Obstetrical nursing notes

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Name:_____________________________________________________________Date:_____________

1. A client, now 37 weeks pregnant, calls the clinic because she's concerned about being short of breath and is unable to sleep unless she places three pillows under her head. After listening to the client's concerns, the nurse should take which action? a. Make an appointment because the dent needs to be evaluated.

b. Explain that these are expected problems for the latter stages of pregnancy.

c. Arrange for the dent to be admitted to the birth center and prepare for birth. d. Tell the client to go to the hospital; she may be experiencing signs of heart failure. RATIONALE: The nurse must distinguish between normal physiologic complaints of the latter stages of pregnancy and those that need referral to the health care

provider. In this case, the client indicates normal physiologic changes caused by the growing uterus and pressure on the diaphragm. These signs don't indicate heart failure. The client doesn't need to be seen or admitted to the birth center. Reference: Maternal & Child Health Nursing: Care of the Childbearing and

Childrearing Family, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 230. 2. During the first trimester, a nurse evaluates a pregnant client for factors that suggest

she might abuse a child. Which parental characteristic is of most concern to the nurse?

a. The client didn’t graduate high school.

b. The client states she is stupid and ugly. c. The client is carrying twins.

The client eats fast food every day.

RATIONALE: Typically, the abusive parent has low self-esteem, which may be evident by self-deprecating statements, and many unmet needs. Lack of nurturing experience and inadequate knowledge of childhood growth and development may also contribute to the potential for child abuse. A low educational level, multiple gestations, and poor diet aren't direct risk factors for committing child abuse.

REFERENCE: Pillitteri, A. Maternal & Child Health Nursing: Care of the Childbearing and Childrearing Family, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 1743.

3. A client in her 15th week of pregnancy has presented with abdominal cramping and vaginal bleeding for the past 8 hours. She has passed several clots. What is the primary nursing diagnosis for this client?

a. Deficient knowledge of pregnancy b. Deficient fluid volume

c. Anticipatory grieving d. Acute pain

RATIONALE: If bleeding and clots are excessive, this client may become

hypovolemic , leading to a nursing diagnosis of Deficient fluid volume. Although Deficient knowledge (pregnancy), Anticipatory grieving, and Acute pain are applicable to this client, they aren't the primary diagnosis

REFERENCE: Pillitteri, A. Maternal & Child Health Nursing: Care of the Childbearing and Childrearing Family 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 400.

4. A nurse is obtaining a prenatal history from a client who's 8 weeks pregnant. To help determine whether the client is at risk for a TORCH infection , the nurse should ask:

a. “Have you ever had osteomyelitis?” b. “Do you have any cats at home? c. “Do you have any birds at home?’

d. “Have you recently had a rubeola vaccination?”

RATIONALE: Toxoplasmosis, Other Rubella virus, Cytomegalovirus, and Herpes simplex virus and agents that may infect the fetus or neonate, causing numerous ill effects. Toxoplasmosis is transmitted to humans through contact with the feces of infected cats (which may occur when emptying a litter box), through ingesting raw meat, or through contact with raw meat followed by improper hand washing.

Osteomyelitis , a serious bone infection; histoplasmosis, which can be transmitted by birds; and rubeola aren't TORCH infections

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A client, 38 weeks pregnant, arrives in the emergency department complaining of contractions. To help confirm that she's in true labor, the nurse should assess for: a. irregular contractions.

b. increased fetal movement.

c. changes in cervical effacement and dilation atter 1 to 2 hours. d. contractions that feel like pressure in the abdomen and qroin.

RATIONALE: True labor is characterized by progressive cervical effacement and dilation after 1 to 2 hours, regular contractions, discomfort that moves from the back to the front of the abdomen and, possibly, bloody show. False labor causes irregular contractions that are felt primarily in the abdomen and groin and commonly decrease with walking, increased fetal movement, and lack of change in cervical effacement or dilation even after 1 or 2 hours.

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A nurse is caring for a client during the first postpartum day. The client asks the nurse how to relieve pain from her episiotomy . What should the nurse instruct the woman to do?

a. Apply an ice pack to her perineum. b. Take a sitz bath.

c. Perform perineal care after voiding or a bowel movement. d. Drink plenty of fluids.

RATIONALE: A cold pack applied to an episiotomy during the first 24 hours after chidbirth may reduce edema and tension on the incision line, thereby reducing pain. After the first 24 hours, a sitz bath may reduce discomfort by promoting circulation and healing. Although perineal care should be performed after each voiding and bowel movement, its purpose is to prevent infection — not reduce discomfort. Drinking plenty of fluids is also important, especially for the breast-feeding woman, but it doesn't relieve perineal discomfort.

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A client who's 24 weeks pregnant has sickle cell anemia . When preparing the care plan, the nurse should identify which factor as a potential trigger for a sickle cell crisis during pregnancy?

a. Sedative use b. Dehydration c. Hypertension d. Tachycardia

RATIONALE: Factors that may precipitate a sickle cell crisis during pregnancy include dehydration , infection , stress, trauma, fever, fatigue, and strenuous activity. Sedative use, hypertension, and tachycardia aren't known to precipitate a sickle cell crisis

8. A nurse is caring for a 1-day postpartum mother who's very talkative but isn't confident in her decision-making skills. The nurse is aware that this is a normal phase for the mother. What is this phase called?

a. Taking-in phase b. Taking-hold phase c. Letting-go phase d. Taking-over phase

RATIONALE: The taking-in phase is a normal first phase for a mother when she's feeling overwhelmed by the responsibilities of caring for the neonate while still fatigued from childbirth. Taking hold is the next phase, when the mother has rested and she can think and learn mothering skills with confidence. During the letting-go or taking-over phase, the mother gives up her previous role. She separates herself from the neonate, giving up the fantasy of birth, and readjusting to the reality of caring for the neonate. Depression may occur during this stage.

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9. Which intervention listed in the care plan for a client with an ectopic pregnancy requires revision?

a. Assessing vital signs

b. Providing for dietary needs c. Managing pain

d. Providing emotional support

RATIONALE: Providing for the client's dietary needs isn't appropriate because the client shouldn't eat or drink anything pending surgery. Assessing vital signs for indicators of potential shock , managing pain, and providing emotional support are essential nursing interventions in caring for a client with an ectopic pregnancy. REFERENCE: Pillitteri, A. Maternal & Child Health Nursing: Care of the Childbearing and Childrearing Family, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 409.

10.A client who's 19 weeks pregnant comes to the clinic for a routine prenatal visit. In addition to checking the client's fundal height, weight, and blood pressure, what should the nurse assess for at each prenatal visit?

a. Edema

b. Pelvic adequacy c. Rh factor changes d. Hemoglobin alterations

RATIONALE: At each prenatal visit, the nurse should assess the client for edema because edema, increased blood pressure, and proteinuria are cardinal signs of gestational hypertension. Pelvic measurements and Rh typing are determined at the first visit only because they don't change. The nurse should monitor the hemoglobin level on the client's first visit, at 24 to 28 weeks' gestation, and at 36 weeks'

gestation.

