Chapter 18: Problems in Pregnancy and Childbearing

Question 1

A 30-year-old woman with type 1 diabetes mellitus comes to the clinic for preconception care. What is the priority education for her at this time?

1. Her insulin requirements will likely increase during the second and third trimesters of pregnancy.
2. Infants of mothers with diabetes can be macrosomic, which can result in more difficult delivery and higher likelihood of cesarean section.
3. Breast feeding is highly recommended, and insulin use is not a contraindication.
4. Achievement of optimal glycemic control at this time is of utmost importance in preventing congenital anomalies.

Answer 1

Ans: 4
The incidence of congenital anomalies is three times higher in the offspring of women with diabetes. Good glycemic control during preconception and early pregnancy significantly reduces this risk and would be the highest priority message to this patient at this point. The other responses are correct but are not of greatest importance at this time. Focus: Prioritization.

Question 2

Which task could be appropriately delegated to the unlicensed assistive personnel (UAP) working with the nurse at the obstetric clinic?

1. Checking the blood pressure of a patient who is 36 weeks’ pregnant and reports a headache
2. Removing the adhesive skin closure strips of a patient who had a cesarean section 2 weeks ago
3. Giving community resource information and emergency numbers to a prenatal patient who may be experiencing domestic violence
4. Dispensing a breast pump with instruction to a lactating patient having trouble with milk supply 4 weeks postpartum

Answer 2

Ans: 1
The UAP can check the blood pressure of this patient and report it to the RN. The RN would include this information in her full assessment of the patient, who may be showing signs of preeclampsia. The other tasks listed require nursing assessment, analysis, and planning and should be performed by the RN. Provision of accurate and supportive education about breast feeding and breast pumping supports the Perinatal Core Measure of increasing the percentage of women who exclusively breast-feed. Focus: Delegation.

Question 3

Several patients have just come into the obstetric triage unit. Which patient should the nurse assess first?

1. A 17-year-old gravida 1, para 0 (G1P0) woman at 40 weeks’ gestation with contractions every 6 minutes who is crying loudly and is surrounded by anxious family members
2. A 22-year-old G3P2 woman at 38 weeks’ gestation with contractions every 3 minutes who is requesting to go to the bathroom to have a bowel movement
3. A 32-year-old G4P3 woman at 27 weeks’ gestation who noted vaginal bleeding today after intercourse
4. A 27-year-old G2P1 woman at 37 weeks’ gestation who experienced spontaneous rupture of membranes 30 minutes ago but feels no contractions

Answer 3

Ans: 2
A multiparous patient in active labor with an urge to have a bowel movement will probably give birth imminently. She needs to be the first assessed, the health care provider must be notified immediately, and she must be moved to a safe location for the birth. She should not be allowed up to the bathroom at this time. The other patients all have needs requiring prompt assessment, but the imminent birth takes priority. Vaginal bleeding after intercourse could be caused by cervical irritation or a vaginal infection or could have a more serious cause such as placenta previa. This patient should be the second one assessed. Focus: Prioritization.

Question 4

A 19-year-old gravida 1, para 0 patient at 40 weeks’ gestation who is in labor is being treated with magnesium sulfate for seizure prophylaxis in preeclampsia. Which are priority assessments with this medication? Select all that apply.

1. Check deep tendon reflexes.
2. Observe for vaginal bleeding.
3. Check the respiratory rate.
4. Note the urine output.
5. Monitor for calf pain.

Answer 4

Ans: 1, 3, 4
Magnesium sulfate toxicity can cause fatal cardiovascular events or respiratory depression or arrest, so monitoring of respiratory rate is of utmost importance. The drug is excreted by the kidneys, and therefore monitoring for adequate urine output is essential. Deep tendon reflexes disappear when serum magnesium is reaching a toxic level. Vaginal bleeding is not associated with magnesium sulfate use. Calf pain can be a sign of a deep vein thrombosis but is not associated with magnesium sulfate therapy. Focus: Prioritization.

Question 5

Which action would best demonstrate evidence-based nursing practice in the care of a patient who is 1 day postpartum and reporting nipple soreness while breast feeding?

1. Give the baby a bottle after 5 minutes of nursing to allow soreness to resolve.
2. Assess the mother–baby couplet for nursing position and latch and correct as indicated.
3. Advise the use of a breast pump until nipple soreness resolves.
4. Advise alternating breast and bottle feedings to avoid excess sucking at the nipple.

Answer 5

Ans: 2
It is recommended to avoid artificial nipples and pacifiers while establishing breast feeding unless medically indicated. Improper latch and position are common causes of nipple soreness and can be corrected with assessment and assistance to the mother. This practice supports the Perinatal Core Measure of increasing the percentage of newborns who are fed breast milk only. Focus: Prioritization.

Question 6

A 24-year-old gravida 2, para 1 woman is being admitted in active labor at 39 weeks’ gestation. What prenatal data would be most important for the nurse to address at this time?

1. Hemoglobin level of 11 g/dL (110 g/L) at 28 weeks’ gestation
2. Positive result on test for group B streptococci at 36 weeks’ gestation
3. Urinary tract infection with Escherichia coli treated at 20 weeks’ gestation
4. Elevated level on glucose screening test at 28 weeks’ gestation followed by normal 3-hour glucose tolerance test results at 29 weeks’ gestation

Answer 6

Ans: 2
The positive group B streptococci result requires immediate action. The health care provider must be notified and orders obtained for prompt antibiotic prophylaxis during labor to reduce the risk of mother-to-newborn transmission of group B streptococci. The other data are not as significant in the care of the patient at this moment. Intrapartum-appropriate antibiotic treatment of the mother with group B streptococci supports the Perinatal Core Measure of reducing health care–acquired bloodstream infections in newborns. Focus: Prioritization.

