Exam 3 - Chapter 21 Flashcards

1
Q
  1. A 25-year-old gravida 2, para 2-0-0-2 gave birth 4 hours ago to a 9-lb, 7-ounce boy after augmentation of labor with Pitocin. She puts on her call light and asks for her nurse right away, stating, “I’m bleeding a lot.” The most likely cause of after birth hemorrhage in this woman is:
    a. retained placental fragments.
    b. unrepaired vaginal lacerations.
    c. uterine atony.
    d. puerperal infection.
A

ANS: C
This woman gave birth to a macrosomic boy after Pitocin augmentation. The most likely cause of bleeding 4 hours after delivery, combined with these risk factors, is uterine atony. Although retained placental fragments may cause after birth hemorrhage, this typically would be detected in the first hour after delivery of the placenta and is not the most likely cause of hemorrhage in this woman. Although unrepaired vaginal lacerations may cause bleeding, they typically would occur in the period immediately after birth. Puerperal infection can cause subinvolution and subsequent bleeding; however, this typically would be detected 24 hours after delivery.

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2
Q
  1. On examining a woman who gave birth 5 hours ago, the nurse finds that the woman has completely saturated a perineal pad within 15 minutes. The nurse’s first action is to:
    a. begin an intravenous (IV) infusion of Ringer’s lactate solution.
    b. assess the woman’s vital signs.
    c. call the woman’s primary health care provider.
    d. massage the woman’s fundus.
A

ANS: D
The nurse should assess the uterus for atony. Uterine tone must be established to prevent excessive blood loss. The nurse may begin an IV infusion to restore circulatory volume, but this would not be the first action. Blood pressure is not a reliable indicator of impending shock from impending hemorrhage; assessing vital signs should not be the nurse’s first action. The physician would be notified after the nurse completes the assessment of the woman.

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3
Q
  1. A woman gave birth vaginally to a 9-lb, 12-ounce girl yesterday. Her primary health care provider has written orders for perineal ice packs, use of a sitz bath tid, and a stool softener. What information is most closely correlated with these orders?
    a. The woman is a gravida 2, para 2.
    b. The woman had a vacuum-assisted birth.
    c. The woman received epidural anesthesia.
    d. The woman has an episiotomy.
A

ANS: D
These orders are typical interventions for a woman who has had an episiotomy, lacerations, and hemorrhoids. A multiparous classification is not an indication for these orders. A vacuum-assisted birth may be used in conjunction with an episiotomy, which would indicate these interventions. Use of epidural anesthesia has no correlation with these orders.

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4
Q
  1. The laboratory results for a after birth woman are as follows: blood type, A; Rh status, positive; rubella titer, 1:8 (EIA 0.8); hematocrit, 30%. How would the nurse best interpret these data?
    a. Rubella vaccine should be given.
    b. A blood transfusion is necessary.
    c. Rh immune globulin is necessary within 72 hours of birth.
    d. A Kleihauer-Betke test should be performed.
A

ANS: A
This patient’s rubella titer indicates that she is not immune and that she needs to receive a vaccine. These data do not indicate that the patient needs a blood transfusion. Rh immune globulin is indicated only if the patient has a negative Rh status and the infant has a positive Rh status. A Kleihauer-Betke test should be performed if a large fetomaternal transfusion is suspected, especially if the mother is Rh negative. The data do not provide any indication for performing this test.

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5
Q
  1. A woman gave birth 48 hours ago to a healthy infant girl. She has decided to bottle-feed. During your assessment you notice that both of her breasts are swollen, warm, and tender on palpation. The woman should be advised that this condition can best be treated by:
    a. running warm water on her breasts during a shower.
    b. applying ice to the breasts for comfort.
    c. expressing small amounts of milk from the breasts to relieve pressure.
    d. wearing a loose-fitting bra to prevent nipple irritation.
A

ANS: B
Applying ice to the breasts for comfort is appropriate for treating engorgement in a mother who is bottle-feeding. This woman is experiencing engorgement, which can be treated by using ice packs (because she is not breastfeeding) and cabbage leaves. A bottle-feeding mother should avoid any breast stimulation, including pumping or expressing milk. A bottle-feeding mother should wear a well-fitted support bra or breast binder continuously for at least the first 72 hours after giving birth. A loose-fitting bra will not aid lactation suppression. Furthermore, the shifting of the bra against the breasts may stimulate the nipples and thereby stimulate lactation.

