OB Exam 3 Flashcards
The nurse expects to administer an oxytocic (e.g., Pitocin, Methergine) to a woman after expulsion of her placenta to:
a. Relieve pain.
b. Stimulate uterine contraction.
c. Prevent infection.
d. Facilitate rest and relaxation.
ANS: B
Oxytocics stimulate uterine contractions, which reduce blood loss after the third stage of labor. Oxytocics are not used to treat pain or prevent infection. They cause the uterus to contract, which reduces blood loss. Oxytocics do not facilitate rest and relaxation.
Medications used to manage postpartum hemorrhage (PPH) include (Select all that apply):
a. Pitocin
b. Methergine
c. Terbutaline
d. Hemabate
e. Magnesium sulfate.
ANS: A, B, D
Pitocin, Methergine, and Hemabate are all used to manage PPH. Terbutaline and magnesium sulfate are tocolytics; relaxation of the uterus causes or worsens PPH.
The perinatal nurse is caring for a woman in the immediate postbirth period. Assessment reveals that the woman is experiencing profuse bleeding. The most likely etiology for the bleeding is:
a. Uterine atony. c. Vaginal hematoma.
b. Uterine inversion. d. Vaginal laceration.
ANS: A
Uterine atony is marked hypotonia of the uterus. It is the leading cause of postpartum hemorrhage. Uterine inversion may lead to hemorrhage, but it is not the most likely source of this clients bleeding. Furthermore, if the woman were experiencing a uterine inversion, it would be evidenced by the presence of a large, red, rounded mass protruding from the introitus. A vaginal hematoma may be associated with hemorrhage. However, the most likely clinical finding would be pain, not the presence of profuse bleeding. A vaginal laceration may cause hemorrhage, but it is more likely that profuse bleeding would result from uterine atony. A vaginal laceration should be suspected if vaginal bleeding continues in the presence of a firm, contracted uterine fundus.
A primary nursing responsibility when caring for a woman experiencing an obstetric hemorrhage associated with uterine atony is to:
a. Establish venous access.
b. Perform fundal massage.
c. Prepare the woman for surgical intervention.
d. Catheterize the bladder.
ANS: B
The initial management of excessive postpartum bleeding is firm massage of the uterine fundus. Although establishing venous access may be a necessary intervention, the initial intervention would be fundal massage. The woman may need surgical intervention to treat her postpartum hemorrhage, but the initial nursing intervention would be to assess the uterus. After uterine massage the nurse may want to catheterize the client to eliminate any bladder distention that may be preventing the uterus from contracting properly.
The perinatal nurse caring for the postpartum woman understands that late postpartum hemorrhage (PPH) is most likely caused by: a. Subinvolution of the placental site b. Defective vascularity of the decidua c. Cervical lacerations .d. Coagulation disorders
ANS: A
Late PPH may be the result of subinvolution of the uterus, pelvic infection, or retained placental fragments. Late PPH is not typically a result of defective vascularity of the decidua, cervical lacerations, or coagulation disorders.
Which woman is at greatest risk for early postpartum hemorrhage (PPH)?
A. A primiparous woman (G 2 P 1 0 0 1) being prepared for an emergency cesarean birth for fetal distress
B. A woman with severe preeclampsia who is receiving magnesium sulfate and whose labor is being induced
C. A multiparous woman (G 3 P 2 0 0 2) with an 8-hour labor
D. A primigravida in spontaneous labor with preterm twins
ANS: B
Magnesium sulfate administration during labor poses a risk for PPH. Magnesium acts as a smooth muscle relaxant, thereby contributing to uterine relaxation and atony. Although many causes and risk factors are associated with PPH, the primiparous woman being prepared for an emergency C-section, the multiparous woman with 8-hour labor, and the primigravida in spontaneous labor do not pose risk factors or causes of early PPH.
The first and most important nursing intervention when a nurse observes profuse postpartum bleeding is to:
a. Call the womans primary health care provider.
b. Administer the standing order for an oxytocic.
c. Palpate the uterus and massage it if it is boggy.
d. Assess maternal blood pressure and pulse for signs of hypovolemic shock.