Question 7

The telephone triage nurse in the prenatal clinic receives the following calls. Which telephone call would require immediate notification of the health care provider?

1. Patient reports leaking vaginal fluid at 34 weeks’ gestation.
2. Patient reports nausea and vomiting at 8 weeks’ gestation.
3. Patient reports pedal edema at 39 weeks’ gestation.
4. Patient reports vaginal itching at 20 weeks’ gestation.

Answer 7

Ans: 1
Leaking vaginal fluid at 34 weeks’ gestation requires immediate attention because it could indicate premature rupture of membranes with the risk of premature birth. An RN in a prenatal clinic can safely give telephone advice regarding nausea, vomiting, and pedal edema, which can be considered normal in pregnancy. The RN would assess the complaint, give the patient evidence-based advice, and define the circumstances under which the patient should call back. Vaginal itching at 20 weeks could be a yeast infection. Depending on clinic protocols, the RN could, after phone assessment, safely recommend an over-the-counter medication or arrange an office visit for the patient. Focus: Prioritization.

Question 8

The nurse in the labor and delivery unit is caring for a 25-year-old gravida 3, para 2 patient in active labor. The nurse has identified late fetal heart decelerations and decreased variability in the fetal heart rate and notified the health care provider (HCP) on call, who thinks that the pattern is acceptable. What would be the priority action at this time?

1. Advise the patient that a different HCP will be called because the first HCP’s response was not adequate.
2. Discuss the concerns with another labor and delivery nurse.
3. Document the conversation with the HCP accurately, including the HCP’s interpretation and recommendation, and continue close observation of the fetal heart rate.
4. Go up the chain of command and communicate the assessment of the fetal heart rate findings clearly to the next appropriate HCP.

Answer 8

Ans: 4
The RN must follow through on the findings of a nonreassuring fetal heart rate. When patient safety is concerned, the nurse is obligated to pursue an appropriate response. Documenting the conversation with the HCP and discussing it with a colleague are appropriate, but something must be done to address the immediate safety concern and possible need for intervention at this time. The RN must persist until the safety concern has been addressed appropriately. Focus: Prioritization.

Question 9

What would be the appropriate first nursing action when caring for a 20- year-old gravida 1, para 0 woman at 39 weeks’ gestation who is in active labor and for whom an assessment reveals mild variable fetal heart rate decelerations?

1. Change the maternal position.
2. Notify the provider.
3. Prepare for delivery.
4. Readjust the fetal monitor.

Answer 9

Ans: 1
The cause of variable fetal heart decelerations is compression of the umbilical cord, which can often be corrected by a change in maternal position. Focus: Prioritization.

Question 10

A 24-year-old gravida 1, para 0 patient, who is receiving oxytocin, is in labor at 41 weeks gestation. Which are appropriate nursing actions in the presence of late fetal heart rate decelerations? Select all that apply.

1. Discontinue the oxytocin.
2. Decrease the maintenance IV fluid rate.
3. Administer oxygen to the mother by mask.
4. Place the woman in high Fowler position.
5. Notify the health care provider.

Answer 10

Ans: 1, 3, 5
Late fetal heart rate decelerations can be an ominous sign of fetal hypoxemia, especially if repetitive and accompanied by decreased variability. Notification of the health care provider is indicated. Turning off the oxytocin and administering oxygen to the mother are recommended nursing interventions to improve fetal oxygenation. An increase in the IV rate can improve hydration, correct hypovolemia, and increase blood flow to the uterus. Putting the woman in a lateral position can increase blood flow to the uterus and increase oxygenation to the fetus. Promptly addressing fetal heart rate changes may allow intrauterine resuscitation and may decrease the need for cesarean section if those measures are effective. This supports the Perinatal Core Measure of reducing of cesarean section rates. Focus: Prioritization.

Question 11

A pregnant woman at 12 weeks’ gestation tells the nurse that she is a vegetarian. What would be the first appropriate nursing action?

1. Recommend vitamin B12 and iron supplementation.
2. Recommend consumption of protein drinks daily.
3. Obtain a 24-hour diet recall history.
4. Determine the reason for her vegetarian diet.

Answer 11

Ans: 3
The care of a vegetarian woman who is pregnant should begin with assessment of her diet, because vegetarian practices vary widely. The RN must first assess exactly what the woman’s diet consists of and then determine any deficiencies. The reason for the diet is less important than what the diet actually contains. It is probable that the woman will need a vitamin B12 supplement, but the assessment comes first. Vegetarian diets can be completely adequate in protein, and therefore protein supplementation is not routinely recommended. Focus: Prioritization.

Question 12

A 26-year-old gravida 1, para 1 patient who underwent cesarean section 24 hours ago tells the nurse that she is having some trouble breast feeding. Which tasks could be appropriately delegated to the unlicensed assistive personnel (UAP) on the postpartum floor? Select all that apply.

