Unit 2 - Class Activities Flashcards
The nurse is caring for a postpartum client who delivered vaginally 4 hours ago and has not voided since delivery: feeling has returned to her perineal area, and she has ambulated to the bathroom and attempted to void twice. She has ice on her edematous perineum. Her uterus is 3 fingerbreadths above the umbilicus, to the right of midline and firm only with massage. What would be the priority nursing actions?
A. Evaluate the client with a bladder scan
B. Insert a Foley catheter
C. Medicate the client with a nonsteroidal anti-inflammatory drug (NSAID)
D. Massage the fundus until it is firm and perform a one-time catherization on the client
D. Massage the fundus until it is firm and perform a one-time catherization on the client
*Uterine massage enables immediate contractions of the uterus to prevent bleeding. In and out catheterization relieves the bladder distention, eliminates displacement, firms the uterus and prevents uterine bleeding.
While performing a complete assessment of a term neonate, which of the following findings would alert the nurse to notify the pediatrician?
A. Red reflect in the eyes
B. Expiratory grunt
C. Respiratory rate of 45 breaths/minute
D. Prominent xiphoid process.
B. Expiratory grunt
*An expiratory grunt is significant and should be reported promptly, because it may indicate respiratory distress and the need for further intervention such as oxygen or resuscitation efforts
HTN + protein in urine =
preeclampsia
HTN + protein in urine + seizures =
eclampsia
HELLP
LIFE THREATENING TO MOTHER/FETUS
hemolysis
elevated liver ezymes
low platelet count
- Occurs between 28-36 weeks gestation BUT my occur postpartum in up to 30% of cases.
- Reported S/Sx’s
- Headache
- Nausea/vomiting/indigestion with pain after eating/Abdominal or chest tenderness and upper right upper side pain (from liver distention)
- Shoulder pain or pain when breathing deeply
- Bleeding/ Changes in vision/ Swelling
- Platelet infusion should only be given in patients with severely low platelet counts, those with significant bleeding or with very extremely low platelet counts and may require caesarean delivery.
- Right upper quadrant ultrasound may show hepatic infarction or subscapular hematoma but has no role in acute management of the patient.
- Most infant death occurs due to abruption of the placenta / placental failure
A 27 yr old female 30 weeks pregnant presents to her MD for routine follow-up : Bp 150/105 Hg. She was previously normotensive. Urinalysis reveals 1+ proteinuria. Serum uric acid level is 5.0mg/dl. Platelet count and liver function tests are normal. 24hr Urine collection shows 1.1g. of protein Which of the following does this patient most likely have? A. Chronic hypertension B. Gestational Hypertension C. Normal Blood pressure for pregnancy D. Pre-eclampsia
D. Pre-eclampsia
A. Chronic hypertension/ present prior to PG
B. Gestational Hypertension/ No proteinuria and resolves within 12 weeks postpartum
C. Normal Blood pressure for pregnancy/ Way too high
38 year old woman who is 36 weeks pg presents with HTN since age 34 with requires antihypertensive drugs. Prior to PG her BP was 130/70. During her first trimester: BP 120/60 and has risen in recent weeks to 150/95. She is complaining of worsening lower extremity edema. 24 hour urine shows 1500 mg of protein. Lab values for lytes, liver function tests platelet count are normal.What is the patients diagnosis?
A. Chronic essential hypertension
B. Eclampsia
C. HELLP syndrome
D. Preeclampsia
D. Preeclampsia
36 week PG woman presents complaining of mid-epigastric tenderness, nausea and vomiting. She looks unwell. Her BP is 146/100, lab test show normal renal function, low platelet count, AST level of 80 IU/L ( elevated liver enzymes, and hemolysis with a microangiopathic blood smear. She is diagnosed with HELLP . Which of the following is the most important initial therapeutic intervention for this patient?
