OB Quiz 2 Flashcards
A nurse is caring for a client who is postpartum and finds the fundus slightly boggy and displaced to the right. Based on these findings, which of the following actions should the nurse take?
Assist the client to the bathroom to void
Rationale: A full bladder causes the uterus to be displaced and above the umbilicus and off to one side. This prevents the uterus from contracting normally and increases the risk of hemorrhage.
What medications are often given for postpartum hemorrhage?
Methylergonovine
Oxytocin
Misoprostol
Carboprost Tromethamine
Before administering methylergonovine (Methergine), the nurse checks the**
a. color of the lochia.
b. blood pressure.
c. location of the fundus.
d. last administration of analgesics.
ANS: B
Rationale: Methylergonovine (Methergine) elevates the blood pressure and should not be given to a woman who is hypertensive. The color of the lochia, location of the fundus, and analgesics are not related to the administration of or contraindicated to this medication.
Which fetal position may cause the laboring patient increased back discomfort?
a. Left occiput anterior
b. Left occiput posterior
c. Right occiput anterior
d. Right occiput transverse
ANS: B
Rationale: In the left occiput posterior position, each contraction pushes the fetal head against the mother’s sacrum, which results in intense back discomfort. Back labor is seen mostly when the fetus is in the posterior position.
A client in the early postpartum period is talkative and enjoys recounting the details of her labor and birth. The nurse recognizes that the behaviors must likely indicate which of the following?
Select one:
a. The taking-hold phase of maternal psychosocial adaptation.
b. Postpartum role transition.
c. The taking-in phase of maternal postpartum adjustment.
d. Positive mother-infant bonding.
Answer: C. The taking-in phase begins immediately following birth and lasts a few hours to a couple of days. It is characterized by the mother being excited and talkative, reliving her birthing experience, and focusing on her own needs and the overall health of her newborn.
A nurse is caring for a client who has postpartum psychosis. Which of the following actions is the nurses priority?
a. Reinforce the need to take antipsychotics as prescribed
b. Ask the client if they have had thoughts of harming themselves or their infant
c. Monitor the infant for indications of failure to thrive
d. Review the clients medical record for a history of bipolar disorder
ANS: B
Which situation would require the administration of Rho(D) immune globulin?
a. Mother Rh-negative, baby Rh-positive
b. Mother Rh-negative, baby Rh-negative
c. Mother Rh-positive, baby Rh-positive
d. Mother Rh-positive, baby Rh-negative
ANS: A
Rationale: An Rh-negative mother delivering an Rh-positive baby may develop antibodies to fetal cells that entered her bloodstream when the placenta separated. The Rho(D) immune globulin works to destroy the fetal cells in the maternal circulation before sensitization occurs. When the blood types are alike as with mother Rh-negative, baby Rh-negative, no antibody formation would be anticipated. If the Rh-positive blood of the mother comes in contact with the Rh-negative blood of the infant, no antibodies would develop because the antigens are in the mother’s blood, not the infant’s.
A nurse is teaching a client who is postpartum and has a new prescription for an injection of Rho (D) immunoglobulin. Which of the following should be included in the teaching?
A. It destroys Rh antibodies in newborns who are Rh positive.
B. It destroys Rh antibodies in mothers who are Rh negative.
C. It prevents the formation of Rh antibodies in mothers who are Rh negative.
D. It prevents the formation of Rh antibodies in newborns who are Rh positive.
It prevents the formation of Rh antibodies in mothers who are Rh negative.
Rationale: Rho (D) immunoglobulin prevents the immune system of a client who is Rh negative from reacting to accidental exposure to fetal blood during pregnancy or delivery. If the client has another Rh positive fetus in the future, these antibodies can destroy the blood cells of the fetus. Rho (D) immunoglobulin is administered routinely to Rh negative mothers at 28 weeks of gestation and following any pregnancy outcome (including birth or any planned or unintentional fetal loss).