ANS: C
The initial management of excessive postpartum bleeding is firm massage of the uterine fundus. Although calling the health care provider, administering an oxytocic, and assessing maternal BP are appropriate interventions, the primary intervention should be to assess the uterus. Uterine atony is the leading cause of postpartum hemorrhage (PPH).
When caring for a postpartum woman experiencing hemorrhagic shock, the nurse recognizes that the most objective and least invasive assessment of adequate organ perfusion and oxygenation is:
a. Absence of cyanosis in the buccal mucosa.
b. Cool, dry skin.
c. Diminished restlessness.
d. Urinary output of at least 30 mL/hr.
ANS: D
Hemorrhage may result in hemorrhagic shock. Shock is an emergency situation in which the perfusion of body organs may become severely compromised and death may occur. The presence of adequate urinary output indicates adequate tissue perfusion. The assessment of the buccal mucosa for cyanosis can be subjective. The presence of cool, pale, clammy skin would be an indicative finding associated with hemorrhagic shock. Hemorrhagic shock is associated with lethargy, not restlessness.
One of the first symptoms of puerperal infection to assess for in the postpartum woman is:
a. Fatigue continuing for longer than 1 week.
b. Pain with voiding.
c. Profuse vaginal bleeding with ambulation.
d. Temperature of 38 C (100.4 F) or higher on 2 successive days starting 24 hours after birth
ANS: D
Postpartum or puerperal infection is any clinical infection of the genital canal that occurs within 28 days after miscarriage, induced abortion, or childbirth. The definition used in the United States continues to be the presence of a fever of 38 C (100.4 F) or higher on 2 successive days of the first 10 postpartum days, starting 24 hours after birth. Fatigue would be a late finding associated with infection. Pain with voiding may indicate a urinary tract infection, but it is not typically one of the earlier symptoms of infection. Profuse lochia may be associated with endometritis, but it is not the first symptom associated with infection.
To provide adequate postpartum care, the nurse should be aware that postpartum depression (PPD)without psychotic features:
a. Means that the woman is experiencing the baby blues. In addition she has a visit with a counselor or psychologist.
b. Is more common among older, Caucasian women because they have higher expectations.
c. Is distinguished by irritability, severe anxiety, and panic attacks.
d. Will disappear on its own without outside help.
ANS: C
PPD is also characterized by spontaneous crying long after the usual duration of the baby blues. PPD, even without psychotic features, is more serious and persistent than postpartum baby blues. It is more common among younger mothers and African-American mothers. Most women need professional help to get through PPD, including pharmacologic intervention.
With shortened hospital stays, new mothers are often discharged before they begin to experience symptoms of the baby blues or postpartum depression. As part of the discharge teaching, the nurse can prepare the mother for this adjustment to her new role by instructing her regarding self-care activities to help prevent postpartum depression. The most accurate statement as related to these activities is to:
a. Stay home and avoid outside activities to ensure adequate rest.
b. Be certain that you are the only caregiver for your baby, to facilitate infant attachment.
c. Keep feelings of sadness and adjustment to your new role to yourself.
d. Realize that this is a common occurrence that affects many women.
ANS: D
Should the new mother experience symptoms of the baby blues, it is important that she be aware that this is nothing to be ashamed of. Up to 80% of women experience this type of mild depression after the birth of their infant. Although it is important for the mother to obtain enough rest, she should not distance herself from family and friends. Her spouse or partner can communicate the best visiting times so the new mother can obtain adequate rest. It is also important that she not isolate herself at home during this time of role adjustment. Even if breastfeeding, other family members can participate in the infants care. If depression occurs, the symptoms can often interfere with mothering functions, and this support will be essential. The new mother should share her feelings with someone else. It is also important that she not overcommit herself or think she has to be superwoman. A telephone call to the hospital warm line may provide reassurance with lactation issues and other infant care questions. Should symptoms continue, a referral to a professional therapist may be necessary.