1. Providing the mother with an ordered abdominal binder 2. Assisting the mother with breast feeding
2. Taking the mother’s vital signs
3. Checking the amount of lochia present
4. Assisting the mother with ambulation

Answer 12

Ans: 1, 3, 5
The UAP could provide an abdominal binder, measure the vital signs of the patient, and assist her to ambulate. The RN would be responsible for evaluating the normality of the vital sign values. The UAP should be given parameter limits for vital signs and told to report values outside these limits to the RN. Assisting in breast feeding for a first-time mother is a very important nursing function because the RN needs to give consistent, evidence-based advice to enhance success at breast feeding. A common complaint of postpartum patients is inconsistent help with and advice on breast feeding. The RN should also be the one to check the amount of lochia because the evaluation requires nursing judgment. The use of the professionally educated RN to provide evidence-based and consistent information and assistance with breast feeding supports the Perinatal Core Measure of increasing the percentage of newborns who are fed breast milk only. Focus: Delegation.

Question 13

Which action by a newly graduated RN during a delivery complicated by shoulder dystocia would require immediate correction by the nurse who is orienting her?

1. Applying fundal pressure
2. Applying suprapubic pressure
3. Requesting immediate presence of the neonatologist
4. Flexing the maternal legs back across the maternal abdomen

Answer 13

Ans: 1
Fundal pressure should never be applied in a case of shoulder dystocia because it may worsen the problem by impacting the fetal shoulder even more firmly into the symphysis pubis. This issue of patient safety would require the supervising RN to intervene immediately. The other responses are appropriate actions in a case of shoulder dystocia. Focus: Supervision, Prioritization.

Question 14

Which statements by a new father indicate that additional discharge teaching is needed for this family, who had their first baby 24 hours ago? Select all that apply.

1. “We have a crib ready for our baby with lots of stuffed animals and two quilts that my mother made.”
2. “My wife wants to receive the flu shot before she goes home.”
3. “We will bring our baby to the pediatrician in 3 weeks.”
4. “I will give the baby formula at night so my wife can rest. She will breast feed in the daytime.”
5. “We will always put our baby to sleep in a face-up position.”

Answer 14

Ans: 1, 3, 4
It is recommended that a newborn be placed on the back in a crib with a firm mattress with no toys and a minimum of blankets as a safety measure for prevention of sudden infant death syndrome. A newborn discharged before 72 hours of life should be seen by an RN or health care provider within 2 days of discharge. Breast-feeding women should breast- feed at all feedings, especially in these early weeks of establishing breast feeding. This supports the Perinatal Core Measure of increasing the percentage of newborns who are fed breast milk only. A more appropriate response would be for the father to help with household chores to allow breast feeding to be established successfully. A flu shot in flu season is a recommended intervention for a new mother. Focus: Prioritization.

Question 15

The charge nurse in the labor and delivery unit needs to assign two patients to one of the RNs because of a staffing shortage. Normally the unit has nurse- patient ratio of 1:1. Which two patients should the charge nurse assign to the RN?

1. A 30-year-old gravida 1, para 0 (G1P0) woman, 40 weeks, 2 cm/90% effaced/–1 station
2. A 25-year-old G3P2 woman, 38 weeks, 8 cm/100% effaced/0 station
3. A 26-year-old G1P1 woman who delivered via normal vaginal delivery 15 minutes ago
4. A 17-year-old G1P0 woman with premature rupture of membranes, no labor at 35 weeks
5. A 40-year-old G6P5 woman with contractions at 28 weeks who has not yet been evaluated by the health care provider

Answer 15

Ans: 1, 4
Patient 1 is in the latent phase of labor with her first child; she typically will cope well at this point and will have many hours before labor becomes more active. Patient 4 would most likely be managed expectantly at this point and require observation and assessment for labor or signs of infection. Patient 2 can be expected to deliver soon and so requires intensive nursing care. Patient 3 is in the first hour of recovery and therefore requires frequent assessments, newborn assessments, and help with initiation of breast feeding if this is her chosen feeding method. Breast feeding in the first hour of the baby’s life supports the Perinatal Core Measure of increasing the percentage of newborns who are fed breast milk only. Patient 5 could be in premature labor and require administration of tocolytic medications to stop contractions or preparation for a preterm delivery if dilation is advanced. Focus: Assignment.

Question 16

While assessing a 29-year-old gravida 2, para 2 patient who had a normal spontaneous vaginal delivery 30 minutes ago, the nurse notes a large amount of red vaginal bleeding. What would be the first priority nursing action?

1. Check vital signs.
2. Notify the health care provider.
3. Firmly massage the uterine fundus.
4. Put the baby to breast.

Answer 16

Ans: 3
Fundal massage would be the priority nursing action because it helps the uterus to contract firmly and thus reduces bleeding. The first two answer choices are appropriate nursing actions but do nothing to stop the immediate bleeding. Putting the baby to the breast does release oxytocin, which causes uterine contraction, but it will be slower to do so than fundal massage. Focus: Prioritization.

Question 17

A 30-year-old gravida 1, para 0 woman at 39 weeks’ gestation experienced a fetal demise and has just delivered a female infant. Her husband is at the bedside. Which are appropriate nursing actions at this time? Select all that apply.

1. Offer the option of autopsy to the parents.
2. Stay with the parents and offer supportive care.
3. Place the infant on the maternal abdomen.
4. Clean and wrap the baby and offer the infant to the parents to view or hold when desired.
5. Ask the parents if there are any special rituals in their religion or culture for a baby who has died that they would like to have done.

Answer 17

Ans: 2, 4, 5
Staying with the parents at this moment and offering physical and emotional support are appropriate. It is also appropriate to prepare the infant in a way that demonstrates care and respect for the baby and to offer the parents the opportunity to view and hold the infant as they desire. The RN must ask the parents if there are cultural or religious rituals they would like for their child to ensure that they feel that their infant has been treated properly with respect to their religion or culture. Autopsy should be discussed but not at the very moments after birth. The infant should not be placed on the maternal abdomen until the nurse assesses the parents’ wishes of when and how to view the infant. Focus: Prioritization.

