Study Guide Maternal Newborn Mid-Term Flashcards
A nurse is caring for a client who has unrelieved episiotomy pain 8 hr following delivery. Which of the following actions should the nurse take?
a. Apply an ice pack to the perineum.
b. Prepare a warm sitz bath.
c. Place a soft pillow under the client’s buttocks.
d. Position a heating lamp toward the episiotomy.
a. Apply an ice pack to the perineum.
During the first 24 hr, ice packs and cool water sitz baths should be used. This should reduce edema and reduce discomfort. The client can also apply witch hazel compresses to reduce edema. The nurse should also teach the client to use prescribed creams, sprays, and ointments.
A nurse is collecting data from a client who is 1 day postpartum. Which of the following findings requires immediate intervention by the nurse?
a. Decreased urge to void
b. Increased urine output
c. Displaced fundus from the midline
d. Fundal height below the umbilicus
c. Displaced fundus from the midline
Uterine atony results from the inability of the uterine muscle to contract adequately after birth. This can lead to postpartum hemorrhage. A distended bladder can cause uterine atony and lateral displacement from the midline of the lower abdomen, usually to the right. This occurs because the distended bladder pushes the uterus up and to the side, which prevents it from contracting firmly. This finding requires immediate intervention by the nurse.
A nurse is assisting with the care of a client who has severe preeclampsia and is receiving magnesium sulfate IV at 2 g/hr. Which of the following findings indicates that is is safe for the nurse to continue the infusion?
a. Diminished deep-tendon reflexes
b. Respiratory rate of 16/min
c. Urine output of 50 mL in 4 hr
d. Heart rate of 60/min
b. Respiratory rate of 16/min
Respiratory rate of 16/min
The client’s respiratory rate should be at least 12/min as a precaution against excessive depression of impulses at the myoneural junction. Based on this finding, the nurse can continue the infusion.
A nurse is reviewing the medical record of a client who experienced a vaginal birth 2 hr ago. The nurse should identify that which of the following findings places the client at risk for a postpartum hemorrhage?
a. Two-vessel umbilical cord
b. Precipitous birth
c. Small for gestational age newborn
d. Gestational hypertension
b. Precipitous birth
A client who has a precipitous birth is at an increased risk for postpartum hemorrhage.
A nurse is admitting a client who is at 36 weeks gestation and has painless, bright red vaginal bleeding. The nurse recognizes this finding as an indication of which of the following conditions?
a. Abruptio placentae
b. Placenta previa
c. Preterm labor
d. Threatened abortion
b. Placenta previa
Painless, bright red vaginal bleeding is a manifestation of placenta previa.
A nurse in a provider’s office is collecting data from a female client in her third trimester of pregnancy. The client describes actions she took to obtain relief from a headache which lasted all day. Which of the following client statements should the nurse identify as the priority?
a. “I ignored the headache pain and just kept on going.”
b. “I skipped lunch and took 1000 mg of acetaminophen with sips of water.”
c. “I drank three 8-ounce cups of coffee with extra sugar and cream.”
d. “I took 400 mg of ibuprofen with a diet soda.”
d. “I took 400 mg of ibuprofen with a diet soda.”
Taking a non-steroidal anti-inflammatory drug (NSAID) during pregnancy indicates the greatest risk is injury to the fetus. Ibuprofen is a category C medication during the first two trimesters of pregnancy, and contraindicated (category D) during the 3rd trimester. NSAIDs inhibit prostaglandin synthesis, which is required to maintain patency of the ductus arteriosus for the fetus and maintain fetal circulation. NSAIDs can also cause blood dyscrasias and increase bleeding time, both of which can harm the mother and fetus.
A nurse is reinforcing teaching about nutritional needs with a client who is pregnant. Which of the following nutrients should the nurse instruct the client to increase to increase during pregnancy?
a. Calcium
b. Vitamin D
c. Vitamin E
d. Iron
d. Iron
During pregnancy, the need for iron increases to allow transfer of the appropriate amounts to the fetus and to support expansion of the client’s red blood cell volume.
