OB TEST 1 PRACTICE

Which is considered a normal physiologic change during pregnancy?

a. ECG T-wave changes
b. Increased cardiac output
c. Increased bleeding time
d. Decreased renal perfusion

increased cardiac output
Which of the following exercises should be taught to a pregnant woman who complains of backaches?
Question options:a) Kegeling.

b) Pelvic tilting.

c) Leg lifting.

d) Crunching.

pelvic tilting
A pregnant woman who is Rh negative is to receive RhoGAM prophylactically at 28 weeks’ gestation. Before receiving the medication, she asks the nurse how the drug works. Which of the following best describes how RhoGAM acts in the expectant mother’s body?
Question options:a) RhoGAM attaches to maternal and paternal Rh antibodies and directly destroys them.

b) RhoGAM suppresses the production of maternal antibodies.

c) RhoGAM destroys fetal Rh positive red blood cells in the maternal circulation before sensitization can occur

d) RhoGAM prevents fetal-maternal bleeding episodes from occurring at the former placenta site.

b) RhoGAM suppresses the production of maternal antibodies.
The phenomenon of physiologic anemia of
pregnancy occurs because of which of the following?
Question options:a) Hemolysis of red blood cells is accelerated during pregnancy.

b) Iron stores are depleted due to nausea and vomiting in early pregnancy.

c) Plasma volume is greater than the red blood cell mass.

d) Red blood cell production decreases during pregnancy.

c) Plasma volume is greater than the red blood cell mass.
A positive early diagnosis of pregnancy is based on the presence of which of the following?
Question options:a) Quickening

b) Chadwick’s sign

c) A fetal heart rate

d) Positive pregnancy test

c) A fetal heart rate
The nurse instructs an expectant couple about the symptoms of pregnancy. The symptoms a woman may experience during the first trimester are which of the following?
Question options:a) amenorrhea, urinary frequency, and quickening.

b) urinary frequency, morning sickness, and amenorrhea.

c) weight gain and Braxton Hicks contractions.

d) amenorrhea, ankle edema, and urinary frequency.

b) urinary frequency, morning sickness, and amenorrhea.
An expectant father tells the nurse that he has been experiencing nausea and vomiting during his wife’s pregnancy. This is an example of which of the following?
Question options:a) Developmental crisis.

b) Couvade.

c) Maladaptive processes.

d) Situational crisis.

b) Couvade.
A multipara in the fourteenth week of pregnancy seems discouraged after her second clinic visit. She tells the nurse, “I guess I am pleased to be pregnant, but these visits are so routine. It’s hard for me to take time from work to sit in the waiting room for just a urine check and weigh-in.” What teaching by the nurse would be emphasized with this client?
Question options:a) “Although pregnancy is normal, one must be prepared for any problems.”

b) “These routine visits are essential to the fetus and to your health.”

c) “Perhaps you might weigh yourself at home each week and call us.”

d) “Have you considered resigning from your job at this time?”

b) “These routine visits are essential to the fetus and to your health.”
A 38 weeks pregnant woman expresses concern
about the striae on her abdomen and breasts and asks when they will disappear. The nurse’s best response would be, “The striae:
Question options:a) “will disappear in approximately 6 weeks.”

b) “are a result of pregnancy and will not disappear.”

c) “will eventually fade to silver or white.”

d) “will disappear with the use of vitamin E oil.”

c) “will eventually fade to silver or white.”
A woman at 36 weeks gestation complains of leg cramps. The nurse knows that this symptom is most likely due to which of the following?
Question options:a) high levels of circulating hormones.

b) decreased number of red blood cells.

c) lack of daily exercise.

d) electrolyte imbalance.

d) electrolyte imbalance.
A 36-week pregnant multigravida complains of dizziness and feels lightheaded when laying on her back. The symptom is caused by which of the following?
Question options:a) pressure of the uterus on the vena cava and aorta.

b) decreased red blood cell count in the third trimester.

c) rapid breathing and subsequent hyperventilation.

d) increased blood pressure due to expanded plasma volume.