REFERENCE: Pillitteri, A. Maternal & Child Health Nursing: Care of the Childbearing and Childrearing Family, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 257.

11.A nurse is caring for a client whose membranes ruptured prematurely 12 hours ago. When assessing this client, the nurse's highest priority is to evaluate:

a. cervical effacement and dation.

b. maternal vital signs and fetal heart rate (FHR). c. frequency and duration of contractions.

d. white blood cell (WBC) count.

RATIONALE: After premature rupture of the membranes (PROM), monitoring maternal vital signs and FHR takes priority. Maternal vital signs, especially

temperature and pulse, may suggest maternal infection caused by PROM. FHR is the most accurate indicator of fetal status after PROM and may suggest sepsis caused by ascending pathogens. Assessing cervical effacement and dilation should be avoided in this client because it requires a pelvic examination, which may introduce

pathogens into the birth canal. Evaluating the frequency and duration of contractions doesn't provide insight into fetal status. The WBC count may suggest maternal infection; however, it can't be measured as often as maternal vital signs and FHR can and therefore provides less current information

REFERENCE: Ricci, S.S. Essentials of Maternity, Newborn, and Women’s Health Nursing. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 531.

12.A client is told that she needs to have a nonstress test to determine fetal well-being. After 20 minutes of monitoring, the nurse reviews the strip and finds two 15-beat accelerations that lasted for 15 seconds. What should the nurse do next ?

a. Continue to monitor the baby for fetal distress.

b. Notify the physician and transfer the mother to labor and delivery for imminent delivery.

c. Inform the physician and prepare for discharge: this client has a reassuring strip.

d. Ask the mother to eat something and return for a repeat test; the results are inconclusive.

RATIONALE: Fetal well-being is determined during a nonstress test by two

accelerations occurring within 20 minutes that demonstrate a rise in heart rate of at least 15 beats. This fetus has successfully demonstrated that the intrauterine

environment is still favorable. The test results don't suggest fetal distress, so immediate delivery is unnecessary. In research studies, eating foods or drinking fluids hasn't been shown to influence the outcome of a nonstress test. REFERENCE:

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Pillitteri, A. Maternal & Child Health Nursing: Care of the Childbearing and

Childrearing Family, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 203. 13. A nurse is caring for four clients who gave birth 12 hours ago. Which client is at

greatest risk for complications?

a. Gravida 2 para 2002, cesarean bith, incision site intact, hemoglobin level 9.8 g/dl

b. Gravida 2 para 1011, cesarean birth, incision site intact, pulse 84 beats/minute c. Gravida 1 para 1001, vaginal delivery, midline episiotomy, temperature of 99.8° F (37.7C)

d. Gravida 1 para 1001, vaginal delivery, membranes ruptured 10 hours before birth RATIONALE: Women who have anemia during pregnancy (defined as a hemoglobin less than 10 g/dl) may experience more complications such as poor wound healing and inability to tolerate activity. An intact incision site and a pulse of 84 beats/minute after a cesarean birth and a temperature of 99.8F after a vaginal delivery with

episiotomy are findings within normal limits. Dehydration can cause a slightly elevated temperature. Although women whose membranes are ruptured more than 24 hours before birth are more prone to developing chorioamnionitis, the client with anemia is at greater risk for complications.

14. Which measure included in the care plan for a client in the fourth stage of labor requires revision?

a. Check vital signs and fundal checks every 15 minutes.

b. Have the client spend time with the neonate to initiate breast-feeding.

c. Obtain an order for catheterization to protect the bladder from trauma. d. Perform perineal assessments for swelling and bleeding.

RATIONALE: Catheterization isn't routinely done to protect the bladder from trauma. It's done, however, for a postpartum complication of urinary retention. The other options are appropriate measures to include in the care plan during the fourth stage of labor. CLIENT NEEDS CATEGORY: Physiological integrity Basic care and comfort REFERENCE: Ricci, S.S. Essentials of Maternity, Newborn, and Women’s Health Nursing. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 370.

15.A client who's 4 weeks pregnant comes to the clinic for her first prenatal visit. When obtaining her health history, the nurse explores her use of drugs, alcohol, and cigarettes. Which client outcome identifies a safe level of alcohol intake for this client?

a. “The clent consumes no more than 2 oz of alcohol dady.” b. “The client consumes no more than 4 oz of alcohol dady.”

c. “The client consumes 2 to 6 oz of alcohol daily, dependlng on body weight." d. “The client consumes no alcohol.”

RATIONALE: A safe level of alcohol intake during pregnancy hasn't been

established. Therefore, authorities recommend that pregnant women abstain from alcohol entirely. Excessive alcohol intake has serious harmful effects on the fetus, especially between the 16th and 18th weeks of pregnancy. Affected neonates exhibit fetal alcohol syndrome, which includes microcephaly, growth retardation, short palpebral fissures, and maxillary hypoplasia. Alcohol intake may also affect the client's nutrition and may predispose her to complications in early pregnancy. REFERENCE: Pillitteri, A. Maternal & Child Health Nursing: Care of the Childbearing and Childrearing Family, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 291.

16.A nurse is teaching a client about hormonal contraceptive therapy. If a client misses three or more pills in a row, the nurse should instruct the client to:

a. take all the missed doses as soon as she discovers the oversight.

b. take two pills for the next 2 days and use an alternative contraceptive method until the next cycle.

c. take three pills for the next 3 days and use an alternative contraceptive method until the next cycle.

d. discard the pack, use an atternative contraceptive method untii her period begins, and start a new pack on the regular schedule.

RATIONALE: A client who misses three or more pills in a row should discard the pack, use an alternative contraceptive method until her period begins, and start a new pack on the regular schedule. Taking all the missed doses, taking two pills for

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the next 2 days, or taking three pills for the next 3 days doesn't ensure effectiveness and can increase the risk of adverse reactions. REFERENCE: Pillitteri, A. Maternal & Child Health Nursing: Care of the Childbearing and Childrearing Family, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 112.

17.A nurse is caring for a client in labor. The external fetal monitor shows a pattern of variable decelerations in fetal heart rate. What should the nurse do first ?

a. Change the client's position. b. Prepare for emergency cesarean birth. c. Check for placenta previa.

d. Administer oxygen.

RATIONALE: Variable decelerations in fetal heart rate are an ominous sign, indicating compression of the umbilical cord. Changing the client's position may immediately correct the problem. An emergency cesarean birth is necessary only if other measures, such as changing position and amnioinfusion with sterile saline, prove unsuccessful. Placenta previa doesn't cause variable decelerations. Administering oxygen may be helpful, but the priority is to change the woman's position and relieve cord compression

18.Normal lochial findings in the first 24 hours after birth include: a. Bright red blood.

b. large- or tissue fragments. c. A foul odor.

d. the complete absence of lochia.

RATIONALE: Bright red blood is a normal lochial finding in the first 24 hours after birth. Lochia should never contain large clots, tissue fragments, or membranes. A foul odor or absence of lochia may signal infection .