A. Bedrest until fetal reaches 40 weeks
B. Immediate delivery
C. Platelet infusion to prevent bleeding
D. Right upper quadrant ultrasound
B. Immediate delivery
- Platelet infusion should only be given in patients with severely low platelet counts, those with significant bleeding or with very extremely low platelet counts and may require caesarean delivery.
- Right upper quadrant ultrasound may show hepatic infarction of subscapular hematoma but has no role in acute management of the patient.
- Most infant death occurs due to abruption of the placenta / placental failure
A prim parous client who is bottle feeding her neonate at 12 hours after birth asks the nurse, “When will my menstrual cycle return? Which of the following responses by the nurse would be most appropriate?
A.“Your menstrual cycle will return in 3 to 4 weeks.”
B.“It will probably be 6 to 10 weeks before it starts again.”
C.“You can expect your menses to start in 12 to 14 weeks.”
D.“Your menses will return in 16 to 18 weeks.”
B.“It will probably be 6 to 10 weeks before it starts again.”
*For clients who are bottle feeding the menstrual flow should return in 6-10 weeks after a rise in the production of follicle-stimulating hormone by the pituitary gland. Non lactating mothers rarely ovulate before 4 to 6 weeks post partum. Therefore, 3-4 weeks is too early for the menstrual cycle to resume. In Breast feeding women the menstrual flow may not return for 3-4 months or in some women for the entire period of lactation because ovulation is suppressed
A client is in the first hour of her recovery after a vaginal deliver. During an assessment, the lochia is moderate, bright red and is trickling from the vagina. The nurse locates the fundus at the umbilicus: it is firm and midline with no palpable bladder. The client vital signs remain at their baseline. Based on this information, the nurse would implement which of the following actions?
A. Increase the I.V. rate
B. Recheck the admission hematocrit and hemoglobin levels
C. Report the finding to the health care provider.
D. Document the findings as normal
C. Report the finding to the health care provider.
*At any point in the postpartum period, the lochia should be dark in color, rather than bright red. The volume should NOT BE be great enough to trickle or run from the vagina. Because the fundus is firm ,midline at the umbilicus (expected findings) this indicates that the bleeding is not coming form the uterus or from uterine atony. ( most likely …cervical or vaginal laceration) The nurse cannot stop this type of bleeding so must notify the health care provider
When developing the plan of care for a prim parous client during the first 12 hours after vaginal delivery, which of the following concerns of the client should be the nurse’s primary focus of care?
A. The neonate
B. The family
C. The client’s own comfort
D. The client’s significant other
C. The client’s own comfort
*The first 12 hours after delivery are part of the taking in phase of maternal postpartum adjustment. Which typically last from 1 to 3 days. During the taking in phase the client is primarily concerned with her own needs. After the first 1 to 3 days postpartum the client is in the taking hold phase and can focus more on the needs of the neonate. Although, the family is an important unity of care and the significant other is important for the mother’s emotional support, during the taking in phase the mother is focused on herself
Two hours after vaginally delivering a viable male neonate under epidural anesthesia, the client with a midline episiotomy ambulates to the bathroom to void. After voiding, the nurse assesses the clients bladder, finding it distended. The nurse interprets this finding based on the understanding that the clients bladder distention is most likely caused by which of the following?
A. Prolonged first stage of labor
B. Urinary tract infection
C. Pressure of the uterus on the bladder
D. Edema in the lower urinary tract area
D. Edema in the lower urinary tract area
A. A prolonged first stage of labor can contribute to exhaustion and uterine atony not urinary retention.
*Urinary retention soon after delivery is usually caused by edema and trauma of the lower urinary tract: this commonly results in difficulty with initiating voiding. Hyperemia of the bladder mucousa also commonly occurs. The combination predisposes to decreased sensation to void, over distention of the bladder, and incomplete bladder emptying. A prolonged first stage of labor can contribute to exhaustion and uterine atony not urinary retention.
At which of the following locations would the nurse expect to palpate the fundus of a prim parous client 12 hrs. after delivery of a neonate?