Which condition is a transient, self-limiting mood disorder that affects new mothers after childbirth?
a. Postpartum depression
b. Postpartum psychosis
c. Postpartum bipolar disorder
d. Postpartum blues
ANS: D
Postpartum blues or baby blues is a transient self-limiting disease that is believed to be related to hormonal fluctuations after childbirth. Postpartum depression is not the normal worries (blues) that many new mothers experience. Many caregivers believe that postpartum depression is underdiagnosed and underreported. Postpartum psychosis is a rare condition that usually surfaces within 3 weeks of delivery. Hospitalization of the woman is usually necessary for treatment of this disorder. Bipolar disorder is one of the two categories of postpartum psychosis, characterized by both manic and depressive episodes.
Possible alternative and complementary therapies for postpartum depression (PPD) for breastfeeding mothers include (Select all that apply):
a. Acupressure
b. Aromatherapy
c. St. Johns wort
d. Wine consumption
e. Yoga
ANS: A, B, E
Possible alternative/complementary therapies for postpartum depression include acupuncture, acupressure, aromatherapy, therapeutic touch, massage, relaxation techniques, reflexology, and yoga. St. Johns wort has not been proven to be safe for women who are breastfeeding. Women who are breastfeeding and/or have a history of PPD should not consume alcohol.
The perinatal nurse caring for the postpartum woman understands that late postpartum hemorrhage (PPH) is most likely caused by:
a. Subinvolution of the placental site.
b. Defective vascularity of the decidua
c. Cervical lacerations
d. Coagulation disorders
ANS: A
Late PPH may be the result of subinvolution of the uterus, pelvic infection, or retained placental fragments. Late PPH is not typically a result of defective vascularity of the decidua, cervical lacerations, or coagulation disorders.
What PPH conditions are considered medical emergencies that require immediate treatment?
a. Inversion of the uterus and hypovolemic shock
b. Hypotonic uterus and coagulopathies
c. Subinvolution of the uterus and idiopathic thrombocytopenic purpura
d. Uterine atony and disseminated intravascular coagulation
ANS: A
Inversion of the uterus and hypovolemic shock are considered medical emergencies. Although hypotonic uterus and coagulopathies, subinvolution of the uterus and idiopathic thrombocytopenic purpura, and uterine atony and disseminated intravascular coagulation are serious conditions, they are not necessarily medical emergencies that require immediate treatment.
An acquired hemorrhagic disorder that is characterized by excessive destruction of platelets is:
a. Aplastic anemia.
b. Thalassemia major.
c. Disseminated intravascular coagulation.
d. Idiopathic thrombocytopenic purpura.
ANS: D
Idiopathic thrombocytopenic purpura is an acquired hemorrhagic disorder characterized by an excessive destruction of platelets, discolorations caused by petechiae beneath the skin, and a normal bone marrow. Aplastic anemia refers to a bone marrow failure condition in which the formed elements of the blood are simultaneously depressed. Thalassemia major is a group of blood disorders characterized by deficiency in the production rate of specific hemoglobin globin chains. Disseminated intravascular coagulation is characterized by diffuse fibrin deposition in the microvasculature, consumption of coagulation factors, and endogenous generation of thrombin and plasma.
The perinatal nurse assisting with establishing lactation is aware that acute mastitis can be minimized by:
a. Washing the nipples and breasts with mild soap and water once a day.
b. Using proper breastfeeding techniques.
c. Wearing a nipple shield for the first few days of breastfeeding.
d. Wearing a supportive bra 24 hours a day
ANS: B
Almost all instances of acute mastitis can be avoided by proper breastfeeding technique to prevent cracked nipples. Washing the nipples and breasts daily is no longer indicated. In fact, this can cause tissue dryness and irritation, which can lead to tissue breakdown and infection. Wearing a nipple shield does not prevent mastitis. Wearing a supportive bra 24 hours a day may contribute to mastitis, especially if an underwire bra is worn, because it may put pressure on the upper, outer area of the breast, thus contributing to blocked ducts and mastitis.
What infection is contracted mostly by first-time mothers who are breastfeeding?
a. Endometritis
b. Wound infections
c. Mastitis
d. Urinary tract infections
ANS: C
Mastitis is infection in a breast, usually confined to a milk duct. Most women who suffer this are primiparas who are breastfeeding.