19.A nurse is performing a physical examination of a primigravid client who's 8 weeks pregnant. At this time, the nurse expects to assess:

a. Hegar's sign. b. fetal outline c. balottement. d.quickening

RATIONALE: When performing a vaginal or rectovaginal examination, the nurse may assess Hegar's sign (softening of the uterine isthmus) between the 6th and 8th weeks of pregnancy. The fetal outline may be palpated after 24 weeks. Ballottement isn't elicited until the fourth or fifth month of pregnancy. Quickening typically is reported after 16 to 20 weeks.

20.A client asks how long she and her husband can safely continue sexual activity during pregnancy. How should the nurse respond?

a. “Unti the end of the frst trimester.” b. "Unti the end of the second trrmester.” c. "Unti the end of the thid trimester.”

d. "As long as you wish, if the pregnancy is normal.”

RATIONALE: During a normal pregnancy, the client and her partner need not discontinue sexual activity. If the client develops complications that could lead to preterm labor, she and her partner should consult with a health practitioner for advice on the safety of sexual activity. REFERENCE: Pillitteri, A. Maternal & Child Health Nursing: Care of the Childbearing and Childrearing Family, 5th ed.

Philadelphia: Lippincott Williams & Wilkins, 2007, p. 275.

21. A stillborn infant was delivered in the birthing suite a few hours ago. After the delivery, the family remained together, holding and touching the baby. Which statement by the nurse would further assist the family in their initial period of grief? a. “What have you named your baby?”

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c. “Don’t worry; there is nothing you could have done to prevent this from happening.”

d. “We will see to it that you have an early discharge so that you don’t have to be reminded of this experience.”

RATIONALE: Nurses should be able to explore measures that help the family create memories of the newborn infant so that the existence of the child is confirmed and the parents can complete the grieving process. Option 1 provides this support and demonstrates a caring and empathetic response. Options 2, 3, and 4 are blocks to communication and devalue the parents’ feelings.

REFERENCES: Wong, D., Perry, S., Hockenberry, M., et al. (2006) Maternal child nursing care

(3rd ed., pp. 681-683). St. Louis: Mosby.

22. A nurse is caring for a pregnant client with preeclampsia. The nurse prepares a plan of care for the client and documents in the plan that if the client progresses from preeclampsia to eclampsia, the nurse’s first action should be to:

a. Administer oxygen by face mask. b. Clear and maintain an open airway. c. Administer magnesium sulfate intravenously. d. Assess the blood pressure and fetal heart rate.

RATIONALE: The immediate care during a seizure (eclampsia) is to ensure a patent airway. Options 1, 3, and 4 are actions that follow or are implemented after the seizure has ceased.

REFERENCES: Wong, D., Perry, S., Hockenberry, M., et al. (2006). Maternal child nursing care

(3rd ed., p. 385). St. Louis: Mosby.

1. A pregnant client in the last trimester has been admitted to the hospital with a

diagnosis of severe preeclampsia. A nurse monitors for complications associated with the diagnosis and assesses the client for:

a. Enlargement of the breasts

b. Complaints of feeling hot when the room is cool c. Periods of fetal movement followed by quiet periods

d. Evidence of bleeding, such as in the gums, petechiae, and purpura RATIONALE: Severe preeclampsia can trigger disseminated intravascular

coagulation (DIC) because of the widespread damage to vascular integrity. Bleeding is an early sign of DIC and should be reported to the health care provider if noted on assessment. Options 1, 2, and 3 are normal occurrences in the last trimester of pregnancy.

REFERENCES: Lowdermilk, D., & Perry, A. (2004). Maternity and women’s health care

(8th ed., pp. 852, 878). St. Louis: Mosby.

1. Immediately after an amniotomy has been performed, the nurse should first assess: a. For bladder distention

b. For cervical dilation

c. The maternal blood pressure

d. The fetal heart rate (FHR) pattern

RATIONALE: The FHR is assessed immediately after amniotomy to detect any changes that may indicate cord compression or prolapse. Bladder distention or maternal blood pressure would not be the first things to check after an amniotomy. Once the membranes are ruptured, minimal vaginal examinations will be done because of the risk of infection.

REFERENCES: Lowdermilk, D., & Perry, S. (2004). Maternity and women’s health care

(8th ed., p. 1009). St. Louis: Mosby.

1. A nurse in the labor room is caring for a client in the active stage of labor. The nurse is assessing the fetal patterns and notes a late deceleration on the monitor strip. The appropriate nursing action is to:

a. Administer oxygen via face mask. b. Place the mother in a supine position.

c. Increase the rate of the oxytocin (Pitocin) IV infusion.

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RATIONALE: Late decelerations are the result of uteroplacental insufficiency as the result of decreased blood flow and oxygen to the fetus during the uterine

contractions. This causes hypoxemia; therefore, oxygen is necessary. The supine position is avoided because it decreases uterine blood flow to the fetus. The client should be turned onto her side to displace pressure of the gravid uterus on the inferior vena cava. An intravenous oxytocin infusion is discontinued when a late deceleration is noted. The oxytocin would cause further hypoxemia because of increased uteroplacental insufficiency resulting from stimulation of contractions by this medication. Option 4 would delay necessary treatment.

REFERENCES: Lowdermilk, D., & Perry, S. (2006). Maternity nursing (7th ed., p. 386). St. Louis: Mosby.

1. A nurse is performing an assessment of a client who is scheduled for a cesarean delivery. Which assessment finding would indicate a need to contact the physician? a. Hemoglobin of 11.0 g/dL

b. Fetal heart rate of 180 beats/min c. Maternal pulse rate of 85 beats/min d. White blood cell count of 12,000/mm3

RATIONALE: A normal fetal heart rate is 120 to 160 beats/min. A count of 180 beats/min could indicate fetal distress and would warrant physician notification. White blood cell counts in a normal pregnancy begin to rise in the second trimester and peak in the third trimester, with a normal range of 11,000 to 15,000/mm3 , up to 18,000/mm3. During the immediate postpartum period, the count may be as high as 25,000 to 30,000/mm3 as a result of increased leukocytosis during delivery. By full term, a normal maternal hemoglobin range is 11 to 13 g/dL as a result of the hemodilution caused by an increase in plasma volume during pregnancy. The maternal pulse rate during pregnancy increases 10 to 15 beats/min over

prepregnancy readings to facilitate increased cardiac output, oxygen transport, and kidney filtration.

REFERENCES: Lowdermilk, D., & Perry, S. (2004). Maternity and women’s health care (8th ed., pp. 356, 358, 518). St. Louis: Mosby.

1. A nurse has provided discharge instructions to a client who delivered a healthy newborn infant by cesarean delivery. Which statement, if made by the client, indicates a need for further instructions?

a. “I will begin abdominal exercises immediately.” b. “I will notify the physician if I develop a fever.”

c. “I will turn on my side and push up with my arms to get out of bed.” d. “I will lift nothing heavier than the newborn infant for at least 2 weeks.”