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6
Q
  1. A 25-year-old multiparous woman gave birth to an infant boy 1 day ago. Today her husband brings a large container of brown seaweed soup to the hospital. When the nurse enters the room, the husband asks for help with warming the soup so that his wife can eat it. The nurse’s most appropriate response is to ask the woman:
    a. “Didn’t you like your lunch?”
    b. “Does your doctor know that you are planning to eat that?”
    c. “What is that anyway?”
    d. “I’ll warm the soup in the microwave for you.”
A

ANS: D
“I’ll warm the soup in the microwave for you” shows cultural sensitivity to the dietary preferences of the woman and is the most appropriate response. Cultural dietary preferences must be respected. Women may request that family members bring favorite or culturally appropriate foods to the hospital. “What is that anyway?” does not show cultural sensitivity.

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7
Q
  1. In many hospitals new mothers are routinely presented with gift bags containing samples of infant formula. This practice:
    a. is inconsistent with the Baby-Friendly Hospital Initiative.
    b. promotes longer periods of breastfeeding.
    c. is perceived as supportive to both bottle-feeding and breastfeeding mothers.
    d. is associated with earlier cessation of breastfeeding.
A

ANS: A
Infant formula should not be given to mothers who are breastfeeding. Such gifts are associated with earlier cessation of breastfeeding. Baby-Friendly USA prohibits the distribution of any gift bags or formula to new mothers

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8
Q
  1. A after birth woman overhears the nurse tell the obstetrics clinician that she has a positive Homans’ sign and asks what it means. The nurse’s best response is:
    a. “You have pitting edema in your ankles.”
    b. “You have deep tendon reflexes rated 2+.”
    c. “You have calf pain when the nurse flexes your foot.”
    d. “You have a ‘fleshy’ odor to your vaginal drainage.”
A

ANS: C
Discomfort in the calf with sharp dorsiflexion of the foot may indicate deep vein thrombosis. Edema is within normal limits for the first few days until the excess interstitial fluid is remobilized and excreted. Deep tendon reflexes should be 1+ to 2+. A “fleshy” odor, not a foul odor, is within normal limits.

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9
Q
  1. In the recovery room, if a woman is asked either to raise her legs (knees extended) off the bed or to flex her knees, place her feet flat on the bed, and raise her buttocks well off the bed, most likely she is being tested to see whether she:
    a. has recovered from epidural or spinal anesthesia.
    b. has hidden bleeding underneath her.
    c. has regained some flexibility.
    d. is a candidate to go home after 6 hours.
A

ANS: A
If the numb or prickly sensations are gone from her legs after these movements, she has likely recovered from the epidural or spinal anesthesia.

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10
Q
  1. Under the Newborns’ and Mothers’ Health Protection Act, all health plans are required to allow new mothers and newborns to remain in the hospital for a minimum of _____ hours after a normal vaginal birth and for _____ hours after a cesarean birth.
    a. 24, 73
    b. 24, 96
    c. 48, 96
    d. 48, 120
A

ANS: C
The specified stays are 48 hours (2 days) for a vaginal birth and 96 hours (4 days) for a cesarean birth. The attending provider and the mother together can decide on an earlier discharge.

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11
Q
  1. In a variation of rooming-in, called couplet care, the mother and infant share a room, and the mother shares the care of the infant with:
    a. the father of the infant.
    b. her mother (the infant’s grandmother).
    c. her eldest daughter (the infant’s sister).
    d. the nurse.
A

ANS: D
In couplet care the mother shares a room with the newborn and shares infant care with a nurse educated in maternity and infant care

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12
Q
  1. Nursing care in the fourth trimester includes an important intervention sometimes referred to as taking the time to mother the mother. Specifically this expression refers to:
    a. formally initializing individualized care by confirming the woman’s and infant’s identification (ID) numbers on their respective wrist bands. (“This is your baby.”)
    b. teaching the mother to check the identity of any person who comes to remove the baby from the room. (“It’s a dangerous world out there.”)
    c. including other family members in the teaching of self-care and child care. (“We’re all in this together.”)
    d. nurturing the woman by providing encouragement and support as she takes on the many tasks of motherhood.
A

ANS: D
Many professionals believe that the nurse’s nurturing and support function is more important than providing physical care and teaching. Matching ID wrist bands is more of a formality, but it is also a get-acquainted procedure. “Mothering the mother” is more a process of encouraging and supporting the woman in her new role. Having the mother check IDs is a security measure for protecting the baby from abduction. Teaching the whole family is just good nursing practice.