A nurse is discussing the signs and symptoms of mastitis with a mother who is breastfeeding. What signs and symptoms should the nurse include in her discussion (Select all that apply)?
a. Breast tenderness
b. Warmth in the breast
c. An area of redness on the breast often resembling the shape of a pie wedge
d. A small white blister on the tip of the nipple
e. Fever and flulike symptoms
ANS: A, B, C, E
Breast tenderness, breast warmth, breast redness, and fever and flulike symptoms are commonly associated with mastitis and should be included in the nurses discussion of mastitis. A small white blister on the tip of the nipple generally is not associated with mastitis. It is commonly seen in women who have a plugged milk duct.
A woman complains of severe abdominal and pelvic pain around the time of menstruation that has gotten worse over the last 5 years. She also complains of pain during intercourse and has tried unsuccessfully to get pregnant for the past 18 months. These symptoms are most likely related to:
a. Endometriosis.
b. PMS.
c. Primary dysmenorrhea.
d. Secondary dysmenorrhea.
ANS: A
Symptoms of endometriosis can change over time and may not reflect the extent of the disease. Major symptoms include dysmenorrhea and deep pelvic dyspareunia (painful intercourse). Impaired fertility may result from adhesions caused by endometriosis. Although endometriosis may be associated with secondary dysmenorrhea, it is not a cause of primary dysmenorrhea or PMS. In addition, this woman is complaining of dyspareunia and infertility, which are associated with endometriosis, not with PMS or primary or secondary dysmenorrhea.
Nafarelin is currently used as a treatment for mild-to-severe endometriosis. The nurse should tell a woman taking this medication that the drug:
a. Stimulates the secretion of gonadotropin-releasing hormone (GnRH), thereby stimulating ovarian activity.
b. Should be sprayed into one nostril every other day.
c. Should be injected into subcutaneous tissue BID.
d. Can cause her to experience some hot flashes and vaginal dryness
ANS: D
Nafarelin is a GnRH agonist, and its side effects are similar to effects of menopause. The hypoestrogenism effect results in hot flashes and vaginal dryness. Nafarelin is a GnRH agonist that suppresses the secretion of GnRH and is administered twice daily by nasal spray.
With regard to endometriosis, nurses should be aware that:
a. It is characterized by the presence and growth of endometrial tissue inside the uterus.
b. It is found more often in African-American women than in white or Asian women.
c. It may worsen with repeated cycles or remain asymptomatic and disappear after menopause.
d. It is unlikely to affect sexual intercourse or fertility.
ANS: C
Symptoms vary among women, ranging from nonexistent to incapacitating. With endometriosis, the endometrial tissue is outside the uterus. Symptoms vary among women, ranging from nonexistent to incapacitating. Endometriosis is found equally in white and African-American women and is slightly more prevalent in Asian women. Women can experience painful intercourse and impaired fertility.
With regard to endometriosis, nurses should be aware that:
a. It is characterized by the presence and growth of endometrial tissue inside the uterus.
b. It is found more often in African-American women than in white or Asian women.
c. It may worsen with repeated cycles or remain asymptomatic and disappear after menopause.
d. It is unlikely to affect sexual intercourse or fertility.
ANS: C
Symptoms vary among women, ranging from nonexistent to incapacitating. With endometriosis, the endometrial tissue is outside the uterus. Symptoms vary among women, ranging from nonexistent to incapacitating. Endometriosis is found equally in white and African-American women and is slightly more prevalent in Asian women. Women can experience painful intercourse and impaired fertility.
In the assessment of a preterm infant, the nurse notices continued respiratory distress even though oxygen and ventilation have been provided. The nurse should suspect:
a. Hypovolemia and/or shock.
b. A nonneutral thermal environment
c. Central nervous system injury
d. Pending renal failure
ANS: A
The nurse should suspect hypovolemia and/or shock. Other symptoms could include hypotension, prolonged capillary refill, and tachycardia followed by bradycardia. Intervention is necessary.