RATIONALE: Abdominal exercises should not start immediately following abdominal surgery, and the client should wait at least 3 to 4 weeks postoperatively to allow for healing of the incision. Options 2, 3, and 4 are appropriate instructions for the client following a cesarean delivery.

REFERENCES: Lowdermilk, D., & Perry, S. (2006). Maternity nursing (7th ed., p. 804). St. Louis: Mosby.

1. A nurse is caring for a client in labor who is receiving oxytocin (Pitocin) by

intravenous infusion to stimulate uterine contractions. Which assessment finding would indicate to the nurse that the infusion needs to be discontinued?

a. Increased urinary output

b. A fetal heart rate of 90 beats/min

c. Three contractions occurring within a 10-minute period

d. Adequate resting tone of the uterus palpated between contractions

RATIONALE: A normal fetal heart rate is 120 to 160 beats/min. Bradycardia or late or variable decelerations indicate fetal distress and the need to discontinue the oxytocin. The goal of labor augmentation is to achieve three good-quality

contractions (appropriate intensity and duration) in a 10-minute period. The uterus should return to resting tone between contractions, and there should be no evidence of fetal distress. Increased urinary output is unrelated to the use of oxytocin.

REFERENCES: McKinney, E., James, S., Murray, S., & Ashwill, J. (2005). Maternal-child nursing

(2nd ed., p. 448). St. Louis: W.B. Saunders.

1. A nurse is monitoring a client in labor. The nurse suspects umbilical cord compression if which of the following is noted on the external monitor tracing during a

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a. Late decelerations b. Early decelerations c. Short-term variability d. Variable decelerations

RATIONALE: Variable decelerations occur if the umbilical cord becomes

compressed, thus reducing blood flow between the placenta and the fetus. Early decelerations result from pressure on the fetal head during a contraction. Late decelerations are an ominous pattern in labor because they suggest uteroplacental insufficiency during a contraction. Short-term variability refers to the beat-to-beat range in the fetal heart rate.

REFERENCES: Lowdermilk, D., & Perry, S. (2006). Maternity nursing

1. A labor and delivery room nurse has just received report on four clients. The nurse should assess which client first?

a. A primiparous client in the active stage of labor

b. A multiparous client who was admitted for induction of labor

c. A client who is not contracting, but has suspected premature rupture of the membranes

d. A client who has just received an IV loading dose of magnesium sulfate to stop preterm labor

RATIONALE: Magnesium sulfate is a central nervous system (CNS) depressant and the client could experience adverse effects that includes depressed respiratory rate (below 12 breaths/min), severe hypotension, and absent deep tendon reflexes (DTRs). This client should be seen before the clients in options 1, 2, and 3 because these clients conditions represent stable ones.

REFERENCES: Lowdermilk, D., & Perry, S. (2006). Maternity nurs

ing (7th ed., p. 778). St. Louis: Mosby.

1. A nurse is reviewing the physician’s orders for a client admitted for premature rupture of the membranes. Gestational age of the fetus is determined to be 37 weeks. Which physician’s order should the nurse question?

a. Perform a vaginal examination every shift. b. Monitor maternal vital signs every 4 hours. c. Monitor fetal heart rate (FHR) continuously.

d. Administer ampicillin 1 gm as an intravenous piggyback (IVPB) every 6 hours. RATIONALE: Vaginal examinations should not be done routinely on a client with premature rupture of the membranes because of the risk of infection. The nurse would expect to administer an antibiotic, monitor maternal vital signs, and monitor the FHR.

1. Fetal distress is occurring with a laboring client. As the nurse prepares the client for a cesarean birth, what other intervention should be done?

a. Slow the intravenous (IV) flow rate.

b. Place the client in a high-Fowler’s position. c. Continue the oxytocin (Pitocin) drip if infusing.

d. Administer oxygen at 8 to 10 L/min via face mask.

RATIONALE: Oxygen is administered at 8 to 10 L/min via face mask to optimize oxygenation of the circulating blood. Option 1 is incorrect because the IV infusion should be increased to increase the maternal blood volume. Option 2 is incorrect because the client is placed in the lateral position with her legs raised to increase maternal blood volume and improve fetal perfusion. Option 3 is incorrect because the oxytocin stimulation of the uterus is discontinued if fetal heart rate patterns change for any reason.

REFERENCES: Lowdermilk, D., & Perry, S. (2006). Maternity nursing

1. A nurse in a labor room is performing a vaginal assessment on a pregnant client in labor. The nurse notes the presence of the umbilical cord protruding from the vagina. Which of the following is the initial nursing action?

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b. Place the client in Trendelenburg’s position. c. Find the closest telephone and page the physician stat.

d. Call the delivery room to notify the staff that the client will be transported immediately.

RATIONALE: When cord prolapse occurs, prompt actions are taken to relieve cord compression and increase fetal oxygenation. The client should be positioned with the hips higher than the head to shift the fetal presenting part toward the diaphragm. The nurse should push the call light to summon help, and other staff members should call the physician and notify the delivery room. If the cord is protruding from the vagina, no attempt should be made to replace it because to do so could traumatize it and further reduce blood flow. The examiner, however, may place a gloved hand into the vagina and hold the presenting part off the umbilical cord. Oxygen at 8 to 10 L/min by face mask is administered to the client to increase fetal oxygenation.

REFERENCES: Lowdermilk, D., & Perry, S. (2006).Maternity nursing (7th ed., p. 811). St. Louis: Mosby.

1. A maternity nurse is caring for a client with abruptio placentae and is monitoring the client for disseminated intravascular coagulopathy. Which assessment finding is least likely to be associated with disseminated intravascular coagulation?

a. Prolonged clotting times b. Decreased platelet count

c. Swelling of the calf of one leg

d. Petechiae, oozing from injection sites, and hematuria

RATIONALE: Disseminated intravascular coagulation (DIC) is a state of diffuse clotting in which clotting factors are consumed, leading to widespread bleeding. Platelets are decreased because they are consumed by the process, coagulation studies show no clot formation (and are thus normal to prolonged), and fibrin plugs may clog the microvasculature diffusely, rather than in an isolated area. The presence of petechiae, oozing from injection sites, and hematuria are signs associated with DIC. Swelling and pain in the calf of one leg are more likely to be associated with thrombophlebitis.

REFERENCES: Mattson, S., & Smith, J. (2004). Core curriculum for maternal-newborn nursing (4th ed., p. 838). Philadelphia: W.B. Saunders.

1. A nurse is assessing a pregnant client in the second trimester of pregnancy who was admitted to the maternity unit with a suspected diagnosis of abruptio placentae. Which of the following assessment findings would the nurse expect to note if this condition is present?

a. A soft abdomen b. Uterine tenderness c. Absence of abdominal pain

d. Painless, bright red vaginal bleeding

RATIONALE: Painless, bright red vaginal bleeding in the second or third trimester of pregnancy is a sign of placenta previa. In abruptio placentae, acute abdominal pain is present. Uterine tenderness accompanies placental abruption, especially with a central abruption and trapped blood behind the placenta. The abdomen will feel hard and board-like on palpation as the blood penetrates the myometrium and causes uterine irritability. Observation of the fetal monitor often reveals increased uterine resting tone, caused by failure of the uterus to relax in an attempt to constrict blood vessels and control bleeding.