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13
Q
  1. Excessive blood loss after childbirth can have several causes; the most common is:
    a. vaginal or vulvar hematomas.
    b. unrepaired lacerations of the vagina or cervix.
    c. failure of the uterine muscle to contract firmly.
    d. retained placental fragments.
A

ANS: C
Uterine atony can best be thwarted by maintaining good uterine tone and preventing bladder distention. Although vaginal or vulvar hematomas, unpaired lacerations of the vagina or cervix, and retained placental fragments are possible causes of excessive blood loss, uterine muscle failure (uterine atony) is the most common cause.

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14
Q
  1. A hospital has a number of different perineal pads available for use. A nurse is observed soaking several of them and writing down what she sees. This activity indicates that the nurse is trying to:
    a. improve the accuracy of blood loss estimation, which usually is a subjective assessment.
    b. determine which pad is best.
    c. demonstrate that other nurses usually underestimate blood loss.
    d. reveal to the nurse supervisor that one of them needs some time off.
A

ANS: A
Saturation of perineal pads is a critical indicator of excessive blood loss, and anything done to aid in assessment is valuable. The nurse is noting the saturation volumes and soaking appearances. It is possible that the nurse is trying to determine which pad is best, but it is more likely that the nurse is noting saturation volumes and soaking appearances to improve the accuracy of blood loss estimation. Nurses usually overestimate blood loss, if anything.

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15
Q
  1. Because a full bladder prevents the uterus from contracting normally, nurses intervene to help the woman empty her bladder spontaneously as soon as possible. If all else fails, the last thing the nurse could try is:
    a. pouring water from a squeeze bottle over the woman’s perineum.
    b. placing oil of peppermint in a bedpan under the woman.
    c. asking the physician to prescribe analgesics.
    d. inserting a sterile catheter
A

ANS: D
Invasive procedures usually are the last to be tried, especially with so many other simple and easy methods available (e.g., water, peppermint vapors, pain medication). Pouring water over the perineum may stimulate voiding. It is easy, noninvasive, and should be tried early. The oil of peppermint releases vapors that may relax the necessary muscles. If the woman is anticipating pain from voiding, pain medications may be helpful. Other nonmedical means and pain medication should be tried before insertion of a catheter.

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16
Q
  1. If a woman is at risk for thrombus and is not ready to ambulate, nurses may intervene by performing a number of interventions. Which intervention should the nurse avoid?
    a. Putting the patient in antiembolic stockings (TED hose) and/or sequential compression device (SCD) boots.
    b. Having the patient flex, extend, and rotate her feet, ankles, and legs.
    c. Having the patient sit in a chair.
    d. Notifying the physician immediately if a positive Homans’ sign occurs.
A

ANS: C
Sitting immobile in a chair will not help. Bed exercise and prophylactic footwear may. TED hose and SCD boots are recommended. Bed exercises, such as flexing, extending, and rotating her feet, ankles, and legs, are useful. A positive Homans’ sign (calf muscle pain or warmth, redness, or tenderness) requires the physician’s immediate attention.

17
Q
  1. As relates to rubella and Rh issues, nurses should be aware that:
    a. breastfeeding mothers cannot be vaccinated with the live attenuated rubella virus.
    b. women should be warned that the rubella vaccination is teratogenic, and that they must avoid pregnancy for 1 month after vaccination.
    c. Rh immune globulin is safely administered intravenously because it cannot harm a nursing infant.
    d. Rh immune globulin boosts the immune system and thereby enhances the effectiveness of vaccinations.
A

ANS: B
Women should understand they must practice contraception for 1 month after being vaccinated. Because the live attenuated rubella virus is not communicable in breast milk, breastfeeding mothers can be vaccinated. Rh immune globulin is administered intramuscularly; it should never be given to an infant. Rh immune globulin suppresses the immune system and therefore could thwart the rubella vaccination.

18
Q
  1. Discharge instruction, or teaching the woman what she needs to know to care for herself and her newborn, officially begins:
    a. at the time of admission to the nurse’s unit.
    b. when the infant is presented to the mother at birth.
    c. during the first visit with the physician in the unit.
    d. when the take-home information packet is given to the couple.
A

ANS: A
Discharge planning, the teaching of maternal and newborn care, begins on the woman’s admission to the unit, continues throughout her stay, and actually never ends as long as she has contact with medical personnel.