Numerous changes in the integumentary system occur during pregnancy. Which change persists after birth?
a. Epulis
b. Chloasma
c. Telangiectasia
d. Striae gravidarum
ANS: D
Striae gravidarum, or stretch marks, reflect separation within the underlying connective tissue of the skin. They usually fade after birth, although they never disappear completely. An epulis is a red, raised nodule on the gums that bleeds easily. Chloasma, or mask of pregnancy, is a blotchy, brown hyperpigmentation of the skin over the cheeks, nose, and forehead, especially in dark-complexioned pregnant women. Chloasma usually fades after the birth. Telangiectasia, or vascular spiders, are tiny, star-shaped or branchlike, slightly raised, pulsating end-arterioles usually found on the neck, thorax, face, and arms. They occur as a result of elevated levels of circulating estrogen. These usually disappear after birth.
Part of the health assessment of a newborn is observing the infants breathing pattern. A full-term newborns breathing pattern is predominantly:
a. Abdominal with synchronous chest movements.
b. Chest breathing with nasal flaring.
c. Diaphragmatic with chest retraction.
d. Deep with a regular rhythm.
ANS: A
In normal infant respiration the chest and abdomen rise synchronously, and breaths are shallow and irregular. Breathing with nasal flaring is a sign of respiratory distress. Diaphragmatic breathing with chest retraction is a sign of respiratory distress. Infant breaths are not deep with a regular rhythm.
A newborn is placed under a radiant heat warmer, and the nurse evaluates the infants body temperature every hour. Maintaining the newborns body temperature is important for preventing:
a. Respiratory depression.
b. Cold stress
c. Tachycardia
d. Vasoconstriction.
ANS: B
Loss of heat must be controlled to protect the infant from the metabolic and physiologic effects of cold stress, and that is the primary reason for placing a newborn under a radiant heat warmer. Cold stress results in an increased respiratory rate and vasoconstriction.
With regard to the respiratory development of the newborn, nurses should be aware that:
a. The first gasping breath is an exaggerated respiratory reaction within 1 minute of birth.
b. Newborns must expel the fluid from the respiratory system within a few minutes of birth.
c. Newborns are instinctive mouth breathers.
d. Seesaw respirations are no cause for concern in the first hour after birth.
ANS: A
The first breath produces a cry. Newborns continue to expel fluid for the first hour of life. Newborns are natural nose breathers; they may not have the mouth-breathing response to nasal blockage for 3 weeks. Seesaw respirations instead of normal abdominal respirations are not normal and should be reported.
With regard to the newborns developing cardiovascular system, nurses should be aware that:
a. The heart rate of a crying infant may rise to 120 beats/min.
b. Heart murmurs heard after the first few hours are cause for concern.
c. The point of maximal impulse (PMI) often is visible on the chest wall.
d. Persistent bradycardia may indicate respiratory distress syndrome (RDS).
ANS: C
The newborns thin chest wall often allows the PMI to be seen. The normal heart rate for infants who are not sleeping is 120 to 160 beats/min. However, a crying infant temporarily could have a heart rate of 180 beats/min. Heart murmurs during the first few days of life have no pathologic significance; an irregular heart rate past the first few hours should be evaluated further. Persistent tachycardia may indicate RDS; bradycardia may be a sign of congenital heart blockage.
During life in utero, oxygenation of the fetus occurs through transplacental gas exchange. When birth occurs, four factors combine to stimulate the respiratory center in the medulla. The initiation of respiration then follows. Which is not one of these essential factors?
a. Chemical
b. Mechanical
c. Thermal
d. Psychologic
ANS: D
A psychologic factor is not one of the essential factors in the initiation of breathing; the fourth factor is sensory. The sensory factors include handling by the provider, drying by the nurse, lights, smells, and sounds. Chemical factors are essential for the initiation of breathing. During labor, decreased levels of oxygen and increased levels of carbon dioxide seem to have a cumulative effect that is involved in the initiation of breathing. Clamping of the cord may also contribute to the start of respirations. Prostaglandins are known to inhibit breathing, and clamping of the cord results in a drop in the level of prostaglandins. Mechanical factors also are necessary to initiate respirations. As the infant passes through the birth canal, the chest is compressed. With birth the chest is relaxed, which allows for negative intrathoracic pressure that encourages air to flow into the lungs. The profound change in temperature between intrauterine and extrauterine life stimulates receptors in the skin to communicate with the receptors in the medulla. This also contributes to the initiation of breathing.