1. A maternity nurse is preparing for the admission of a client in the third trimester of pregnancy that is experiencing vaginal bleeding and has a suspected diagnosis of placenta previa. The nurse reviews the physician’s orders and would question which order?

a. Prepare the client for an ultrasound.

b. Obtain equipment for a manual pelvic examination. c. Prepare to draw a hemoglobin and hematocrit blood sample.

d. Obtain equipment for external electronic fetal heart rate monitoring.

RATIONALE: Manual pelvic examinations are contraindicated when vaginal bleeding is apparent in the third trimester until a diagnosis is made and placenta previa is ruled out. Digital examination of the cervix can lead to maternal and fetal

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hemorrhage. A diagnosis of placenta previa is made by ultrasound. The hemoglobin and hematocrit levels are monitored, and external electronic fetal heart rate

monitoring is initiated. Electronic fetal monitoring (external) is crucial in evaluating the status of the fetus that is at risk for severe hypoxia.

REFERENCES: Lowdermilk, D., & Perry, S. (2004). Maternity and women’s health c

are (8th ed., pp. 872, 874-875). St. Louis: Mosby.

1. An ultrasound is performed on a client at term gestation that is experiencing moderate vaginal bleeding. The results of the ultrasound indicate that abruptio placentae is present. Based on these findings, the nurse would prepare the client for: a. Delivery of the fetus

b. Strict monitoring of intake and output

c. Complete bed rest for the remainder of the pregnancy

d. The need for weekly monitoring of coagulation studies until the time of delivery RATIONALE: The goal of management in abruptio placentae is to control the hemorrhage and deliver the fetus as soon as possible. Delivery is the treatment of choice if the fetus is at term gestation or if the bleeding is moderate to severe and the mother or fetus is in jeopardy. Because delivery of the fetus is necessary, options 2, 3, and 4 are incorrect regarding management of the client with abruptio placentae. REFERENCES: Lowdermilk, D., & Perry, S. (2004).

Maternity and women’s health care (8th ed., p. 877). St. Louis: Mosby.

1. A clinic nurse is performing a prenatal assessment on a pregnant client. The nurse would implement teaching related to the risk of abruptio placentae if which of the following information was obtained on assessment?

a. The client is 28 years of age. b. This is the second pregnancy.

c. The client has a history of hypertension.

d. The client performs moderate exercise on a regular daily schedule.

RATIONALE: Abruptio placentae is associated with conditions characterized by poor uteroplacental circulation, such as hypertension, smoking, and alcohol or cocaine abuse. The condition also is associated with physical and mechanical factors, such as overdistention of the uterus, which occurs with multiple gestation or polyhydramnios. In addition, a short umbilical cord, physical trauma, and increased maternal age and parity are risk factors.

REFERENCES: Wong, D., Perry, S., Hockenberry, M., et al. (2006). Maternal child nursing ca

re. (3rd ed., p. 404). St. Louis: Mosby.

1. A nurse is caring for a client who is experiencing a precipitous birth. The nurse is waiting for the physician to arrive. When the infant’s head crowns, the nurse would instruct the client to:

a. Bear down. b. Hold her breath.

c. Breathe rapidly (pant). d. Push with each contraction.

RATIONALE: During a precipitous birth, when the infant’s head crowns, the nurse instructs the client to breathe rapidly to decrease the urge to push. The client is not instructed to push or bear down. Holding the breath decreases the amount of oxygen to the mother and to the fetus.

REFERENCES: Murray, S., & McKinney, E. (2006). Foundations of maternal-newborn nursing

(4th ed., p. 706). Philadelphia: W.B. Saunders.

1. A nurse is assigned to care for a client with hypotonic uterine dysfunction and signs of a slowing labor. The nurse is reviewing the physician’s orders and would expect to note which of the following prescribed treatments for this condition?

a. Increased hydration

b. Oxytocin (Pitocin) infusion

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d. Administration of a tocolytic medication

RATIONALE: Therapeutic management for hypotonic uterine dysfunction includes oxytocin augmentation and amniotomy to stimulate a labor that slows. A cesarean birth will be performed if no progress in labor occurs. Options 1, 3, and 4 identify therapeutic measures for a client with hypertonic dysfunction.

(4th ed., p. 698-699). Philadelphia: W.B. Saunders.

1. A nurse is preparing to perform a fundal assessment on a postpartum client. The initial nursing action in performing this assessment is which of the following? a. Ask the client to turn on her side.

b. Ask the client to urinate and empty her bladder.

c. Massage the fundus gently before determining the level of the fundus. d. Ask the client to lie flat on her back with the knees and legs flat and straight. RATIONALE: Before starting the fundal assessment, the nurse should ask the client to empty her bladder so that an accurate assessment can be done. When the nurse is performing fundal assessment, the nurse asks the client to lie flat on her back with the knees flexed. Massaging the fundus is not appropriate unless the fundus is boggy or soft, and then it should be massaged gently until firm.

1. A nurse is caring for four 1-day postpartum clients. Which client has an abnormal finding that would require further intervention?

a. The client with mild afterpains

b. The client with a pulse rate of 60 beats/min

c. The client with colostrum discharge from both breasts

d. The client with lochia that is red and has a foul-smelling odor

RATIONALE: Lochia, the discharge present after birth, is red for the first 1 to 3 days and gradually decreases in amount. Normal lochia has a fleshy odor or an odor similar to menstrual flow. Foul-smelling or purulent lochia usually indicates infection, and these findings are not normal. The other options are normal findings for a 1-day postpartum client.

1. A postpartum nurse is taking the vital signs of a client who delivered a healthy newborn infant 4 hours ago. The nurse notes that the client’s temperature is 100.2° F. Which of the following actions would be appropriate?

a. Notify the physician. b. Document the findings.

c. Retake the temperature in 15 minutes.

d. Increase hydration by encouraging oral fluids.

RATIONALE: The client’s temperature should be taken every 4 hours while she is awake. Temperatures up to 100.4° F (38.0° C) in the first 24 hours after birth often are related to the dehydrating effects of labor. The appropriate action is to increase hydration by encouraging oral fluids, which should bring the temperature to a normal reading. Although the nurse also would document the findings, the appropriate action would be to increase the hydration. Contacting the physician is not necessary. Taking the temperature in another 15 minutes is not a necessary action.

(4th ed., pp. 405, 409, 419). Philadelphia: W.B. Saunders.

1. A nurse is assessing a client who is 6 hours postpartum after delivering a full-term healthy newborn infant. The client complains to the nurse of feelings of faintness and dizziness. Which of the following nursing actions would be most appropriate?

a. Elevate the client’s legs.

b. Determine hemoglobin and hematocrit levels.

c. Instruct the client to request help when getting out of bed.

d. Inform the nursery room nurse to avoid bringing the newborn infant to the client until the feelings of lightheadedness and dizziness have subsided.