A. Halfway between the umbilicus and the symphysis pubis
B. At the level of the umbilicus
C. Just below the level of the umbilicus
D. Above the level of the umbilicus
B. At the level of the umbilicus
*Within 12 hours postpartum, the fundus should be palpated at the level of the umbilicus. The fundus after birth may be part way down and then rise to level or above and then settle to umbilicus level. After the first 12 hours the fundus should decrease one fingerbreadth (1cm) Per day in size. By the ninth or tenth day, the fundus usually is no longer palpable
A client delivered vaginally two hours ago and has a third-degree laceration. There is ice in place on her perineum. However, her perineum is slightly edematous and the client is complaining of pain rated 6 on a scale of 1 to 10. Which nursing intervention would be the most appropriate at this time?
A. Begin sitz baths
B. Administer pain medication per order
C. Replace ice packs to the perineum
D. Initiate anesthetic sprays to the perineum
B. Administer pain medication per order
A. Sitz bath are initiated at the conclusion of ice therapy.
C. Replace ice packs to the perineum/Ice has already been initiated and will prevent further edema to the rectal sphincter and perineum and continue to reduce some of the pain.
D. D.Initiate anesthetic sprays to the perineum /Anesthetic sprays can also be used but would not lower the pain to a level that the client considers tolerable.
*Pain medication is the first strategy to initiate at this pain level. When trauma has occurred to any area, the usual intervention is ice for the first 24 hours and heat after 24 hours. Sitz bath are initiated at the conclusion of ice therapy. Try Tylenol ( acetaminophen ) or Ibuprofen before opioids
While the nurse is preparing to assist the primparous client to the bathroom to void 6 hours after a vaginal delivery under epidural anesthesia, the client says that she feels dizzy when sitting up on the side of the bed. The nurse explains that this is most likely caused by which of the following.
A. Effects of the anesthetic during labor.
B. Hemorrhage during the delivery process
C. Effects of analgesics used during labor
D. Decreased blood volume in the vascular system
D. Decreased blood volume in the vascular system
A. By 6 hours postpartum the effects of the anesthesia should be worn off completely. Typically the effects of the epidural anesthesia wear off by 1 to 2 hours postpartum and the effects of local anesthesia disappear by 1 hour.
*The clients dizziness is most likely caused by orthostatic hypotension secondary to the decreased volume of blood in the vascular system resulting from the physiologic changes occurring in the mother after delivery. The client is experiencing dizziness because not enough blood volume is available to perfuse the brain. The nurse should first allow the client to “dangle” on the side of the bed for a few minute before attempting to ambulate/ By 6 hours postpartum the effects of the anesthesia should be worn off completely. Typically the effects of the epidural anesthesia wear off by 1 to 2 hours postpartum and the effects of local anesthesia disappear by 1 hour.
The nurse is assessing a cesarean section client who delivered 12 hours ago. Finding include a distended abdomen with faint bowel sounds x 1 quadrant, fundus firm at umbilicus, lochia scant , rubra, and pain rated 4 on a scale of 1 to 10. The I.V. and Foley catheter have been discontinued and the client was medicated 3 hours ago for pain. When planning care for this client, what should the nurse identify as the highest priority interventions.
A. Medicate the client
B. Incentive spirometry
C. Ambulate the client
D. Encourage caring for infant
C. Ambulate the client
*The client should have more active bowel sounds by this time postpartum. Ambulation will encourage passing flatus and begin peristaltic action
While making a home visit to a postpartum client on day 11, the nurse would anticipate that the client’s lochia would be which of the following colors?
A. Dark red
B. Pink
C. Brown
D. White
D. White
*On about the 11 th postpartum day, the lochia should be lochia alba, clear or white in color. Lochia rubra, which is dark red to red, may persist for the first 2 to 3 days , postpartum. From day 3 to about day 10, lochia serosa, which is pink or brown , is normal.
A primiparous client who underwent a caesarean delivery 30 minutes ago is a candidate for Rho(D) immune globulin (RhoGAM). The nurse anticipates administering this ordered medication within which of the following time frames after delivery?