a) pressure of the uterus on the vena cava and aorta.
A pregnant woman informs the nurse that her last
normal menstrual period was on September 20, 2006. Using Nagele’s rule, the nurse calcuates the client’s estimated date of delivery as:
Question options:a) May 30, 2007

b) June 20, 2007

c) June 27, 2007

d) July 3, 2007

c) June 27, 2007
The nurse determines that a woman is in her tenth week of gestation. Which of the following signs of pregnancy would the nurse expect to observe?
Question options:a) Breast tenderness

b) Quickening

c) Dyspnea

d) Dependent edema

a) Breast tenderness
During the first trimester of pregnancy, a woman
can expect which one of the following changes in her sexual desire?
Question options:a) Increase because of enlarging breasts

b) Decrease because of nausea and fatigue

c) No change in the first trimester

d) Increase due to lack of need for birth control

b) Decrease because of nausea and fatigue
A woman is 8 months pregnant. She told the nurse
that she knows her baby listens to her, but her husband thinks she is imagining things. Which one of the following responses by the nurse is most appropriate?
Question options:a) “Many women imagine what their baby is like.”

b) “Babies in utero respond to sounds including their mother’s voice.”

c) “You’ll need to ask the physician if the baby can hear yet.”

d) “Thinking that your baby hears will help you bond to the baby.”

b) “Babies in utero respond to sounds including their mother’s voice.”
A couple is preparing to interview obstetric primary care providers in order to determine who they wll go to for care during their pregnancy and delivery. In order to make the best choice, which of the following actions should the couple perform first?
Question options:a) Take a tour of hospital delivery areas.

b) Develop a preliminary birth plan.

c) Make appointments with three or four obstetric care providers.

d) Search the internet for the malpractice histories of the providers.

b) Develop a preliminary birth plan.
A client makes the following statement after finding
out that her pregnancy test is positive, “This is not a good time. I am in college and the baby will be due during final exams!” Which of the following responses by the nurse would be most appropriate at this time?
Question options:a) “I’m absolutely positive that everything will turn out all right.”

b) “I suggest that you email your professors to set up an alternative plan.”

c) “It sounds like you’re feeling a little overwhelmed right now.”

d) “You and the baby’s father will find a way to get through the pregnancy.”

c) “It sounds like you’re feeling a little overwhelmed right now.”
A new expectant father asks about leisure activities
he can enjoy with his wife during their pregnancy. Which response by the nurse best indicatesa an understanding of the needs of the couple during pregnancy?
Question options:a) “Although she may tire easily, you can continue most activities you have enjoyed in the past.”

b) “You may wish to continue with your hobbies, and allow you wife to enjoy leisure activites with her friends.”

c) “You should explore more sedentary recreation now, since active exercise needs to be limited.”

d) “This is a time to prepare yourselves for the role of new parents, rather than thinking of yourselves.”

a) “Although she may tire easily, you can continue most
activities you have enjoyed in the past.”
The nurse recognizes which of the following
maternal behaviors during the first trimester of pregnancy as a sign of normal maternal adaptation?
Question options:a) Accepting the reality of the pregnancy

b) Selecting a name for the newborn

c) Taking prepared childbirth classes

d) Buying newborn clothes

a) Accepting the reality of the pregnancy
While providing preconception counseling to a
couple, the nurse explains that during development the fetus is most vulnerable to damaging agents during the:
Question options:
a)
second trimester.
b)
embryonic period.
c)
third trimester.
d)
period immediately after conception.
b)
embryonic period.
The nurse obtains a fetal heart rate (FHR) of 150
beats per minute. The normal baseline range for a FHR is which of the following?
Question options:
a)
80 to 160 beats per minute.
b)
130 to 180 beats per minute.
c)
120 to 160 beats per minute.
d)
110 to 220 beats per minute.
c)
120 to 160 beats per minute.80 BPM is considered bradycardia & would require in utero rescutation by means of nursing intervention or medical intervention.

A pregnant woman must have a glucose challenge test (GCT). Which of the following should be included in the preprocedure teaching?
Question options:
a)
Fast for 12 hours before the test.
b)
Bring a urine specimen to the laboratory on the day of the test.
c)
Be prepared to have 4 blood specimens taken on the day of the test.
d)
The test should take one hour to complete.

d) The test should take one hour to complete.