RATIONALE: Orthostatic hypotension may be evident during the first 8 hours after birth. Feelings of faintness or dizziness are signs that caution the nurse to beware for

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the client’s safety. The nurse should advise the client to get help the first few times the mother gets out of bed. Option 1 is not the most appropriate or helpful action in this situation. Option 2 requires a physician’s order. Option 4 is unnecessary.

1. A postpartum nurse is providing instructions to a client after delivery of a healthy newborn infant. The nurse instructs the client that she should expect normal bowel elimination to return:

a. 3 days postpartum b. 7 days postpartum c. On the day of delivery d. Within 2 weeks postpartum

RATIONALE: After birth, the nurse should auscultate the client’s abdomen in all four quadrants to determine the return of bowel sounds. Normal bowel elimination usually returns 2 to 3 days postpartum. Surgery, anesthesia, and the use of opioids and pain control agents also contribute to the longer period of altered bowel functions. Options 2, 3, and 4 are incorrect.

1. A nurse is planning care for a postpartum client who had a vaginal delivery 2 hours ago. The client had a midline episiotomy and has several hemorrhoids. What is the priority nursing diagnosis for this client?

a. Acute pain

b. Disturbed body image c. Impaired urinary elimination d. Risk for imbalanced fluid volume

RATIONALE: The priority nursing diagnosis for a client who delivered 2 hours ago and who has a midline episiotomy and hemorrhoids is acute pain. Most clients have some degree of discomfort during the immediate postpartum period. There is no data in the question that indicate the presence of Disturbed body image, Impaired urinary elimination, Risk for imbalanced fluid volume.

1. A nurse is teaching a postpartum client about breast-feeding. Which of the following instructions should the nurse include?

a. The diet should include additional fluids. b. Prenatal vitamins should be discontinued. c. Soap should be used to cleanse the breasts.

d. Birth control measures are not necessary while breastfeeding.

RATIONALE: The diet for a breast-feeding client should include additional fluids. Prenatal vitamins should be taken as prescribed, and soap should not be used on the breast because it tends to remove natural oils, which increases the chance of cracked nipples. Breast-feeding is not a method of contraception, so birth control measures should be resumed.

REFERENCES: Wong, D., Perry, S., Hockenberry, M., et al. (2006). Maternal child nursing care

(3rd ed., p. 781). St. Louis: Mosby.

1. A postpartum client is diagnosed with cystitis. The nurse plans for which priority nursing intervention in the care of the client?

a. Providing sitz baths

b. Encouraging fluid intake c. Placing ice on the perineum

d. Monitoring hemoglobin and hematocrit levels

RATIONALE: Cystitis is an infection of the bladder. The client should consume 3000 mL of fluids per day. Sitz baths and ice would be appropriate interventions for perineal discomfort. Hemoglobin and hematocrit levels would be monitored with hemorrhage.

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1. A nurse is monitoring a postpartum client who received epidural anesthesia for the presence of a vulvar hematoma. Which of the following assessment findings would best indicate the presence of a hematoma?

a. Changes in vital signs b. Signs of heavy bruising c. Complaints of intense pain

d. Complaints of a tearing sensation

RATIONALE: Because the client has had epidural anesthesia and is anesthetized, she cannot feel pain, pressure, or a tearing sensation. Changes in vital signs indicate hypovolemia in the anesthetized postpartum woman with vulvar hematoma. Option 2 (heavy bruising) may be visualized, but vital sign changes indicate hematoma caused by blood collection in the perineal tissues.

Use the process of elimination, noting the strategic words epidural anesthesia. With this in mind, eliminate options 3 and 4. From the remaining options, use the ABCs— airway, breathing, and circulation—to direct you to option 1. Review the signs of a vulvar hematoma in a client who had epidural anesthesia if you had difficulty with this question.

1. A nurse is providing instructions about measures to prevent postpartum mastitis to a client who is breast-feeding her newborn. Which of the following, if stated by the client, would indicate a need for further instructions?

a. “I should breast-feed every 2 to 3 hours.” b. “I should change the breast pads frequently.”

c. “I should wash my hands well before breast-feeding.”

d. “I should wash my nipples daily with soap and water.”

RATIONALE: Mastitis generally is caused by an organism that enters through an injured area of the nipples, such as a crack or blister. Measures to prevent the development of mastitis include changing nursing pads when they are wet and avoiding continuous pressure on the breasts. Soap is drying and could lead to

cracking of the nipples, and the mother should be instructed to avoid the use of soap on the nipples during breast-feeding. The mother is taught about the importance of hand washing and that she should breast-feed every 2 to 3 hours.

REFERENCES: Murray, S., & Gorrie, T. (2006). Foundations of maternal-newborn nursing (4th ed., p. 750). Philadelphia: W.B. Saunders.

1. A client in the postpartum care unit who is recovering from disseminated

intravascular coagulopathy is to be discharged on low dosages of an anticoagulant medication. In developing home care instructions for this client, the nurse includes which priority safety instruction regarding this medication?

a. Avoid all activities because bruising injuries can occur. b. Avoid walking long distances and climbing stairs. c. Avoid taking acetylsalicylic acid (aspirin). d. Avoid brushing the teeth.

RATIONALE: Aspirin can interact with the anticoagulant medication to increase clotting time beyond therapeutic ranges. Avoiding aspirin is a priority. Not all activities need to be avoided. Walking and climbing stairs are acceptable activities. The client does not need to avoid brushing the teeth; however, the client should be instructed to use a soft toothbrush.

REFERENCES: Kee, J., Hayes, E., & McCuistion, L. (2006). Pharmacology: A nursing process approach

1. The uterus returns to the pelvic cavity in which time frame? a. 7 to 9 days postpartum

b. 2 weeks postpartum c. 6 weeks postpartum

d. When the lochia changes to alba

RATIONALE: The normal involutional process returns the uterus to the pelvic cavity in 7 to 9 days. A significant involutional complication is the failure of the uterus to return to the pelvic cavity within the ordered time period. This is known as

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REFERENCE: Pillitteri, A. Maternal & Child Health Nursing: Care of the

Childbearing and Childrearing Family, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 628.

2. A postpartum client asks the nurse about the rhythm (symptothermal) method of family planning. The nurse explains that this method involves:

a. using chemical barriers that act as spermicidal agents. b. using hormones that prevent ovulation.

c. using mechanical barriers that prevent sperm from reaching the cervix. d. determining the fertile period to identify safe times for sexual intercourse.

RATIONALE: The symptothermal method of family planning combines basal body temperature measurement with analysis of cervical mucus changes to determine the fertile period more accurately and thus identify safe and unsafe periods for sexual intercourse. A natural family planning method, it doesn't involve use of chemical barriers, hormones, or mechanical barriers. REFERENCE: Pillitteri, A. Maternal & Child Health Nursing: Care of the Childbearing and Childrearing Family, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 109.