A. 8 hours
B. 24 hours
C. 72 hours
D. 96 hours
C. 72 hours
*For maximum effectiveness, RhoGAM should be administered within 72 hours postpartum. Most Rh-negative clients also receive RhoGAM during prenatal period at 28 weeks’ gestation and then again after delivery. The drug is given the Rh-negative mothers who have a delivered Rh-positive neonates. If there’s is doubt about the fetus’s blood type after pregnancy is terminated, the mother should receive the medication. A Coombs test(antiglobulin test) may be ordered: a positive coombs test means the mother has formed antibodies that coat and damage the infants RBC’s. As the infant’s RBC’s rupture, the bilirubin rises and is deposited in the infant’s brain, causing retardation
After instructing a primiparous client about episiotomy care, which of the following client statements indicates successful teaching?
A “I’ll use hot , sudsy water to clean the episiotomy area.”
B. “I wipe the area from front to back using a blotting motion.”
C. “Before bedtime, I’ll use a cold water sitz bath.”
D. “I can use ice packs for 3 to 4 days after delivery.”
B. “I wipe the area from front to back using a blotting motion.”
*The nurse should instruct the client to cleanse the perineal area with warm water and to wipe from front to back with a blotting motion. Warm water is soothing to the tender tissue and wiping from front to back reduces the risk of contamination. Hot, sudsy water may increase the client’s discomfort and may even burn the client in very tender area. After the first 24 hours, warm water sitz baths taken three or four times a day for 20 minutes can help increase circulation to the area. Ice packs are helpful for the first 24 hours.
A 26 year old primiparous client is seen in the urgent care clinic 2 weeks after delivering a viable female neonate. The client, who is breast-feeding, is diagnosed with infectious mastitis of the right breast. The client asks the nurse, “Can I continue breast-feeding?” Which of the following responses would be most appropriate?
A.“ You can continue to breast-feed, feeding a your baby more frequently.”
B. You can continue once your symptoms begin to decrease.’
C. “You must discontinue breast-feeding until antibiotic therapy is completed.”
D. “You must stop breast-feeding because the breast is contaminated.”
A.“ You can continue to breast-feed, feeding a your baby more frequently.”
*They should continue to breast-feed often, or at least every 2 to 3 hours. Treatment also includes bed rest, increased fluid intake, local heat application, analgesics and antibiotic therapy. Continually emptying the breasts decreases the risk of engorgement or breast abscess.
After instructing a primiparous client who is bottle-feeding, which of the following client statements indicates that the client needs further teaching?
A. “I’ll burp him after 15 minutes of feeding him formula.”
B. “After he takes one-half ounce of formula, I’ll burp him.”
C. “I’ll burp him while he is in a upright position.”
D. “I’ll gently pat his back to get him to burp”
A. “I’ll burp him after 15 minutes of feeding him formula.”
*The entire feeding should take only 15 to 20 minutes, and the neonate should be burped before that time. During initial feedings, the burping should be done after each half-ounce of formula with the neonate in an upright position, patting the neonate gently on the back
Mrs. Jones now asks: “ This hurt a lot , I don’t want to have another baby for a long time, if I continue to breast feed I won’t have to worry about it….right?”you respond:
A. “that right”
B. “ that may or may not be correct”
C. “ odds are you will get pregnant”
D. “ whats wrong with you, Jordan Junior needs a sibling”
B. “ that may or may not be correct”
*Not a guarantee but………………………….Ovulation and menstruation occurs approx. 6 weeks after birth if NOT breastfeedingIf breastfeeding at least 3 months after birth/ but for some may not return until breastfeeding in stopped. Exclusive breastfeeding reduces risk of pregnancy
The physician orders an intramuscular injection of phytonadione (AquaMephtyton) Vit K. for a term neonate. The nurse explains to the mother that this medication is used to prevent which of the following?
A. Hypoglycemia
B. Hyperbilirubinemia
C. Hemorrhage
D. Polycythemia
C. Hemorrhage
A.Hypoglycemia is prevented and treated by feeding the infant.