Infants of mothers with diabetes (IDMs) are at higher risk for developing:
a. Anemia.
b. Hyponatremia
c. Respiratory distress syndrome
d. Sepsis.
ANS: C
IDMs are at risk for macrosomia, birth injury, perinatal asphyxia, respiratory distress syndrome, hypoglycemia, hypocalcemia, hypomagnesemia, cardiomyopathy, hyperbilirubinemia, and polycythemia. They are not at risk for anemia, hyponatremia, or sepsis.
A premature infant with respiratory distress syndrome receives artificial surfactant. How would the nurse explain surfactant therapy to the parents?
a. Surfactant improves the ability of your babys lungs to exchange oxygen and carbon dioxide.
b. The drug keeps your baby from requiring too much sedation.
c. Surfactant is used to reduce episodes of periodic apnea.
d. Your baby needs this medication to fight a possible respiratory tract infection.
ANS: A
Surfactant can be administered as an adjunct to oxygen and ventilation therapy. With administration of artificial surfactant, respiratory compliance is improved until the infant can generate enough surfactant on his or her own. Surfactant has no bearing on the sedation needs of the infant. Surfactant is used to improve respiratory compliance, including the exchange of oxygen and carbon dioxide. The goal of surfactant therapy in an infant with respiratory distress syndrome (RDS) is to stimulate production of surfactant in the type 2 cells of the alveoli. The clinical presentation of RDS and neonatal pneumonia may be similar. The infant may be started on broad-spectrum antibiotics to treat infection.
An infant is to receive gastrostomy feedings. What intervention should the nurse institute to prevent bloating, gastrointestinal reflux into the esophagus, vomiting, and respiratory compromise?
a. Rapid bolusing of the entire amount in 15 minutes
b. Warm cloths to the abdomen for the first 10 minutes
c. Slow, small, warm bolus feedings over 30 minutes
d. Cold, medium bolus feedings over 20 minutes
ANS: C
Feedings by gravity are done slowly over 20- to 30-minute periods to prevent adverse reactions. Rapid bolusing of the entire amount in 15 minutes would most likely lead to the adverse reactions listed. Temperature stability in the newborn is critical. Warm cloths to the abdomen for the first 10 minutes would not be appropriate because it is not a thermoregulated environment. Additionally, abdominal warming is not indicated with feedings of any kind. Small feedings at room temperature are recommended to prevent adverse reactions.
An infant at 26 weeks of gestation arrives intubated from the delivery room. The nurse weighs the infant, places him under the radiant warmer, and attaches him to the ventilator at the prescribed settings. A pulse oximeter and cardiorespiratory monitor are placed. The pulse oximeter is recording oxygen saturations of 80%. The prescribed saturations are 92%. The nurses most appropriate action would be to:
a. Listen to breath sounds and ensure the patency of the endotracheal tube, increase oxygen, and notify a physician.
b. Continue to observe and make no changes until the saturations are 75%.
c. Continue with the admission process to ensure that a thorough assessment is completed.
d. Notify the parents that their infant is not doing well.
ANS: A
Listening to breath sounds and ensuring the patency of the endotracheal tube, increasing oxygen, and notifying a physician are appropriate nursing interventions to assist in optimal oxygen saturation of the infant. Oxygenation of the infant is crucial. O2 saturation should be maintained above 92%. Oxygenation status of the infant is crucial. The nurse should delay other tasks to stabilize the infant. Notifying the parents that the infant is not doing well is not an appropriate action. Further assessment and intervention are warranted before determination of fetal status.