3. A nurse is preparing to perform a postpartum assessment on a client who gave birth 5 hours ago. Which precaution should the nurse plan to take for this procedure? a. washing the hands

b. washing the hands and wearing latex gloves

c. washing the hands and wearing latex gloves and a barrier gown

d. washing the hands and wearing latex gloves, a barrier gown, and protective eyewear

RATIONALE: During a postpartum assessment, the nurse is likely to come into contact with the client's blood or body fluids, especially when examining the perineal region. Therefore, the nurse must wear latex gloves; hand washing alone would neither provide adequate protection nor comply with universal precautions. The nurse should wear a barrier gown and protective eyewear in addition to latex gloves only when anticipating splashing of blood or body fluids such as during childbirth. Splashing isn't likely to occur during a postpartum assessment.

REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 531.

4. A nurse in a prenatal clinic is assessing a client who's 24 weeks pregnant. Which findings lead this nurse to suspect that the client has mild preeclampsia?

a. Glycosuria, hypertension, seizures

b. Hematuria, blurry vision, reduced urine output c. Burning on urination, hypotension, abdominal pain d. Hypertension, edema, proteinuria

RATIONALE: The typical findings of mild preeclampsia are hypertension, edema, and proteinuria. Abdominal pain, blurry vision, and reduced urine output are signs of severe preeclampsia. Seizures are a sign of eclampsia. The other findings aren't typically found in women with preeclampsia.

5. On her second visit to the prenatal facility, a client states, "I guess I really am pregnant. I've missed two periods now." Based on this statement, the nurse

determines that the client has accomplished which psychological task of pregnancy? a. Identifying the fetus as a separate being

b. Assuming caretaking responsibility for the neonate c. Preparing to relinquish the neonate through labor d. Accepting the biological fact of pregnancy

RATIONALE: The first maternal psychological task of pregnancy is to accept the pregnancy as a biological fact. If the client doesn't accept that she's pregnant, she's unlikely to seek prenatal care. Identifying the fetus as a separate being usually occurs after the client feels fetal movements. Assuming caretaking responsibility for the neonate should occur during the postpartum period. Preparing to relinquish the neonate through labor normally occurs during the third trimester.

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6. On the second postpartum day a gravida 6, para 5 complains of intermittent abdominal cramping. The nurse should assess for:

a. endometritis.

b. postpartum hemorrhage. c. subinvolution.

d. afterpains.

RATIONALE: In a multiparous client, decreased uterine muscle tone causes alternating relaxation and contraction during uterine involution, which leads to afterpains. The client's symptoms don't suggest endometritis, hemorrhage, or subinvolution.

7. A client is 8 weeks pregnant. Which teaching topic is most appropriate at this time? a. Breathing techniques during labor

b. Common discomforts of pregnancy c. Infant care responsibilities?

d. Neonatal nutrition

RATIONALE: During the first trimester, a pregnant client is most concerned with her own needs. Because she's likely to experience discomforts of pregnancy, such as morning sickness, fatigue, and urinary frequency, the nurse should teach her how to relieve these discomforts. The nurse should teach labor breathing techniques during the second half of the pregnancy, when the client is most strongly motivated to learn them. The postpartum period is the best time to teach about infant care

responsibilities and neonatal nutrition if the client didn't attend prenatal classes. Otherwise, infant care is taught during the third trimester and reinforced in the postpartum period.

8. Certain drugs used during the postpartum period may affect blood pressure. Which drug decreases a postpartum client's blood pressure?

a. Oxytocin (Pitocin) b. Codeine phosphate

c. Ergonovine (Ergotrate Maleate) d. Methylergonovine (Methergine)

RATIONALE: Codeine phosphate, given to relieve postpartum pain, may cause a decrease in blood pressure. Oxytocin reduces postpartum bleeding after expulsion of the placenta and may cause hypertension. Ergonovine and methylergonovine

prevent or treat postpartum hemorrhage from uterine atony or subinvolution and may cause an increase in blood pressure. REFERENCE: Pillitteri, A. Maternal & Child Health Nursing: Care of the Childbearing and Childrearing Family, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 639.

9. During the first 3 months, which hormone is responsible for maintaining pregnancy? a. Human chorionic gonadotropin (hCG)

b. Progesterone c. Estrogen d. Relaxin

RATIONALE: The hormone hCG is responsible for maintaining the pregnancy until the placenta is in place and functioning. Serial hCG levels are used to determine the status of the pregnancy in clients with complications. Progesterone and estrogen are important hormones responsible for many of the body's changes during pregnancy. Relaxin is an ovarian hormone that causes the mother to feel tired, thus promoting her to seek rest.

10. A nurse coming onto the night shift assesses a client who gave birth vaginally that morning. The nurse finds that the client's vaginal bleeding has saturated two perineal pads within 30 minutes. What is the first action the nurse should take?

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a. Ask the client to get out of bed and try to urinate.

b. Call the physician for a methylergonovine (Methergine) order. c. Assess the fundus and massage it if it's boggy.

d. Give the client a new pad and check her in 30 minutes.

RATIONALE: The nurse should first assess the fundus to determine if clots are present or if uterine involution has occurred. Clots, no uterine involution, and the saturation of two perineal pads within 30 minutes could indicate postpartum hemorrhage. If the fundus is boggy, massaging it will suppress bleeding by encouraging the uterus to contract upon itself and the open vessels that were attached to the placenta. Massaging also helps to expel clots or tissue remaining from the birth. If the nurse assesses a firm fundus, she should next assess for a full bladder and then ask the client to try to urinate. If the uterus remains boggy after massage, the nurse should obtain an order from the physician for methylergonovine. Waiting 30 minutes without intervening could contribute to uterine hemorrhage. REFERENCE: Pillitteri, A. Maternal & Child Health Nursing: Care of the

11.A client in labor is receiving oxytocin (Pitocin). The electronic fetal monitoring strip shows contractions occurring every 30 seconds to 2 minutes, with an intensity of 90 mm Hg and increasing resting tone. How should the nurse respond to these findings? a. Administer oxygen as ordered.

b. Call the physician.

c. Check the fetal heart rate (FHR). d. Discontinue the oxytocin infusion.

RATIONALE: Oxytocin should be discontinued when contractions occur less than 2 minutes apart or last longer than 90 seconds. The nurse can stop oxytocin infusion independently without seeking permission from the physician - an action that would waste valuable time. This client isn't oxygen deprived and, therefore, doesn't need supplemental oxygen. Checking the FHR isn't appropriate in this situation because the decelerations occur and resolve with each contraction, independent of oxytocin administration.

REFERENCE: Ricci, S.S. Essentials of Maternity, Newborn, and Women’s Health Nursing. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 599.

12. When assessing the fetal heart rate tracing, a nurse assesses the fetal heart rate at 170 beats/minute. This rate is considered fetal tachycardia if:

a. the fetal heart rate remains at greater than 160 beats/minute for 5 minutes. b. the fetal heart rate remains at greater than 160 beats/minute for 10 minutes.

c. the fetal heart rate remains at greater than 160 beats/minute for more than 20 minutes.

d. the fetal heart rate is at least 170 beats/minute at any time.