A 29-year-old gravida 3 para 3, was admitted to the recovery unit 2 hours after the birth of a 9-lb baby girl. The nurse assesses the client an hour later and finds her fundus, which is slightly boggy, three fingerbreadths above the umbilicus and displaced to the right. The peripad, which was changed before the client’s transfer, is now saturated. The nurse recognizes:
1
A distended bladder
2
A probable perineal infection
3
Uncontrolled postpartum pain
4
A typical finding in the immediate postpartum period
-A distended bladder
Urine retention resulting in a distended bladder will lift and displace the uterus, making it difficult to remain contracted. These findings would not be caused by uncontrolled postpartum pain. It is too early after the delivery for signs of a perineal infection to be noted. The loss of uterine tone (atony) leads to an increase in bleeding.
A patient who underwent a vaginal delivery 3 hours earlier reports having severe perineal pain. Which would be the first step taken by the nurse in this situation
Apply ice packs in the perineum
if the patient reports severe perineal pain after vaginal delivery, the nurse should apply ice packs in the first 24 hours to reduce edema, pain, and vulvar irritation. Administering fluids and blood compensates for blood loss in the patient, but they do not reduce pain. Postpartum hematologic studies are performed to assess the consequences of blood loss. This intervention does not reduce pain in the patient.
What are some physical assessment findings you would see any patient with premature ruptured membranes?
-temperature elevation
-increased maternal heart rate for fetal heart rate
-foul smelling fluid of a vaginal discharge
-abdominal tenderness
-assessed for prolapsed umbilical cord
* abrupt fetal heart rate variable or prolong deceleration
* visible or palpable court introitus
A nurse is caring for a client who is 7 days postpartum and calls the clinic to report pain and redness of her left calf. Besides seeing her provider, which of the following interventions should the nurse suggest?
Flex her knee while resting.
Massage the area.
Elevate her leg.
Apply cold compresse
elevate her leg
Rationale: The client should elevate her leg to encourage venous return and to relieve pain
A nurse is planning care for a client who is 2 hours postpartum following a cesarean birth. The client has a history of thromboembolic disease. Which of the following nursing interventions should be included in the plan of care?
A.
Place 3 to 4 pillows under the client’s knees when resting in bed.
B.
Massage the client’s posterior lower legs.
C.
Have the client ambulate.
D.
Apply warm, moist heat to the client’s lower extremities.
Have the client ambulate
Rationale: Venous stasis is a major cause of thrombophlebitis. To prevent clot formation, have the client ambulate as soon as she can after delivery and as often as possible.
A nurse is caring for a client who experienced a vaginal birth 12 hr ago. The nurse recognizes the client is in the dependent, taking in phase of maternal postpartum adjustment. Which of the following findings should the nurse expect during this phase?
A. Expression of excitement
B. Lack of appetite
C. Focus on the family unit and its members
D. Eagerness to learn newborn care skills
Expressions of excitement
Rationale: Expressing excitement and being talkative are characteristic of this phase.
A nurse is caring for a client who is postpartum and received methylergonovine (methergine). Which of the following findings indicates that the medication was effective?
A.
Report of absent breast pain
B.
Increase in lochia
C.
Increase in blood pressure
D.
Fundus firm to palpation
Fundus firm to palpation
Rationale: Methylergonovine is an oxytocic medication that is administered to promote uterine contractions. This medication is indicated for treatment of postpartum hemorrhage caused by uterine atony or subinvolution; the desired effect is an increase in uterine tone.
To monitor for potential hemorrhage in the patient who has just had a cesarean birth, which action should the recovery room nurse implement?
a. Monitor her urinary output.
b. Maintain an intravenous infusion at 1 mL/hour.
c. Assess the abdominal dressings for drainage.
d. Assess the uterus for firmness every 15 minutes.
ANS: D
Rationale: Maintaining contraction of the uterus is important for controlling bleeding from the placental site. Maintaining proper fluid balance will not control hemorrhage. Monitoring urine output is an important assessment, but hemorrhage will first be noted vaginally. Assessing the abdominal dressing is an important assessment to prevent future hemorrhaging from occurring but is not the first priority assessment in the recovery room.