19
Q
  1. A recently delivered mother and her baby are at the clinic for a 6-week after birth checkup. The nurse should be concerned that psychosocial outcomes are not being met if the woman:
    a. discusses her labor and birth experience excessively.
    b. believes that her baby is more attractive and clever than any others.
    c. has not given the baby a name.
    d. has a partner or family members who react very positively about the baby.
A

ANS: C
If the mother is having difficulty naming her new infant, it may be a signal that she is not adapting well to parenthood. Other red flags include refusal to hold or feed the baby, lack of interaction with the infant, and becoming upset when the baby vomits or needs a diaper change. A new mother who is having difficulty would be unwilling to discuss her labor and birth experience. An appropriate nursing diagnosis could be Impaired parenting related to a long, difficult labor, or unmet expectations of birth. A mother who is willing to discuss her birth experience is making a healthy personal adjustment. The mother who is not coping well would find her baby unattractive and messy. She may also be overly disappointed in the baby’s sex. The patient may voice concern that the baby reminds her of a family member whom she does not like. Having a partner and/or other family members react positively is an indication that this new mother has a good support system in place. This support system will help reduce anxiety related to her new role as a mother.

20
Q
  1. Postpartal overdistention of the bladder and urinary retention can lead to which complications?
    a. After birth hemorrhage and eclampsia
    b. Fever and increased blood pressure
    c. After birth hemorrhage and urinary tract infection
    d. Urinary tract infection and uterine rupture
A

ANS: C
Incomplete emptying and overdistention of the bladder can lead to urinary tract infection. Overdistention of the bladder displaces the uterus and prevents contraction of the uterine muscle, thus leading to after birth hemorrhage. There is no correlation between bladder distention and high blood pressure or eclampsia. The risk of uterine rupture decreases after the birth of the infant.

21
Q
  1. Rho immune globulin will be ordered after birth if which situation occurs?
    a. Mother Rh-, baby Rh+
    b. Mother Rh-, baby Rh-
    c. Mother Rh+, baby Rh+
    d. Mother Rh+, baby Rh-
A

ANS: A
An Rh- mother delivering an Rh+ baby may develop antibodies to fetal cells that entered her bloodstream when the placenta separated. The Rho immune globulin works to destroy the fetal cells in the maternal circulation before sensitization occurs. If mother and baby are both Rh+ or Rh- the blood types are alike, so no antibody formation would be anticipated. If the Rh+ blood of the mother comes in contact with the Rh- blood of the infant, no antibodies would develop because the antigens are in the mother’s blood, not the infant’s.

22
Q
  1. Which nursing action is most appropriate to correct a boggy uterus that is displaced above and to the right of the umbilicus?
    a. Notify the physician of an impending hemorrhage.
    b. Assess the blood pressure and pulse.
    c. Evaluate the lochia.
    d. Assist the patient in emptying her bladder
A

ANS: D
Urinary retention may cause overdistention of the urinary bladder, which lifts and displaces the uterus. Nursing actions need to be implemented before notifying the physician. It is important to evaluate blood pressure, pulse, and lochia if the bleeding continues; however, the focus at this point in time is to assist the patient in emptying her bladder.

23
Q
  1. When caring for a newly delivered woman, the nurse is aware that the best measure to prevent abdominal distention after a cesarean birth is:
    a. rectal suppositories.
    b. early and frequent ambulation.
    c. tightening and relaxing abdominal muscles.
    d. carbonated beverages.
A

ANS: B
Activity will aid the movement of accumulated gas in the gastrointestinal tract. Rectal suppositories can be helpful after distention occurs; however, they do not prevent it. Ambulation is the best prevention. Carbonated beverages may increase distention.

24
Q
  1. The nurse caring for the after birth woman understands that breast engorgement is caused by:
    a. overproduction of colostrum.
    b. accumulation of milk in the lactiferous ducts and glands.
    c. hyperplasia of mammary tissue.
    d. congestion of veins and lymphatics.
A

ANS: D
Breast engorgement is caused by the temporary congestion of veins and lymphatics. Breast engorgement is not the result of overproduction of colostrum. Accumulation of milk in the lactiferous ducts and glands does not cause breast engorgement. Hyperplasia of mammary tissue does not cause breast engorgement.