RATIONALE: The normal parameter for the fetal heart rate is 120 to 160

beats/minute. Fetal tachycardia is defined as a fetal heart rate greater than 160 beats/minute for more than 10 minutes. This definition takes into account the difference between tachycardia and acceleration. REFERENCE: Pillitteri, A. Maternal & Child Health Nursing: Care of the Childbearing and Childrearing Family, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 525. 13. A client asks about complementary therapies for relief of discomforts related to

pregnancy. Which comfort measure mentioned by the client indicates a need for further teaching?

a. Meditation b. Music therapy c. Acupuncture d. Herbal remedies

RATIONALE: A pregnant woman should avoid all medication unless her physician instructs her to use it. This includes herbal remedies because their effects on the fetus haven't been identified. Meditation, music therapy, and acupuncture have all proven to enhance relaxation without harm to the mother or baby.

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a. Supporting the mother's ability to successfully feed and care for her neonate

b. Involving the family in the teaching

c. Providing group discussions on neonatal care

RATIONALE: Most of the nursing interventions during the postpartum period are directed toward helping the mother successfully adapt to the parenting role. Although family involvement in teaching, group discussions on neonatal care, and lochia monitoring are important aspects of care, the mother's ability to feed and care for her neonate takes priority.

15. A client has her first prenatal visit at 15 weeks' gestation. Which finding requires further investigation?

a. Fundal height of 18 cm

b. Blood pressure of 124/72 mm Hg c. Urine negative for protein

d. Weight of 144 lb (65.kg)

RATIONALE: Fundal height (in centimeters) should equal the number of weeks' gestation. This client should have a fundal height of 15 to 16 cm. The blood pressure, urine, and weight findings are within normal limits for this client.

16. A client who gave birth 24 hours ago continues to experience urine retention after several catheterizations. The physician orders bethanechol (Urecholine), 10 mg by mouth three times per day. The client asks, "How does bethanechol act on the bladder ?" How should the nurse respond?

a. “It constricts the urinary sphincter.” b. "It dilates the urethra.”

c. “It stimulates the smooth muscle of the bladder.” d. “It inhibits the skeletal muscle of the bladder.”

RATIONALE: Bethanechol stimulates the smooth muscle of the bladder, causing it to release retained urine. Bethanechol doesn't act on the urinary sphincter or dilate the urethra. The bladder contains smooth muscle, not skeletal muscle.

REFERENCE: Springhouse Nurse’s Drug Guide 2007 Philadelphia: Lippincott Williams & Wilkins, 2007, p. 215.

17. A client is using the rhythm (calendar-basal body temperature) method of family planning. In this method, the unsafe period for sexual intercourse is indicated by: a. return to preovulatory basal body temperature.

b. basal body temperature increase of 0.1° F to 0.2° F (0.06° C to 0.11° C) on the 2nd or 3rd day of the cycle. c. 3 full days of elevated basal body temperature and clear, thin cervical mucus.

d. breast tenderness and mittelschmerz

RATIONALE: Ovulation (the period when pregnancy can occur) is accompanied by a basal body temperature increase of 0.7F to 0.8F (0.39C to 0.44 C) and clear, thin cervical mucus. A return to the preovulatory body temperature indicates a safe period for sexual intercourse. A slight rise in basal temperature early in the cycle isn't significant. Breast tenderness and mittelschmerz aren't reliable indicators of

ovulation.

18. A pregnant client comes to the facility for her first prenatal visit. After obtaining her health history and performing a physical examination, the nurse reviews the client's laboratory test results. Which findings suggest iron deficiency anemia?

a. Hemoglobin (Hb) 15 g/L; hematocrit (HCT) 35% b. Hb 13 g/L; HCT 32%

c. Hb 10 g/L; HCT 35% d. Hb 9 g/L; HCT 30%

RATIONALE: With iron deficiency anemia, the Hb level is below 12 g/L and HCT drops below 33%.

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19. A client who's breast-feeding has a temperature of 102° F (38.9° C) and complains that her breasts are engorged. Her breasts are swollen, hard, and red. Which action by the client requires intervention?

a. Applying frozen cabbage leaves to the breasts b. Showering with her back to the water

c. nursing her baby frequently

d. Applying a breast binder to support the breasts

RATIONALE: Engorgement in a breast-feeding woman requires careful management to preserve the milk supply while managing the increased blood flow to the breasts. Binding the breasts isn't appropriate because the constriction will diminish the milk supply. Frozen cabbage leaves work well to reduce the pain and swelling and should be applied every 4 hours. Facing the shower head can stimulate the breasts and intensify the problem. Frequent feedings will permit the breasts to empty fully and establish the supply-demand cycle that is appropriate for the infant. REFERENCE: Ricci, S.S. Essentials of Maternity, Newborn, and Women’s Health Nursing. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 414.

20. A client in the 13th week of pregnancy develops hyperemesis gravidarum. Which laboratory finding indicates the need for intervention?

a. Urine specific gravity 1.010 b. Serum potassium 4 mEq/L c. Serum sodium 140 mEq/L d. Ketones in the urine

RATIONALE: Ketones in the urine of a client with hyperemesis gravidarum indicate that the body is breaking down stores of fat and protein to provide for growth needs. A urine specific gravity of 1.010, a serum potassium level of 4 mEq/L, and a serum sodium level of 140 mEq/L are all within normal limits.

21. During the sixth month of pregnancy, a client reports intermittent earaches and a constant feeling of fullness in the ears. What is the most likely cause of these symptoms?

a. A serious neurologic disorder

b. Eustachian tube vascularization c. Increasing progesterone levels d. An ear infection

RATIONALE: During pregnancy, increasing levels of estrogen — not

progesterone — cause vascularization of the eustachian tubes, leading to such problems as earaches, impaired hearing, and a constant feeling of fullness in the ears. The client's symptoms don't suggest a serious neurologic disorder or an ear infection.

REFERENCE: Ricci, S.S. Essentials of Maternity, Newborn, and Women’s Health Nursing. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 245.

22. A client says she wants to practice natural family planning. The nurse teaches her how to use the calendar method to determine when she's fertile and advises her to avoid unprotected intercourse. When teaching her how to determine her fertile period , the nurse should instruct her to:

a. abstain from unprotected intercourse between days 14 and 16 of the menstrual cycle.

b. subtract 11 days from her shortest menstrual cycle and 18 days from her longest cycle.

c. subtract 18 days from her shortest menstrual cycle and 11 days from her longest cycle.

d. add 25 days to the first day of her last menstrual period and abstain from unprotected intercourse for the next 5 days.

RATIONALE: To determine the fertile period, the client should subtract 18 days from her shortest menstrual cycle and 11 days from her longest cycle; if she doesn't wish to become pregnant, she should abstain from unprotected intercourse between the days calculated. For example, if her menstrual cycles range from 28 to 30 days, her