Question 18

A 27-year-old patient underwent a primary cesarean section because of breech presentation 24 hours ago. Which assessment finding would be of the most concern?

1. Small amount of lochia rubra
2. Temperature of 99°F (37.2°C)
3. Slight redness of the left calf
4. Pain rated as 3 of 10 in the incisional area

Answer 18

Ans: 3
Slight redness in the left calf could be suggestive of thrombophlebitis and requires further investigation. The other findings are within normal limits. Focus: Prioritization.

Question 19

A 22-year-old gravida 1, para 0 woman is being given an epidural anesthetic for pain control during labor and birth. Which are appropriate nursing actions when epidural anesthesia is used during labor? Select all that apply.

1. Request the anesthesiologist to discontinue the epidural anesthetic when the patient’s cervix is completely dilated to allow the patient to sense the urge to push.
2. Insert an indwelling catheter because the woman is likely to be unable to void.
3. Encourage pushing efforts when the cervix is completely dilated in the absence of an urge to push.
4. Encourage the patient to turn from side to side during the course of labor.
5. Teach the patient that pain relief can be expected to last 1 to 2 hours.

Answer 19

Ans: 2, 4
Insertion of an indwelling catheter is indicated because the woman will usually be unable to void because of the effect of the anesthetic in the bladder area. Positioning the patient on her side enhances blood flow and helps to prevent hypotension. Changing maternal position encourages progress in labor. In management of the second stage of labor when epidural anesthesia is used, laboring down as opposed to immediately pushing without the urge to push is advocated. It is not recommended to routinely discontinue an epidural anesthetic at complete dilation. A continuous epidural infusion provides pain relief throughout labor and birth. Use of evidence-based practices with a laboring woman supports the Perinatal Core Measure of reducing the percentage of women who are delivered by cesarean section. Focus: Prioritization.

Question 20

A 36-year-old gravida 1, para 0 patient has received an epidural anesthetic. Her cervix is 6 cm dilated. Her blood pressure is currently 60/38 mm Hg. Which would be appropriate priority nursing actions? Select all that apply.

1. Place the patient in high Fowler position.
2. Turn the patient to a lateral position.
3. Notify the anesthesiologist.
4. Prepare for emergency cesarean section.
5. Decrease the IV fluid rate.

Answer 20

Ans: 2, 3
The patient may be experiencing supine hypotension caused by the pressure of the uterus on the vena cava and the effects of epidural medication. Maternal hypotension can cause uteroplacental insufficiency, leading to fetal hypoxia. Placing the woman in lateral position can relieve the pressure on the vena cava. The anesthesiologist should be notified and may need to treat the patient with ephedrine to correct the hypotension. IV fluids are increased per protocol when supine hypotension occurs. The correction of common problems in labor supports the Perinatal Core Measure of reducing the percentage of women who are delivered by cesarean section. Focus: Prioritization.

Question 21

A 17-year-old gravida 1, para 0 woman at 40 weeks’ gestation is in labor. She has chosen natural childbirth with assistance from a doula. Her mother and her boyfriend are at the bedside. What nursing action can help the patient achieve her goal of an unmedicated labor and birth?

1. Encourage the patient to stay in bed.
2. Allow the patient’s support people to provide labor support and minimize nursing presence.
3. Assess the effectiveness of the labor support team and offer suggestions as indicated.
4. Offer pain medication on a regular basis so the patient knows it is available if desired.

Answer 21

Ans: 3
The RN remains an important part of the labor and birth in this scenario. Even with a good support team present, the RN needs to observe and assess the patient’s comfort and safety as part of essential nursing care during labor. The RN’s expertise allows the RN to make helpful suggestions to the support people and patient. The patient should be encouraged to use positions and activities that are most comfortable to her. It is appropriate to let the patient and support people know of all pain control options, but it would not be appropriate to continually offer pain medication to a patient who has chosen natural childbirth. Expert nursing care in labor supports the Perinatal Core Measure of reducing the percentage of women who are delivered by cesarean section. Focus: Prioritization.

Question 22

A 25-year-old gravida 2, para 1 patient has come to the obstetric triage room at 32 weeks’ gestation reporting painless vaginal bleeding. The nurse is providing orientation for a new RN on the unit. Which statement by the new RN to the patient would require the nurse to promptly intervene?

1. “I’m going to check your vital signs.”
2. “I’m going to apply a fetal monitor to check the baby’s heart rate and to see if you are having contractions.”
3. “I’m going to perform a vaginal examination to see if your cervix is dilated.”
4. “I’m going to feel your abdomen to check the position of the baby.”

Answer 22

Ans: 3
Painless vaginal bleeding can be a symptom of placenta previa. A digital vaginal examination is contraindicated until ultrasonography can be performed to rule out placenta previa. If a digital examination is performed when placenta previa is present, it can cause increased bleeding. The other statements reflect appropriate assessment of an incoming patient with vaginal bleeding. Focus: Assignment; Test Taking Tip: The nurse should consider the possible causes of the symptom listed and choose the answer option that assures patient safety until the specific cause of a symptom is known.

Question 23

A 30-year-old gravida 6, para 5 woman at 12 weeks’ gestation has just begun prenatal care, and her initial laboratory work reveals that she has tested positive for human immunodeficiency virus (HIV) infection. What would be priority evidence-based nursing education for this patient today?