Rationale The GCT is done at approx 24 weeks gestation to assess the client’s ability to metabolixe glucose. it is a one hour. nonfasting screening test. One hour after the client consumes 50 grams of concentrated glucose, as glucose serum is drawn. If the level is 130 mg/dL or higher, the client is referred for a 3 hour glucose tolerance test to determine if she has gestational diabetes.

In her fourth lunar month of pregnancy, a woman is
advised to adjust her daily routine as a typist. Office activities and the requirements of her work are discussed. Which of the following tasks needs to be modified for her to promote a healthy pregnancy?
Question options:
a)
Sitting in one position for 6 hours without a break.
b)
Delivering messages to several adjacent departments each day.
c)
Answering the phone as relief for the receptionist 1 hour each day.
d)
Filing vouchers fro sales personnel for 2 hours daily.
a)
Sitting in one position for 6 hours without a break.Rationale. To promote comfort and enhance venous circulation, she must change positions more frequently than once every 6 hours. The other activities discussed are not problematic.

To promote comfort and enhance venous circulation, she must change positions more frequently than once every 6 hours. The other activities discussed are not problematic.

A woman provides the nurse with the following
obstetrical history: Delivered a son, now 7 years old at 28 weeks gestation; delivered a daughter, now 5 years old, at 39 weeks gestation; had a miscarriage 3 years ago; and had a first trimester abortion 2 years ago. She is currently pregnant. Which of the following correctly protrays her GTPAL?
Question options:
a)
G4P2121
b)
G4P1212
c)
G5P1122
d)
G5P2211

c) G5P1122

Rationale: This client has been pregnant 5 times (G5). She birthed a son and a daughter, had 1 miscarriage, had 1 abortion and is currently pregnant. Her parity reflects her obstetrical history: 1 full term birth (daughter); 1 preterm birth (son); 2 abortions (miscarriages count as abortions and are referred to as such even though they aren’t induced), and has two living children.

The following four changes occur during pregnancy. Which of them will most likely increase the father’s interest and involvement in the pregnancy?
Question options:
a)
Learning the results of the pregnancy test.
b)
Attending childbirth education classes.
c)
Hearing the fetal heartbeat.
d)
Meeting the obstetrician or midwife.

c) Hearing the fetal heartbeat.

Rationale: Father’s have a hard time seeing the pregnancy as real, and many times the physical complaints of the woman (morning sickness, fatigue, breast tenderness, and urinary frequency) put them off the whole idea. But when they first hear the heart beat..the pregnancy becomes real and they become very excited.

A pregnant woman at 10 weeks of gestation jogs about the effect of exercise on the fetus. The nurse would inform her that:
Question options:
a)
“You do not need to modify your exercising anytime during your pregnancy.”
b)
“Stop exercising because it will harm the fetus.”
c)
“You may find that you will need to switch to walking during the third trimester.”
d)
“Jogging is too hard on your body; switch to walking now.”

c) “You may find that you will need to switch to walking during the third trimester.”

No rationale provided but review page 238-239 if help is needed

A pregnant woman reports that she is still playing
tennis competitively at 32 weeks of gestation. The nurse would be most concerned that this woman consume which of the following during and after tennis matches?
Question options:
a)
Several glasses of fluid
b)
Extra protein sources such as peanut butter
c)
Salty foods to replace lost sodium
d)
Easily digested sources of carbohydrate
a)
Several glasses of fluidno rationale but page 239 states “wear loose comfortable clothes, drink plenty of fluids, and avoid prolonged overheating -> Hyperthermia is teratogenic”

1. A woman who is at 36 weeks of gestation is having a nonstress test. Which statement by the woman would indicate a correct understanding of the test?
A. “I will need to have a full bladder for the test to be done accurately.”
B. “I should have my husband drive me home after the test because I may be nauseous.”
C. “This test will help to determine whether the baby has Down syndrome or a neural tube defect.”
D. “This test will observe for fetal activity and an acceleration of the fetal heart rate to determine the well-being of the baby.”

D. “This test will observe for fetal activity and an acceleration of the fetal heart rate to determine the well-being of the baby.”

An ultrasound is the test that requires a full bladder.
A pregnant woman should be driven home after having an amniocentesis test. A nonstress test should not cause nausea.
A maternal alpha-fetoprotein test is used in conjunction with unconjugated estriol levels, and human chorionic gonadotropin helps to determine the presence of Down syndrome.
The nonstress test is one of the most widely used techniques to determine fetal well-being and is accomplished by monitoring fetal heart rate in conjunction with fetal activity and movements.

