The most common cause of pathologic hyperbilirubinemia is: Hepatic disease.Postmaturity.>>Hemolytic disorders in the newborn.Congenital heart defect.
Which infant would be more likely to have Rh incompatibility? >>Infant of an Rh-negative mother and a father who is Rh positive and homozygous for the Rh factorInfant who is Rh negative and whose mother is Rh negativeInfant of an Rh-negative mother and a father who is Rh positive and heterozygous for the Rh factorInfant who is Rh positive and whose mother is Rh positive
A major nursing intervention for an infant born with myelomeningocele is to: >>Protect the sac from injury.Prepare the parents for the child's paralysis from the waist down.Prepare the parents for closure of the sac at around 2 years of age.Assess for cyanosis.
The priority nursing diagnosis for a newborn diagnosed with a diaphragmatic hernia would be: Risk for impaired parent-infant attachment.Imbalanced nutrition: less than body requirements.Risk for infection.>>Impaired gas exchange.
An infant diagnosed with erythroblastosis fetalis would characteristically exhibit: Edema.Enlargement of the heart.>>Immature red blood cells.Ascites.
With regard to hemolytic diseases of the newborn, nurses should be aware that: Rh incompatibility matters only when an Rh-negative offspring is born to an Rh-positive mother.ABO incompatibility is more likely than Rh incompatibility to precipitate significant anemia.Exchange transfusions frequently are required in the treatment of hemolytic disorders.>>The indirect Coombs' test is performed on the mother before birth; the direct Coombs' test is performed on the cord blood after birth.
With regard to congenital anomalies of the cardiovascular and respiratory systems, nurses should be aware that: >>Cardiac disease may be manifested by respiratory signs and symptoms.Screening for congenital anomalies of the respiratory system need only be done for infants having respiratory distress.Choanal atresia can be corrected by a suction catheter.Congenital diaphragmatic hernias are diagnosed and treated after birth.
When attempting to diagnose and treat developmental dysplasia of the hip (DDH), the nurse should: Be able to perform the Ortolani and Barlow tests.Teach double or triple diapering for added support.Explain to the parents the need for serial casting.>>Carefully monitor infants for DDH at follow-up visits.




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