1. Medication for HIV infection is safe and can greatly reduce transmission of HIV to the infant.
2. Breast feeding is still recommended due to the great benefits to the infant.
3. Pregnancy is known to accelerate the course of HIV disease in the mother.
4. Cesarean section is not recommended because of the increased risk of HIV transmission with the bleeding at surgery.

Answer 23

Ans: 1
Administration of antiviral medications to the pregnant woman and the newborn, cesarean birth, and avoidance of breast feeding have reduced the incidence of perinatal transmission of HIV from approximately 26% to 1– 2%. Pregnancy is not known to accelerate HIV disease in the mother. The most important nursing action is to engage the mother in prenatal care and educate her as to the great benefits of medication for HIV during pregnancy. Focus: Prioritization.

Question 24

A 22-year-old woman is 6 weeks postpartum. In the clinic, she admits to crying every day, feeling overwhelmed, and sometimes thinking that she may hurt the baby. What would be the priority nursing action at this time?

1. Advise the patient of community resources, parent groups, and depression hotlines.
2. Counsel the mother that the “baby blues” are common at this time and assess her nutrition, rest, and availability of help at home.
3. Contact the health care provider to evaluate the patient before allowing her to leave the clinic.
4. Advise the woman that she cannot use medication for depression because she is breast feeding.

Answer 24

Ans: 3
When a patient discloses fear of hurting herself or her baby, the RN must have the woman immediately evaluated before allowing her to leave. Merely informing the patient about community resources is not sufficient. The “baby blues” are typically milder and occur 1 to 2 weeks postpartum. After the woman has been evaluated, the provider can prescribe antidepressants that can be safely used while breast feeding. Focus: Prioritization; Test Taking Tip: When a situation presents the potential for harm to a patient, choose the option that best protects patient safety.

Question 25

A 23-year-old gravida 1, para 0 patient at 10 weeks’ gestation states that she exercises 5 days a week. The nurse has discussed exercise in pregnancy with her. Which statement by the patient indicates that more teaching of evidence- based principles is needed?

1. “I will continue to exercise 5 days a week.”
2. “I will reduce my exercise at this time in my pregnancy to reduce the risk of miscarriage but will increase it in the second trimester.”
3. “I will drink more fluid before and after exercising.”
4. “I will stop playing football while I am pregnant.”

Answer 25

Ans: 2
There is no evidence that exercise should be avoided in the first trimester of pregnancy in a healthy woman without medical or obstetric complications. The American College of Obstetricians and Gynecologists recommends 30 minutes or more of exercise on most if not all days of the week for pregnant women. Exercise in which injury is more likely to occur should be avoided. Focus: Prioritization.

Question 26

A 3-day-old breast-fed infant is brought to the clinic by his parents for routine assessment following a normal full-term delivery without complications. Which statement by the parents suggests an abnormal finding on a newborn of this age?

1. “The baby urinated only three times yesterday.”
2. “The bowel movement of the baby was dark at first, but yesterday it was greenish yellow.”
3. “The baby cried for 2 hours last night.”
4. “The baby ate four times in the past 24 hours.”

Answer 26

Ans: 4
A newborn baby should feed 8 to 12 times in 24 hours. The other findings are normal for an infant of this age. The baby should void 6 to 8 times a day after the fourth day of life. Helpful guidance at this point may help parents understand infant feeding and help support the Perinatal Core Measure of increasing the percentage of infants who are fed breast milk only. Focus: Prioritization; Test Taking Tip: Consider the age of the infant as the most important information when choosing an answer option in many questions in pediatrics because infant and child needs and norms change very significantly with age.

Question 27

A full-term newborn is at the clinic with his parents. He is 4 days old. His birth weight was 7 lb (3.2 kg). Which assessment made by the RN is most significant?

1. The infant’s weight today is 6 lb 9 oz (3 kg).
2. The infant’s skin is peeling.
3. The infant’s breast tissue is swollen.
4. There is a yellow discharge from the infant’s right eye.

Answer 27

Ans: 4
The yellow eye discharge could be a conjunctivitis related to an infection acquired during birth or afterward. The other findings are normal variants on a newborn of this age. A newborn may normally experience a weight loss of 5% to 10% in the first days of life. Focus: Prioritization.

Question 28

The nurse has received orders to initiate phototherapy on a 36-hour-old newborn with an elevated bilirubin level. What instructions should the nurse give the student nurse who is assisting in the care of the infant? Select all that apply.

1. Cover the infant’s eyes with a mask.
2. Monitor the infant’s temperature closely.
3. Keep the infant NPO during the treatment.
4. Apply ointment to the infant’s skin before light exposure. 5. Offer the infant sterile water feedings during the treatment.

Answer 28

Ans: 1, 2
During phototherapy, the infant’s eyes must be protected and the temperature carefully monitored to avoid both hypothermia and hyperthermia. Breast feeding should be continued to avoid dehydration and to increase passage of meconium, which helps to excrete bilirubin. Ointments or lotions should not be applied to the skin during phototherapy as they may cause burns. Encouraging continued breast feeding and teaching the family the benefits of breast feeding in this scenario supports the Perinatal Core Measure of increasing the percentage of infants who are fed breast milk only. Focus: Supervision.

Question 29

A patient in the obstetric clinic is at 8 weeks’ gestation. She tells the nurse of her plans to travel next month to visit family in a country that is affected by the Zika virus. What is the priority counseling by the nurse today?