2. Which choice gives indicators for performing a contraction stress test?
A. Increased fetal movement and small for gestational age
B. Maternal diabetes mellitus and postmaturity
C. Adolescent pregnancy and poor prenatal care
D. History of preterm labor and intrauterine growth restriction

B. Maternal diabetes mellitus and postmaturity

Decreased fetal movement is an indicator for performing a contraction stress test; the size (small for gestational age) is not an indicator.
Maternal diabetes mellitus and postmaturity are two indications for performing a contraction stress test.
Although adolescent pregnancy and poor prenatal care are risk factors of poor fetal outcomes, they are not indicators for performing a contraction stress test.
Intrauterine growth restriction is an indicator; but history of a previous stillbirth, not preterm labor, would be the other indicator.

3. The nurse sees a woman for the first time when she is 30 weeks pregnant. The woman has smoked throughout the pregnancy, and fundal height measurements now are suggestive of growth restriction in the fetus. In addition to ultrasound to measure fetal size, what would be another tool useful in confirming the diagnosis?
A. Doppler blood flow analysis
B. Contraction stress test (CST)
C. Amniocentesis
D. Daily fetal movement counts

A. Doppler blood flow analysis

Doppler blood flow analysis allows the examiner to study the blood flow noninvasively in the fetus and the placenta. It is a helpful tool in the management of high risk pregnancies because of intrauterine growth restriction (IUGR), diabetes mellitus, multiple fetuses, or preterm labor.
Because of the potential risk of inducing labor and causing fetal distress, a CST is not performed on a woman whose fetus is preterm.
Indications for an amniocentesis include diagnosis of genetic disorders or congenital anomalies, assessment of pulmonary maturity, and the diagnosis of fetal hemolytic disease, not IUGR.
Fetal kick count monitoring is performed to monitor the fetus in pregnancies complicated by conditions that may affect fetal oxygenation. Although this may be a useful tool at some point later in this woman’s pregnancy, it is not used to diagnose IUGR.

4. A 40-year-old woman is 10 weeks pregnant. Which diagnostic tool would be appropriate to suggest to her at this time?
A. Biophysical profile
B. Amniocentesis
C. Maternal serum alpha-fetoprotein (MSAFP)
D. Transvaginal ultrasound

D. Transvaginal ultrasound

A biophysical profile would be a method of biophysical assessment of fetal well-being in the third trimester.
An amniocentesis is performed after the fourteenth week of pregnancy.
An MSAFP test is performed from week 15 to week 22 of the gestation (weeks 16 to 18 are ideal).
An ultrasound is the method of biophysical assessment of the infant that would be performed at this gestational age.

5. Nurses should be aware of the strengths and limitations of various biochemical assessments during pregnancy, including that:
A. Chorionic villus sampling (CVS) is becoming more popular because it provides early diagnosis.
B. Screening for maternal serum alpha-fetoprotein (MSAFP) levels is recommended only for women at risk for neural tube defects.
C. Percutaneous umbilical blood sampling (PUBS) is one of the triple-marker tests for Down syndrome.
D. MSAFP is a screening tool only; it identifies candidates for more definitive procedures.

D. MSAFP is a screening tool only; it identifies candidates for more definitive procedures.

CVS does provide a rapid result, but it is declining in popularity because of advances in noninvasive screening techniques.
MSAFP screening is recommended for all pregnant women.
MSAFP, not PUBS, is part of the triple-marker tests for Down syndrome.
MSAFP is a screening tool, not a diagnostic tool.

6. The nurse providing care for the antepartum woman should understand that the contraction stress test (CST):
A. Sometimes uses vibroacoustic stimulation.
B. Is an invasive test; however, contractions are stimulated.
C. Is considered negative if no late decelerations are observed with the contractions.
D. Is more effective than the nonstress test (NST) if the membranes have already been ruptured.

C. Is considered negative if no late decelerations are observed with the contractions.

Vibroacoustic stimulation is sometimes used with the NST.
The CST is invasive if stimulation is by intravenous oxytocin but not if by nipple stimulation.
No late decelerations is good news.
The CST is contraindicated if the membranes have ruptured.