A nurse is caring for a client who is postpartum and asks, “When will my breast milk come in?” Which of the following responses should the nurse make?
a. Within 2 days after delivery
b. In 3 to 5 days after delivery
c. In 6 to 8 days after delivery
d. In about 10 days after delivery
b. In 3 to 5 days after delivery
By day 3 to 5, most clients who are breastfeeding begin to produce copious amounts of breast milk.
A nurse is reinforcing teaching with a client about checking her basal temperature to identify when ovulation occurs. The nurse should instruct the client to check her temperature at which of the following times?
a. Every morning before arising
b. Only on days 13 to 17 of her menstrual cycle
c. 1 hr after vaginal intercourse
d. Immediately after getting into bed at night
a. Every morning before arising
The nurse should instruct the client to measure her temperature every morning throughout her menstrual cycle, upon waking, before getting out of bed. Activity or movement can raise body temperature slightly and provide inaccurate results. The client should use a special thermometer that is accurate to the tenth of a degree.
A nurse is assisting with the care of a client who is using pattern-paced breathing during the first stage of labor. The client says she feels lightheaded and her fingers are tingling. Which of the following actions should the nurse take?
a. Administer oxygen via nasal cannula.
b. Assist the client to breathe into a paper bag.
c. Have the client tuck her chin to her chest.
d. Instruct the client to maintain a breathing rate no less than twice the normal rate.
b. Assist the client to breathe into a paper bag.
This client is experiencing respiratory alkalosis due to hyperventilation. She needs to rebreathe carbon dioxide to replace the bicarbonate ion by breathing into a paper bag or her cupped hands.
A nurse is admitting a term newborn to the nursery following a cesarean birth. The nurse observes that the newborn’s skin is slightly yellow. This finding indicates the newborn is experiencing a complication related to which of the following?
a. Maternal/newborn blood group incompatibility
b. Absence of vitamin K
c. Physiologic jaundice
d. Maternal cocaine abuse
a. Maternal/newborn blood group incompatibility
Maternal/newborn blood group incompatibility is the most common cause of pathologic jaundice, with the jaundice appearing within the first 24 hr of life.
A nurse is assisting a client who is postpartum with her first breastfeeding experience. When the client asks how much of the nipple she should put into the baby’s mouth, which of the following responses by the nurse is appropriate?
a. “You should place your nipple and some of the areola into her mouth.”
b. “Babies know instinctively exactly how much of the nipple to take into their mouth.”
c. “Your baby’s mouth is rather small so she will only take part of the nipple.”
d. “Try to place the nipple, the entire areola, and some breast tissue beyond the areola into her mouth.”
a. “You should place your nipple and some of the areola into her mouth.”
Placing the nipple and part of the areola into the baby’s mouth will aid in adequately compressing the milk ducts. This placement also decreases stress on the nipple and helps prevent cracking and soreness.
A nurse is reinforcing teaching about reducing the risk of perineal infection with a client who had a vaginal birth. Which of the following information should the nurse include in the teaching? (Select all that apply.)
a. Sit on an inflatable donut to protect the perineum.
b. Apply ice packs to the perineal area several times daily.
c. Clean the perineal area from front to back.
d. Blot the perineal area dry after voiding.
e. Perform hand hygiene before and after voiding.
c. Clean the perineal area from front to back.
d. Blot the perineal area dry after voiding.
e. Perform hand hygiene before and after voiding.
Blot the perineal area dry after voiding is correct. The nurse should instruct the client to blot the perineal area dry after voiding. Secretions that are allowed to remain on the perineum can be a medium for bacterial growth, which increases the risk for infection. Therefore, the perineal area should be thoroughly dried by blotting after each void.
Clean the perineal area from front to back is correct. The nurse should instruct the client to clean the perineal area from front to back. Cleaning the perineum from front to back decreases the chances of transmitting fecal organisms to other areas, such as the urinary meatus, episiotomy incision, or lacerations resulting from childbirth.
Perform hand hygiene before and after voiding is correct. The nurse should instruct the client to perform hand hygiene before and after voiding. Hand hygiene is the primary method of reducing micro-organisms on the hands, thereby reducing the risk of transmission that can lead to infection.
Apply ice packs to the perineal area several times daily is incorrect. The nurse should not instruct the client to apply ice packs to the perineal area to reduce the risk of infection. Ice packs can be applied to the perineal area for the first 24 hr after birth to decrease edema and to reduce discomfort.