1. It is recommended that a patient not travel to a country impacted by Zika. The Zika virus has been linked to a very serious birth defect called microcephaly.
2. It is recommended that long sleeved shirts and long pants be always worn while there and that mosquito repellent be applied because mosquitos carry the virus.
3. It is recommended that mosquito repellent containing DEET be avoided because it is hazardous in pregnancy.
4. It is recommended that family members from the Zika impacted country not travel to visit the patient because they may carry the Zika virus.

Answer 29

Ans: 1
Option 1 clearly states the current recommendation of the Centers for Disease Control and Prevention (CDC) and the rationale for the recommendation. The nurse must always check the most recent recommendations online at CDC.gov. With any disease outbreak, the recommendations may change weekly, and it is a vital nursing responsibility to be sure the advice given to patients is consistent with the latest evidence- based information. Option 2 is appropriate advice for someone in a Zika- impacted area but does not appropriately counsel the patient not to travel to such an area at this time. Options 3 and 4 are incorrect information to give. Repellent containing DEET is recommended for a person in a Zika-impacted country. Casual or household contact with persons from a Zika-impacted area is not thought at this time to spread the Zika virus. Focus: Prioritization.

Question 30

A female same-sex couple is being seen in the clinic today. They inform the nurse that they are planning a pregnancy and plan to use donor sperm to be inseminated into one of the women. What is the priority education at this time?

1. Refer the couple to another health center specializing in same-sex issues and explain that you do not have the expertise to deal with their issues.
2. Review all preconception education issues, including vaccines, diet, folic acid use, avoidance of alcohol and medications, and the importance of physical and mental health prior to pregnancy.
3. Ask the couple if they have considered the effects on a child of having same-sex parents.
4. Inform them that donor sperm carry an increased risk of infection and chromosomal disorders.

Answer 30

Ans: 2
Option 2 provides the correct preconception information that should be given to all couples planning pregnancy. Option 1 does not demonstrate the nurse using her or his professional knowledge to offer appropriate information to the couple. Option 3 suggests judgment of the couple for their choice to have a child and would be inappropriate. Although it can be appropriate for the nurse to discuss a woman’s motivations for pregnancy in some cases when the pregnancy might seriously adversely affect the woman’s health, it would not be appropriate to do so based on the fact that the women are in a same-sex relationship. Option 4 is incorrect information. Focus: Prioritization.

Question 31

A same-sex couple are in the delivery room, and a healthy baby boy has just been born to one of the women. She breast fed the baby with a good latch, and now the baby has fallen asleep. She tells the nurse that both she and her partner are planning to breast feed the baby. What should the nurse do next?

1. Wake the baby and help the baby to latch on to the other woman’s breasts. Alternate the baby between the two women for nursing.
2. Inquire as to what preparation the partner has done for breast feeding. Let her know you will work with their plan while also assuring adequate intake for the baby.
3. Explain that the baby must first suck 20 minutes on each of the birth mother’s breasts and then can be placed on the other mother’s breasts.
4. Suggest that the birth mother breast-feed the infant and the partner supplement the baby with formula.

Answer 31

Ans: 2
The priority of nursing care of a newborn being breast fed is to assure adequate transfer of milk from mother to baby. The process of lactation requires hormonal stimulation during pregnancy and after birth. There are protocols for stimulation of lactation in a woman who has not given birth as in this case or in adoption cases. The protocols involve hormonal stimulation of the breasts before birth and mechanical stimulation with pumping. The nurse would need to find out if the partner has been preparing for lactation in this way to know how to best help them achieve their goal. The nurse must clearly communicate the obligation to follow practices that assure the newborn adequate intake. Option 1 without knowledge of how the partner has been preparing for lactation would be inappropriate and might put the infant at risk for inadequate intake. Options 3 and 4 are not appropriate responses for any couple planning to breast-feed their baby. This item supports the Perinatal Core Measurement of increasing breast feeding. Focus: Prioritization.

Question 32

The nurse on the locked postpartum unit observes another nurse with more experience open the door for a middle-aged woman without a visitor badge and then go to lunch. The nurse observes the woman wandering in the hall. In what order should the following actions be performed?

1. Find the nurse who let the woman in and question her about why she did that and see if she knows the woman.
2. Ask the supervisor to clarify the access policies for the postpartum unit to all staff.
3. Go up to the woman and ask if you can help her. Confirm with her which patient she is visiting and request that she get a visitor pass.
4. Ask the unit desk secretary to closely monitor the infant security system.

Answer 32

Ans: 3, 4, 1, 2
The correct order of action always puts patient safety first. In this case, the nurse should simply ask the unauthorized visitor to identify herself and her purpose on the unit. If any hostility or combativeness is encountered, security should be immediately called. Alerting the desk secretary to maintain close attentiveness to the infant security system would enhance patient safety and allow a security code to be quickly called if an infant were missing. After patient safety is assured, it is then the professional responsibility of the nurse to look at the system issues that caused the breach. The other nurse should be asked why the unauthorized visitor was allowed into the unit and explain the risk this action caused to others on the unit. A review of policies with the staff by the unit leadership would then further remind all staff of the need for constant vigilance and adherence to security systems in place to avoid risk to the patients in their care. Focus: Prioritization.

Question 33

A patient in labor had a positive QuantiFERON-TB gold tuberculosis (TB) test during pregnancy. A chest x-ray examination was done and showed no active TB in the lungs. How should the nurse care for this patient during the maternity stay?