An infant is being discharged from the neonatal intensive care unit after 70 days of hospitalization. The infant was born at 30 weeks of gestation with several conditions associated with prematurity, including respiratory distress syndrome, mild bronchopulmonary dysplasia, and retinopathy of prematurity requiring surgical treatment. During discharge teaching the infants mother asks the nurse whether her baby will meet developmental milestones on time, as did her son who was born at term. The nurses most appropriate response is:
a. Your baby will develop exactly like your first child did.
b. Your baby does not appear to have any problems at the present time.
c. Your baby will need to be corrected for prematurity. Your baby is currently 40 weeks of postconceptional age and can be expected to be doing what a 40-week-old infant would be doing.
d. Your baby will need to be followed very closely.
ANS: C
The age of a preterm newborn is corrected by adding the gestational age and the postnatal age. The infants responses are evaluated accordingly against the norm expected for the corrected age of the infant. Although it is impossible to predict with complete accuracy the growth and development potential of each preterm infant, certain measurable factors predict normal growth and development. The preterm infant experiences catch-up body growth during the first 2 to 3 years of life. The growth and developmental milestones are corrected for gestational age until the child is approximately 2.5 years old. Stating that the baby does not appear to have any problems at the present time is inaccurate. Development will need to be evaluated over time.
A pregnant woman was admitted for induction of labor at 43 weeks of gestation with sure dates. A nonstress test (NST) in the obstetricians office revealed a nonreactive tracing. On artificial rupture of membranes, thick, meconium-stained fluid was noted. The nurse caring for the infant after birth should anticipate:
a. Meconium aspiration, hypoglycemia, and dry, cracked skin.
b. Excessive vernix caseosa covering the skin, lethargy, and respiratory distress syndrome.
c. Golden yellow- to green stainedskin and nails, absence of scalp hair, and an increased amount of subcutaneous fat.
d. Hyperglycemia, hyperthermia, and an alert, wide-eyed appearance.
ANS: A
Meconium aspiration, hypoglycemia, and dry, cracked skin are consistent with a postmature infant. Excessive vernix caseosa covering the skin, lethargy, and respiratory distress syndrome would be consistent with a very premature infant. The skin may be meconium stained, but the infant would most likely have longer hair and decreased amounts of subcutaneous fat. Postmaturity with a nonreactive NST would indicate hypoxia. Signs and symptoms associated with fetal hypoxia are hypoglycemia, temperature instability, and lethargy.
In the assessment of a preterm infant, the nurse notices continued respiratory distress even though oxygen and ventilation have been provided. The nurse should suspect:
a. Hypovolemia and/or shock.
b. A nonneutral thermal environment.
c. Central nervous system injury.
d. Pending renal failure.
ANS: A
The nurse should suspect hypovolemia and/or shock. Other symptoms could include hypotension, prolonged capillary refill, and tachycardia followed by bradycardia. Intervention is necessary.
Premature infants who exhibit 5 to 10 seconds of respiratory pauses followed by 10 to 15 seconds of compensatory rapid respiration are:
a. Suffering from sleep or wakeful apnea.
b. Experiencing severe swings in blood pressure.
c. Trying to maintain a neutral thermal environment.
d. Breathing in a respiratory pattern common to premature infants.
ANS: D
This pattern is called periodic breathing and is common to premature infants. It may still require nursing intervention of oxygen and/or ventilation. Apnea is a cessation of respirations for 20 seconds or longer. It should not be confused with periodic breathing.
A nursing student is helping the nursery nurses with morning vital signs. A baby born 10 hours ago by cesarean section is found to have moist lung sounds. What is the best interpretation of these data?
a. The nurse should notify the pediatrician stat for this emergency situation.
b. The neonate must have aspirated surfactant.
c. If this baby was born vaginally, it could indicate a pneumothorax.
d. The lungs of a baby delivered by cesarean section may sound moist for 24 hours after birth.
ANS: D
The condition will resolve itself within a few hours. For this common condition of newborns, surfactant acts to keep the expanded alveoli partially open between respirations. In vaginal births, absorption of remaining lung fluid is accelerated by the process of labor and delivery. Remaining lung fluid will move into interstitial spaces and be absorbed by the circulatory and lymphatic systems. This is a particularly common condition for infants delivered by cesarean section. Surfactant is produced by the lungs, so aspiration is not a concern.