B.Hyperbilirubinemia severity can be decreased by early feeding and passage of meconium to excrete the bilirubin. Hyperbilirubinemia is treated with phototherapy.
D. Polycythemia may occur in neonates who are large for gestational age or post-term. Clamping of the umbilical cord before pulsations cease reduces the incidence of polycythemia.Generally, polycythemia is not treated unless it is extremely severe.
*Phytonadione (vit K or AquaMEPHYTON) acts as a preventive measure against neonatal hemorrhagic disease. At birth, the neonate does not have the intestinal flora to produce vit K., which is necessary for coagulation.
Where do you give it?
- Middle third of the vastus lateralis muscle
A viable female neonate delivered vaginally at term has Apgar scores of 9 at 1 minute and 10 at 5 minutes after birth. Immediately postpartum, the nurse keeps the infant under a radiant warmer away from the cooling ducts in the room to prevent heat loss by which of the following mechanisms
A. Evaporation
B. Convection
C. Conduction
D. Radiation
B. Convection
A.Evaporation ( nfant also loses heat through evaporation. Wet skin)
B.Convection (Keeping the neonate away form drafts and cooling ducts prevent heat loss by convection / flow of heat from the body surface to the cooler surrounding air.) C. Conduction (transfer of body heat to a cooler solid object in contact with the baby like scale or cold stethoscope)
D.Radiation (transfer of heat to cooler solid object that are not in direct contact with the baby as when the neonate is placed near a cold window surface or air conditioner)
The nurse makes a home visit to a 3-day old full term neonate who weighed 3,912 g ( 8lb.10oz) at birth. Today the neonate who is being bottle-fed weighs 3,572g ( 7lb, 14 Oz) . Which of the following instructions would the nurse most likely give to the mother?
A.Continue feeding every 3 to 4 hours since the weight loss is normal.
B.Contact the physician if the weight loss continues over the next few days
C.Switch to a soy-based formula because the current one seems inadequate
D.Change to a higher – calorie formula to prevent further weight loss.
A.Continue feeding every 3 to 4 hours since the weight loss is normal.
*The 3 day old neonates weight loss falls within a normal range, and no action is needed at this time. Full term neonates tend to lose 5% to 10% of their birth weight during the first few days after birth, most likely because of minimal nutritional intake. With bottle-feeding the neonates intake varies from one feeding to another. Additionally the neonate experiences a loss of extracellular fluid. Typically, neonates regain any weight loss by 7 to 10 days of life. If the weight loss continues after that time the physician should be called.
While making a home visit to a primiparous client and her 3 day old son, the nurse observes, the mother changing the baby’s disposable diaper. Before putting the clean diaper on the neonate, the mother begins to apply baby powered to the neonate’s buttocks. Which of the following statements about baby powder would the nurse relate to the mother?
A. It may cause pneumonia to develop
B. It helps prevent diaper rash
C. It keeps the diaper from adhering to the skin
D. It can result in allergies late in life
A. It may cause pneumonia to develop
*Baby powder can enter the neonates lungs and result in pneumonia secondary to aspiration of the particles. The best prevention of diaper rash is frequent diaper changing and keeping the neonates skin dry. The new disposable diapers have moisture collecting materials and generally do not adhere to the skin unless the diaper becomes saturated. Allergies are not associated with the use of baby powder in neonates
Approximately 90 minutes after birth, the nurse encourages the mother of a term neonate to do which of the following?
A. Feed the neonate
B. Allow the neonate to sleep
C. Get to know the neonate
D. Change the neonate’s diaper
B. Allow the neonate to sleep
*As part of the neonates physiologic adaptation to birth, at 90 minutes after birth the neonate typically is in the rest or sleep phase. During this time, the heart and respiratory rates slow and the neonates sleeps, unresponsive to stimuli. At this time, the heart and resp. rates slow and the neonate sleeps, unresponsive to stimuli. Mother should rest and allow the neonate to sleep. Feedings should be given during the first period of reactivity, considered the first 30 minutes after birth. During this period, the neonates resp. and H.R. are elevated. Getting to know the neonate typically occurs within the first hour after birth and then when the neonate is awake and during feedings.