1. Isolate the mother, initiate droplet precautions, separate the mother and baby, and do not allow breast feeding at this time.
2. The mother and infant can room together in isolation from the other maternity patients, and breast feeding should be encouraged.
3. The patient requires no isolation procedures at this time and should be encouraged to breast feed. The patient should be encouraged to follow up postpartum for possible initiation of medication for latent TB treatment.
4. Place a face mask on the mother while transporting her outside her room. Isolate her from the baby but encourage her to pump milk, which can be fed to the baby by a healthy family member.

Answer 33

Ans: 3
The key information in the question is that the chest x-ray examination showed no evidence of active TB processes in the lungs. The patient is therefore not considered infectious to other patients or to her newborn nor through her milk. Treatment of latent TB postpartum is appropriate for most patients depending on their medical profile. The other options are inappropriate in this scenario. Focus: Prioritization.

Question 34

The charge nurse is orienting a new nurse on the postpartum floor. What action by the new nurse would require intervention by the charge nurse?

1. Telling a patient with active varicella that she may breast-feed her newborn
2. Telling a patient with active varicella that she should pump her milk and a healthy family member may feed her milk to the infant
3. Telling a patient with active varicella that other family members should be vaccinated against varicella
4. Telling a patient with active varicella that she must wear a face mask when being transported from her room

Answer 34

Ans: 2
The mother with varicella can breast feed her infant. The newborn should have received varicella-zoster immune globulin and may room with the mother in isolation from other patients. The mother should avoid having the infant skin contact any varicella lesions. The other advice given by the new nurse is accurate. A mother with varicella should have standard, airborne, and contact precautions. The new nurse should be shown the unit policy on varicella and helped to understand why the mother can breast feed. The information should be corrected by the new nurse so the mother at this difficult time has no misconceptions or guilt. Focus: Supervision.

Question 35

The health care provider has ordered a flu vaccine for a patient in the prenatal clinic. As the nurse prepares to give it, the patient states she does not want the vaccine as she never gets it and never had the flu. How can the nurse best respond to the patient?

1. Respect the patient’s preference and offer education on how to avoid getting the flu by good hand washing, good nutrition, and adequate rest.
2. Inform the patient that changes in the heart, lungs, and immune system in pregnancy puts her in a higher risk group for complications of flu and that the flu in pregnancy is also associated with pregnancy complications such as premature delivery.
3. Inform the patient that it is acceptable to defer the vaccine until the postpartum period if she is worried about vaccine’s effects in pregnancy.
4. Explain that the vaccine is mandatory in pregnancy.

Answer 35

Ans: 2
Option 2 factually explains to the patient the real risks associated with the disease in pregnancy. Research has shown that describing to patients the specific risks a disease may have for them or their children help them to accept the vaccine. Option 1 does offer useful information for preventing the flu but does not go far enough in factually explaining the vaccine. Option 3 is incorrect because giving the vaccine postpartum does not impact the risk of flu during pregnancy. Option 4 is incorrect. Even though an intervention can be highly recommended, a patient may always decline. Focus: Prioritization.

Question 36

The postpartum nurse has just taken report from the night nurse. Place the following patients in the order in which they should be seen by the oncoming nurse.

1. A 32-year-old woman gravida 1, para 1 (G1P1) day 2 after normal spontaneous vaginal delivery who is tearful because the baby has been up all night crying and not nursing well
2. A 22-year-old G3P3 6 hours after normal spontaneous vaginal delivery who has expressed a wish to speak with a social worker about giving up her baby for adoption
3. A 16-year-old G1P1 day one postpartum with blood pressure of 160/90 mm Hg who is complaining of a headache
4. A 26-year-old G2P2 day 1 after cesarean section with temperature of 100.5°F (38.1°C)

Answer 36

Ans: 3, 1, 2, 4
In prioritization, patient safety always takes precedence. In this case, a 16-year-old woman with elevated blood pressure and a headache is showing symptoms of preeclampsia, which can be life threatening. This patient would need prompt assessment and notification of the health care provider for immediate evaluation. The patient is tearful and discouraged about breast feeding and needs timely help from the nurse because she is at a vulnerable time in breast feeding when many women give up without compassionate skillful interventions by a nurse or lactation consultant. The nurse could delegate to the unit secretary the task of notifying the social worker of the woman who wants to discuss possible adoption with her. The nurse would also assess the patient and explore her situation, but by delegating the call, the process can begin. A temperature of 100.5°F (38.1°C) on day one after cesarean section is not an unusual finding and needs to be monitored via routine assessments for rising temperature or clinical symptoms of infection. Focus: Prioritization.

Question 37

A patient who was recently diagnosed with influenza is in labor. She has been placed on droplet precautions. The student nurse who has been assigned to work with her has given the following information to the patient and her family. Which of the following instructions would require the nurse to intervene with further explanation? Select all that apply.

1. “I will be wearing gowns and gloves and masks as we care for you today.”
2. “I will be putting on a mask as I care for you today.”
3. “Any visitors to the room will be offered a mask to wear.”
4. “I will be moving you to a negative pressure room to prevent the spread of influenza.”
5. “You must wear a mask when you are outside of your room.”
6. “Droplets of your breast milk will be infectious at this time, so you will need to pump and dump your milk after delivery.”

Answer 37

Ans: 1, 4, 6
Droplet precautions dictate health care providers to wear a mask while in the room and discard it before leaving the room. In this case, a gown and gloves would be required only if care involved contact with bodily fluids (which may happen frequently in labor and delivery). Use of a negative pressure room is incorrect because it is a feature of airborne precautions. The breast milk itself does not carry influenza and may contain protective antibodies against influenza which may benefit the newborn. The other options are correct choices in the case of droplet precautions. The nurse should review with the student nurse the types of isolation procedures and clarify the features of each and the need to review information before communicating it to the patient. Focus: Assignment.