Sit on an inflatable donut to protect the perineum is incorrect. The nurse should not instruct the client to sit on an inflatable donut because this separates the buttocks, which decreases venous blood flow. This does not decrease the client’s risk of perineal infection.
A nurse is assisting with a community program to educate adolescents about contraception. After the class, a 15-year-old girl asks the nurse which method is best for her to use. Which of the following statements is an appropriate nursing response?
a. “You are so young. Are you sure you are ready for the responsibilities of a sexual relationship?”
b. ”Because of your age, we need your parents’ consent for an examination, and then we’ll talk.”
c. ”Before I can help you with that question, I need to know more about your sexual activity.”
d. ”The doctor can best help you with that after your physical examination.”
c. ”Before I can help you with that question, I need to know more about your sexual activity.”
Effective consultation with a client about the best form of birth control for her requires further data collection about the frequency of intercourse, number of partners, and her own motivation and reliability.
A nurse is reinforcing teaching with a client who is pregnant and has a body mass index (BMI) of 26.5 She asks the nurse how much weight she should gain over the course of her pregnancy. Which of the following statements is an appropriate response by the nurse?
a. “You should gain 11 to 20 pounds.”
b. “The recommendation for you is about 15 to 25 pounds.”
c. ”A gain of about 25 to 35 pounds is best for you and for your baby.”
d. “It really doesn’t matter exactly how much weight you gain, as long as your diet is healthy.”
b. “The recommendation for you is about 15 to 25 pounds.”
The client’s BMI indicates that she is overweight. Overweight clients should gain 7 to 11.5 kg (15 to 25 lb). The nurse should also reinforce that the pattern of weight gain is important, with minimal gain in the first trimester.
A nurse is caring for a client in the immediate postoperative period following removal of an ectopic pregnancy via salpingostomy. For which of the following indications should the nurse administer Rho(D) immune globulin?
a. The client is Rh-negative.
b. The client has previously given birth to an Rh-negative infant.
c. The client has expressed a desire to conceive again.
d. The client has had significant blood loss during the procedure.
a. The client is Rh-negative.
Administering Rho(d) immune globulin to the client prevents the formation of antibodies to Rh-positive blood. Exposure can occur following delivery, spontaneous or induced abortion, or amniocentesis involving an Rh-positive fetus.
A nurse is caring for a client who is experiencing shaking chills during the immediate postpartum period. Which of the following actions should the nurse take?
a. Place the client on seizure precautions.
b. Notify the charge nurse.
c. Cover the client with warm blankets.
d. Determine the client’s temperature.
c. Cover the client with warm blankets.
Shaking chills often occur immediately postpartum due to the cool birthing room, excess epinephrine production during the birth, and the sudden release of pressure on the pelvic nerves. The nurse should cover the client with a warm blanket following delivery.
A nurse is caring for a client who is at 36 weeks of gestation and has suspected placenta previa. For which of the following findings should the nurse monitor the client?
a. A large amount of bright red vaginal bleeding without pain
b. Severe abdominal pain with increasing fundal height
c. Abdominal pain with minimal red vaginal bleeding
d. Intermittent abdominal pain following passage of bloody mucus
a. A large amount of bright red vaginal bleeding without pain
With placenta previa, the placenta implants in the lower part of the uterus, partly or completely obstructing the cervical os, or outlet to the vagina. Clients who have placenta previa have sudden, painless vaginal bleeding, typically in the third trimester.
A nurse is assisting with the care of a client who is in labor. Immediately after delivery of a newborn, which of the following actions should the nurse take first?
a. Conduct a gestational age assessment
b. Examine the newborn for birth defects.
c. Confirm identification and apply a bracelet.
d. Dry the newborn.
d. Dry the newborn.
Using the urgent vs nonurgent framework for nursing care, the nurse should first dry the newborn. Failing to dry and keep the newborn warm can cause cold stress, which results in unnecessary use of oxygen by the newborn, resulting in respiratory distress and decreased PaO2.
A nurse is assisting with the admission of a client who is at 39 weeks of gestation and has heavy vaginal bleeding. Which of the following actions should the nurse take?
a. Request the RN perform a cervical examination.
b. Initiate an IV infusion of magnesium sulfate.
c. Administer antibiotics.
d. Prepare for cesarean birth.
d. Prepare for cesarean birth.