Which of the following observations would the nurse expect when assessing the gestational age of a neonate delivered at term?
A. Ear lying flat against the head
B. Absence of rugae in the scrotum
C. Sole creases covering the entire foot
D. Square window sign angle of 90 degrees
C. Sole creases covering the entire foot
A. Ear lying flat against the head/If the neonate’s ear is lying flat against the head, the neonate is most likely preterm
B.Absence of rugae in the scrotum/ An absence of rugae in the scrotum typically suggests preterm neonate
C.Sole creases covering the entire foot/Sole creases covering the entire foot are indicative of a term neonate….
D.Square window sign angle of 90 degrees / A square window sign angle of 0 degrees occurs in neonates of 40 to 42 weeks’ gestation/A 90 degree square window angle suggests an immature neonate of approximately 28 to 30 weeks gestation.
Assessment of a term neonate at 2 hours after birth reveals a heart rate of 110 bpm. Periods of apnea approximately 25 to 30 seconds in length and mild cyanosis around the mouth. The nurse notifies the pediatrician based on the interpretation that these findings may lead to which condition?
A. Respiratory arrest
B. Bronchial pneumonia
C. Intraventricular hemorrhage
D. Epiglottitis
A. Respiratory arrest
*Periods of apnea lasting longer than 20 seconds , mild cyanosis and a heart rate of 110 ( bradycardia) are associated with potentially life threatening event and subsequent respiratory arrest
When instilling erythromycin ointment into the eyes of a neonate 1 hour old, the nurse would explain to the parents that the medication is used to prevent which of the following?
A. Chorioretinitis from cytomegalovirus
B. Blindness secondary to gonorrhea
C. Cataracts from beta-hemolytic streptococcus
D. Strabismus resulting from neonatal maturation
B. Blindness secondary to gonorrhea
*It is also effective against Chlamydia trachomatis. The medication may result in redness of the neonates eyes with some swelling, but this redness will eventually disappear in a day or two.
While changing the neonate’s diaper, the client asks the nurse about some red-tinged drainage from the neonate’s vagina. Which of the following responses would be most appropriate?
A. “It’s of no concern because it is such a small amount.”
B. “The cause is usually related to swallowing blood during the delivery.”
C. “Sometimes baby girls have this from hormones received from the mother.”
D. “This vaginal spotting is caused by hemorrhagic disease of the newborn”
C. “Sometimes baby girls have this from hormones received from the mother.”
*It is associated with female neonates due to hormones received from the mother. Estrogen is believed to cause slight vaginal bleeding or spotting in the female neonate. The condition disappears spontaneously so there is no need for concern.
Hands and feet Blue called: _____ and is very common for several hours and temporary
acrocyanosis
A 6lb, 8 Oz. neonate was delivered vaginally at 38 weeks’ gestation. At 5 minutes of life, the neonate has the following signs: heart rate 110, intermittent grunting with respiratory rate of 70, flaccid tone, no response to stimulus, overall pale white in color. The Apgar score is:
A. 2
B. 3
C. 4
D. 6
C. 4
*The neonate has a heart rate greater than 10, which earns him 2 points. His respiratory rate of 70 is equivalent to a 2 on the scale. His flaccid muscle tone is equal to 0 on the scale. The lack of response to stimulus also equals 0, as does his overall pale white color. Thus the total score equals 4.
Initial assessment of a term female neonate about 4 hours old reveals a normal anterior fontanel. The nurse documents its shape as which of the following?
A. Oval
B. Square
C. Diamond shaped
D. Triangular
C. Diamond shaped
*The anterior fontanel is normally diamond shaped approximately 2 to 3cm wide and 3-4cm long. This allows for brain growth during the early months of life. The posterior fontanel is small and triangular