What medication should the nurse anticipate giving to a client in preterm labor to stimulate maturation of the baby’s lungs?
- Magnesium sulfate
- Terbutaline
- Methotrexate
- Betamethasone
- Correct: Betamethasone is used to stimulate maturation of the baby’s lungs in case preterm birth occurs. This medication is given to help prevent respiratory distress syndrome (RDS) by improving storage and secretion of surfactant that helps to keep the alveoli from collapsing.
Which is the priority nursing assessment for the patient undergoing tocolytic therapy with terbutaline (Brethine)?
a. Intake and output
b. Maternal blood glucose level
c. Internal temperature and odor of amniotic fluid
d. Fetal heart rate, maternal pulse, and blood pressure
ANS: D
Rationale: All assessments are important; however, those most relevant to tocolytic therapy include the fetal heart rate and maternal pulse, which tend to increase, and the maternal blood pressure, which tends to exhibit a wide pulse pressure. Intake and output and glucose are not important assessments to monitor for side effects of terbutaline. Internal temperature and odor of amniotic fluid are important if the membranes have ruptured; however, these are not relevant to the medication.
Emergency measures used in the treatment of a prolapsed cord include which of the following? (Select all that apply.)
a. Administration of oxygen via face mask at 8 to 10 L/minute
b. Maternal change of position to knee-chest
c. Administration of tocolytic agent
d. Administration of oxytocin (Pitocin)
e. Vaginal elevation
f. Insertion of cord back into vaginal area
ANS: A,B,C,E
Rationale: Prolapsed cord is a medical emergency. Oxygen should be administered to the mother to increase perfusion from mother to fetus. The maternal position change to knee-chest or Trendelenburg to offset pressure on the presenting cord should be done. A tocolytic drug such as terbutaline inhibits contractions, increasing placental blood flow and reducing intermittent pressure of the fetus against the pelvis and cord. Vaginal elevation should be done to offset pressure on the presenting cord. Pitocin and manipulation of the cord by reinsertion are contraindicated.
The nurse providing care for a woman with preterm labor who is receiving terbutaline would include which intervention to identify side effects of the drug? a. Assessing deep tendon reflexes (DTRS) b. Assessing for chest discomfort and palpitations с. Assessing for bradycardia d. Assessing for hypoglycemia
ANS: B Terbutaline is a b2-adrenergic agonist that affects the cardiopulmonary and metabolic systems of the mother. Signs of cardiopulmonary decompensation would include chest pain and palpitations. Assessing DTRS would not address these concerns. b2-Adrenergic agonist drugs cause tachycardia, not bradycardia. The metabolic effect leads to hyperglycemia, not hypoglycemia.
A nurse is caring for a client who is at 28 weeks of gestation and received terbutaline. Which of the following findings should the nurse expect?
Fetal heart rate 100//min
Weakened uterine contractions
Enhanced production of fetal lung surfactant
Maternal blood glucose 63mg//dL
Weakened uterine contractions
What are the 4 T’s if postpartum hemorrhage?
Tissue, Tone, Traumatic Delivery, Thrombin
The nurse is assessing the breast of a woman who is 1 month postpartum. The woman reports a painful area on one breast with a red area. The nurse notes a local area on one breast to be red and warm to touch. What should the nurse consider as the potential diagnosis?
breast yeast
mastitis
plugged milk duct
engorgement
Mastitis
- Mastitis usually occurs 2 to 3 weeks after birth and is noted to be unilateral. Mastitis needs to be assessed and treated with antibiotic therapy.
Subinvolution of Uterus ati:
findings:
enlarged or higher than normal uterus relative to umbilicus
boggy uterus
prolonged lochia discharge w/ irregular bleeding
medications:
give methergine, antibiotics
monitor:
Fundus, lochia , cultures, VS, pain levels
therapeutic procedure:
D&C