The nurse should begin preparing for a cesarean birth for a client who is full term and has heavy vaginal bleeding. A client who has heavy vaginal bleeding is at risk for hemorrhage and subsequent fetal compromise. Therefore, immediate delivery via cesarean section will likely be advised.
A nurse is reinforcing teaching with a client who is at 23 weeks of gestation and will return to the facility the following week for an amniocentesis. Which of the following instructions should the nurse include?
a. Refrain from eating breakfast the day of the procedure.
b. Give herself a hypertonic enema the day before the procedure.
c. Empty her bladder immediately prior to the procedure.
d. Wash her abdomen with soap and water the morning of the procedure.
c. Empty her bladder immediately prior to the procedure.
Emptying her bladder before amniocentesis prevents possible puncture of the bladder and displacement of the uterus and fetus.
A nurse is caring for a group of clients on an intrapartum unit. Which of the following findings should be reported to the RN immediately?
a. A client who is at 32 weeks of gestation and is experiencing irregular, frequent contractions is tearful
b. A client who is at 28 weeks of gestation and receiving terbutaline reports fine tremors
c. A client who has preeclampsia has 2+ patellar reflexes and 2+ proteinuria
d. A client who has preeclampsia and reports epigastric pain and unresolved headache
d. A client who has preeclampsia and reports epigastric pain and unresolved headache
When using the urgent vs nonurgent framework for nursing care, the nurse should report these findings to the charge nurse. These manifestations indicate that the client’s condition is worsening and are manifestations of severe preeclampsia. Manifestations of severe preeclampsia include BP 160/100 mm Hg or greater; proteinuria 3 to 4+; oliguria; elevated serum creatinine greater than 1.2 mg/dL; cerebral or visual disturbances; hyperreflexia with possible ankle clonus; pulmonary, cardiac, or hepatic involvement, including elevated liver enzymes, nausea, vomiting, epigastric pain, and right upper-quadrant pain; extensive peripheral edema; and thrombocytopenia.
A nurse is reinforcing teaching about quickening with a client who is at 6 weeks of gestation. Which of the following information should the nurse include?
a. Quickening starts soon after implantation.
b. Quickening occurs between the second and third months of pregnancy.
c. Quickening occurs between the fourth and fifth months of pregnancy.
d. Quickening starts during the last weeks of pregnancy.
c. Quickening occurs between the fourth and fifth months of pregnancy.
Quickening is defined as the first time the client is able to feel the fetus move. It usually occurs between 14 and 18 weeks of gestation.
A nurse in a prenatal clinic is caring for a client who is at 12 weeks of gestation. The client asks about the cause of her heartburn. Which of the following responses should the nurse make?
a. Increased pancreatic activity results in intolerance of fat in the diet.
b. Increased estrogen production causes increased secretion of hydrochloric acid.
c. Pressure from the growing uterus displaces the stomach.
d. Increased progesterone production causes decreased motility of smooth muscle.
d. Increased progesterone production causes decreased motility of smooth muscle.
Increased progesterone production causes a relaxation of the cardiac sphincter and delayed gastric emptying, which can result in heartburn.
A nurse reinforcing teaching about vitamin K with a client who is postpartum. Which of the following statements should the nurse include?
a. Vitamin K decreases the newborn’s risk of hemorrhagic disorders.
b. Vitamin K decreases the newborn’s risk of jaundice.
c. Vitamin K decreases the newborn’s risk of health care-associated infections.
d. Vitamin K decreases the newborn’s risk of complications from the Hepatitis B vaccine.
a. Vitamin K decreases the newborn’s risk of hemorrhagic disorders.
Newborns cannot produce vitamin K until about 8 days after birth. It is administered in the delivery suite to prevent hemorrhagic disorders.
A nurse is collecting data from a client who is 12 hr postpartum following a spontaneous vaginal delivery. The nurse should expect to find the uterine fundus at which of the following positions on the client’s abdomen?
a. At the level of the umbilicus
b. Three fingerbreadths above the umbilicus
c. One fingerbreadth above the symphysis pubis
d. To the right of the umbilicus
a. At the level of the umbilicus
Within 12 hr, the fundus should rise to the level of the umbilicus and then recede 1 to 2 cm each day.