7. In the past factors to determine whether a woman was likely to develop a high risk pregnancy were evaluated primarily from a medical point of view. A broader, more comprehensive approach to high risk pregnancy has been adopted today. There are now four categories based on threats to the health of the woman and the outcome of pregnancy. These categories include all of the following except:
A. Biophysical.
B. Psychosocial.
C. Geographic.
D. Environmental.

C. Geographic.

Biophysical is one of the broad categories used for determining risk. These include genetic considerations, nutritional status, and medical and obstetric disorders.
Psychosocial risks include smoking, caffeine, drugs, alcohol, and psychologic status. All of these adverse lifestyles can have a negative effect on the health of the mother or fetus.
This category is correctly referred to as sociodemographic risk, not geographic risk. These factors stem from the mother and her family. Ethnicity may be one of the risks to pregnancy; however, it is not the only factor in this category. Low income, lack of prenatal care, age, parity, and marital status also are included.
Environmental risks are those that can affect both fertility and fetal development. These include infections, chemicals, radiation, pesticides, illicit drugs, and industrial pollutants.

8. MSAFP levels have been used as a screening tool for ______________________________ in pregnancy.
“neural tube defects”
9. The nurse is caring for a woman with mitral stenosis who is in the active stage of labor. Which action should the nurse take to promote cardiac function?
A. Maintain the woman in a side-lying position with the head and shoulders elevated to facilitate hemodynamics
B. Prepare the woman for delivery by cesarean section because this is the recommended delivery method to sustain hemodynamics
C. Encourage the woman to avoid the use of narcotics or epidural regional analgesia because this alters cardiac function
D. Promote the use of the Valsalva maneuver during pushing in the second stage to improve diastolic ventricular filling

A. Maintain the woman in a side-lying position with the head and shoulders elevated to facilitate hemodynamics

The side-lying position with the head and shoulders elevated helps to facilitate hemodynamics during labor.
A vaginal delivery is the preferred method of delivery for a woman with cardiac disease because it sustains hemodynamics better than a cesarean section.
The use of supportive care, medication, and narcotics or epidural regional analgesia is not contraindicated for a woman with heart disease.
The use of the Valsalva maneuver during pushing in the second stage should be avoided because it reduces diastolic ventricular filling and obstructs left ventricular outflow.

10. In planning for the care of a 30-year-old woman with pregestational diabetes, the nurse recognizes that the most important factor affecting pregnancy outcome is the:
A. Mother’s age.
B. Number of years since diabetes was diagnosed.
C. Amount of insulin required prenatally.
D. Degree of glycemic control during pregnancy.

D. Degree of glycemic control during pregnancy.

Mother’s age is not relevant to the plan of care for a patient with pregestational diabetes.
The number of years a woman has been a diabetic is not as important as determining the degree of glycemic control during the current pregnancy.
The amount of insulin required prenatally is only relevant in relation to the current level of glycemic control.
Women with excellent glucose control and no blood vessel disease should have good pregnancy outcomes.

11. Diabetes in pregnancy puts the fetus at risk in several ways. Nurses should be aware that:
A. With good control of maternal glucose levels, sudden and unexplained stillbirth is no longer a major concern.
B. The most important cause of perinatal loss in diabetic pregnancy is congenital malformations.
C. Infants of mothers with diabetes have the same risks for respiratory distress syndrome because of the careful monitoring.
D. At birth the neonate of a diabetic mother is no longer in any risk.

B. The most important cause of perinatal loss in diabetic pregnancy is congenital malformations.

Even with good control, sudden and unexplained stillbirth remains a major concern.
Congenital malformations account for 30% to 50% of perinatal deaths.
Infants of diabetic mothers are at increased risk for respiratory distress syndrome.
The transition to extrauterine life often is marked by hypoglycemia and other metabolic abnormalities.

12. A new mother with which of these thyroid disorders would be strongly discouraged from breastfeeding?
A. Hyperthyroidism
B. Phenylketonuria (PKU)
C. Hypothyroidism
D. Thyroid storm

B. Phenylketonuria (PKU)

A woman with hyperthyroidism would have no particular reason not to breastfeed.
PKU is a cause of mental retardation in infants; mothers with PKU pass on phenylalanine through breast milk.
A woman with hypothyroidism would have no particular reason not to breastfeed.
A thyroid storm is a complication of hyperthyroidism.