Question 38

The patient is 32 weeks pregnant with a diagnosis of complete placenta previa and is experiencing heavy vaginal bleeding. The plan of care is immediate blood transfusion and emergency cesarean section. The patient tells the nurse that she does not want the blood transfusion because she is concerned about getting hepatitis from it. Her husband shares this concern, and the couple is declining the transfusion. How should the nurse proceed?

1. Allow the patient to decline the blood transfusion, move her quickly to the operating room to prepare for emergent cesarean section, and inform the obstetrician that the patient has declined.
2. Quickly inform the patient that the blood transfusion is mandatory because of the amount of bleeding she is experiencing. State that there is virtually no risk of bloodborne infection.
3. Speak quickly and intently to the couple while moving to the operating room. Collaborate with the obstetrician to quickly counsel the couple about the risk-to-benefit ratio she is facing.
4. Call the blood bank and request that they come to the bedside and outline the risks and benefits of blood transfusion in this case before the surgery is allowed to start.

Answer 38

Ans: 3
This is a situation no nurse would choose to be in. These conversations would have been better held during the prenatal visits when the diagnosis of placenta previa was made and the discussion could have been more lengthy and thorough. At this moment, however, with active bleeding, the lives of the baby and the mother are at risk, so teaching must be accurate and succinct. Option 3 directly addresses the concerns of the couple and gives them information to quickly consider in their decision. It also brings the obstetrician rapidly into the conversation to allow the obstetrician and nurse to collaborate effectively in communicating to the patient. The essential clinical information to communicate quickly is that the risk of hepatitis B is about 1 in 250,000, and the risk of hepatitis C and HIV are 1 in 2 million from a blood transfusion in the United States. Explain that because of the bleeding she is having, her anemia, and the surgery she is about to have, she is at risk for significant blood loss and resulting severe anemia, which is linked with slower recovery, breast-feeding problems, increased risk of infection, hemorrhagic shock, and death. Option 1 does not show the nurse using her professional knowledge to educate the patient about the risks and benefits, but just allowing the patient to make a consequential decision without being provided adequate information. Option 2 is inaccurate, and Option 4 is too time consuming for the clinical scenario at hand. Focus: Prioritization.

Question 39

There are four patients on the busy labor and delivery unit undergoing induction of labor with oxytocin. The nurse supervisor for the unit is reviewing the patients. Which patient situation would require the supervising nurse to alert the bedside nurse to take immediate action?

1. A patient with contractions every 10 minutes with a fetal heart rate of 150 beats/min.
2. A patient with contractions every 1 1⁄2 minutes with a fetal heart rate of 140 beats/min.
3. A patient with contractions every 5 minutes with a fetal heart rate of 130 beats/min who is moaning and crying.
4. A patient with contractions every 6 minutes who is leaking clear amniotic fluid with a fetal heart rate of 150 beats/min.

Answer 39

Ans: 2
Oxytocin is a high-alert medication, and although frequently used in labor and delivery, it requires meticulous monitoring to avoid complications. In Option 2, the contractions are too close together, which is stressful for the fetus because oxygenation is decreased. If this pattern of tachysystole is allowed to continue, fetal hypoxia may occur. Although the fetal heart rate is now normal, the nursing action required at this time would be to stop the oxytocin or decrease the dose and notify the health care provider while keeping a close eye on the fetal heart rate and placing the patient in optimal position for maternal fetal circulation. This option involves patient safety and so is the priority case. The other options are normal findings during induction of labor and varying stages of labor. This item addresses the Perinatal Core Measurement of reducing the incidence of cesarean sections. Focus: Prioritization.

Question 40

A patient on the postpartum unit tells the nurse she is so happy that her 3- year-old son will visit today and get to meet the new baby. She mentions that the toddler has been sick with vomiting and diarrhea that was going around his day-care center. How should the nurse respond?

1. “Your toddler will need extra love and hugs during his visit because he has been sick.”
2. “I am very sorry, but because of the toddler’s illness, he cannot visit you because of the risk of spreading the virus to you, the baby, and other vulnerable mothers and babies on the unit. We will set up another way for you to interact with your toddler today.”
3. “Because of your toddler’s illness, you should pump your milk and discard it for 24 hours because of the risk of transmission of the virus to the newborn.”
4. “Because of your exposure to the virus, you should wear a mask, gown, and gloves when holding your newborn today.”

Answer 40

Ans: 2
Family-centered care and open family visitation is the optimal choice in the postpartum unit. Family members and young children can be welcomed into the units. However, mothers and newborns are a vulnerable group, and there are times when concerns regarding infectious disease spread must take precedence. The toddler described likely had norovirus, a highly contagious gastrointestinal disease. Excluding the toddler and any other ill family members from visiting the postpartum unit would be recommended. The nurse must realize this may be extremely disappointing to the family and must work hard to find a substitute way for the mother, toddler, and newborn to interact possibly through internet connection, photos, phone calls, and so on. It would also be the nurse’s responsibility to discuss the illness of the toddler with associated health care providers and infectious disease nurses at the hospital as well as consulting Centers for Disease Control and Prevention guidelines to offer the patient evidence- based advice regarding measures to take upon discharge to prevent spread of the infection. The other options would not be recommended. Focus: Prioritization.