A nurse is assisting with the care of a client who is at 37 weeks of gestation and has placenta previa. Which of the following risks is the primary reason the nurse should avoid performing a pelvic examination?
a. Infection
b. Preterm labor
c. Profound bleeding
d. Rupture of the fetal membranes
c. Profound bleeding
The greatest risk to the client is hemorrhage. The nurse should place the client on pelvic rest, which means no vaginal examinations, no douching, and no vaginal intercourse. This is because any pressure on the placenta could cause its premature separation and life-threatening hemorrhage.
A nurse is caring for a client who is pregnant and undergoing a nonstress test. The nurse records the FHR as 130 to 150/min, with no fetal movement for 15 min. Which of the following actions should the nurse take?
a. Encourage the client to walk around and then resume monitoring.
b. Apply vibroacoustic stimulation to the woman’s abdomen.
c. Report the findings to the provider and prepare the client for induction of labor.
d. Turn the client onto her left side.
b. Apply vibroacoustic stimulation to the woman’s abdomen.
This technique is sometimes used with a nonstress test to stimulate a fetal response. A sound source, typically a laryngeal stimulator, is applied to the client’s abdomen over the fetal head for 3 seconds.
A nurse is reinforcing teaching about comfort measures for breast engorgement with a client who is postpartum and is bottle feeding her newborn. Which of the following statements by the client indicates a need for further teaching?
a. “I will wear a snug fitting bra.”
b. “I will apply ice packs to my breasts.”
c. “I should stimulate my nipples by squeezing softly.”
d. “I should crush cabbage leaves and place them on my breast.”
c. “I should stimulate my nipples by squeezing softly.”
Nipple stimulation should be avoided during breast engorgement. Nipple stimulation causes milk production and can exacerbate the engorgement. Breast engorgement is characterized by painful overfilling of the breasts. Cold compresses, raw cabbage leaves, a snug-fitting bra, and analgesics can be used to relieve the swelling and pain.
A nurse is caring for a client who is at 20 weeks of gestation and tells the nurse that she is concerned that exercising might pose risks to her pregnancy. Which of the following statements should the nurse make?
a. “Be careful about exercises that include stretching.”
b. “Moderate exercise can help improve your circulation.”
c. “It is a good idea to increase your weight-bearing exercises.”
d. “You should rest for 5 minutes following exercise.”
b. “Moderate exercise can help improve your circulation.”
Improving circulation is one of many benefits of moderate exercise during pregnancy. It can also enhance well-being and promote rest and relaxation. It also improves muscle tone, which might shorten the duration of labor.
A nurse is assisting in the care of a client who is pregnant.
Medical History
Client is a 19-year-old primigravida who is at 28 weeks of gestation
Physical Examination
Client reports constant headache and vision changes. Rates headache pain a 6 on a 0-10 scale, describes as throbbing and unrelieved by acetaminophen and rest. 3+ pitting edema noted in lower extremities. Client reports occasional urinary frequency, denies contractions or back ache. Deep tendon reflexes 3+. Client reports a 2.7 kg (6 lb) weight gain in past week. Fetal heart rate 158/min.
Nurses Notes
Peripheral IV started in left basilic vein.
Vital Signs
Temperature 37.1°C (98.8°F)
Respiratory rate 18/min
Pulse 82/min
Blood pressure 164/112 mm Hg
Oxygen saturation 100% on room air
Diagnostic Results
Urine reagent strip: 3+ protein
Casual Blood glucose: 122 mg/dL
Hgb 15 g/dL
Hct 44%
Platelet count 99,000/mm3
BUN 38 mg/dL
Uric acid 7.9 mg/dL
24 hr urine protein: pending collection
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client’s progress.
The nurse should assist with initiation of an infusion of magnesium sulfate and administer an antihypertensive medication because the client is most likely experiencing preeclampsia with severe features as evidenced by increased blood pressure, vision changes, headache, and proteinuria. The nurse should monitor the serum magnesium level to monitor for magnesium toxicity and check the blood pressure every 15 to 30 minutes to closely monitor for changes in the client’s condition.