13. While providing care in an obstetric setting, the nurse should understand that postpartum care of the woman with cardiac disease:
A. Is the same as that for any pregnant woman.
B. Includes rest, stool softeners, and monitoring of the effect of activity.
C. Includes ambulating frequently, alternating with active range of motion.
D. Includes limiting visits with the infant to once per day.

B. Includes rest, stool softeners, and monitoring of the effect of activity.

Care of the woman with cardiac disease in the postpartum period is tailored to the woman’s functional capacity.
Bed rest may be ordered, with or without bathroom privileges. Bowel movements without stress or strain for the woman are promoted with stool softeners, diet, and fluid.
The woman will be on bed rest to conserve energy and reduce the strain on the heart.
Although the woman may need help caring for the infant, breastfeeding and infant visits are not contraindicated.

14. A woman with gestational diabetes has had little or no experience reading and interpreting glucose levels. She shows the nurse her readings for the past few days. Which one should the nurse tell her indicates a need for adjustment (insulin or sugar)?
A. 75 mg/dl before lunch; this is low, better eat now
B. 115 mg/dl 1 hour after lunch; this is a little high, maybe eat a little less next time
C. 115 mg/dl 2 hours after lunch; this is too high, time for insulin
D. 60 mg/dl just after waking up from a nap; this is too low, maybe eat a snack before going to sleep

D. 60 mg/dl just after waking up from a nap; this is too low, maybe eat a snack before going to sleep

The premeal acceptable range is 65 to 95 mg/dl.
The readings 1 hour after a meal should be less than 130 mg/dl.
Two hours after eating, the readings should be under 120 mg/dl.
A reading of 60 mg/dl is too low. During hours of sleep glucose levels should not be under 60 mg/dl. Snacks before sleeping can be helpful.

15. A woman with asthma is experiencing a postpartum hemorrhage. Which drug would NOT be used to treat her bleeding because it may exacerbate her asthma?
A. Pitocin
B. Nonsteroidal antiinflammatory drugs (NSAIDs)
C. Hemabate
D. Fentanyl

C. Hemabate

Prostaglandin derivatives should not be used to treat women with asthma, because they may exacerbate symptoms. Oxytocin is the recommended medication for uterine bleeding.
Pitocin would be the drug of choice to treat this woman’s bleeding because it would not exacerbate her asthma.
NSAIDs are not used to treat bleeding.
Fentanyl is used to treat pain, not bleeding.

16. During a physical assessment of an at-risk patient, the nurse notes generalized edema, crackles at the base of the lungs, and some pulse irregularity. These are most likely signs of:
A. Euglycemia.
B. Rheumatic fever.
C. Pneumonia.
D. Cardiac decompensation.

A. Cardiac decompensation.

Euglycemia is a condition of normal glucose levels. These symptoms indicate cardiac decompensation.
Rheumatic fever can cause heart problems, but it does not present with these symptoms, which indicate cardiac decompensation.
Pneumonia is an inflammation of the lungs and would not likely generate these symptoms, which indicate cardiac decompensation.
These symptoms of cardiac decompensation may appear abruptly or gradually.

17. With regard to anemia, nurses should be aware that:
A. It is the most common medical disorder of pregnancy.
B. It can trigger reflex brachycardia.
C. The most common form of anemia is caused by folate deficiency.
D. Thalassemia is a European version of sickle cell anemia.

A. It is the most common medical disorder of pregnancy.

Anemia is the most common medical disorder of pregnancy. Combined with any other complication, anemia can result in congestive heart failure.
Reflex bradycardia is a slowing of the heart in response to the blood flow that increases immediately after birth.
The most common form of anemia is iron deficiency anemia.
Both thalassemia and sickle cell hemoglobinopathy are hereditary but not directly related or confined to geographic areas.

18. The most common neurologic disorder accompanying pregnancy is:
A. Eclampsia.
B. Bell’s palsy.
C. Epilepsy.
D. Multiple sclerosis.

C. Epilepsy.

Eclampsia sometimes may be confused with epilepsy, which is the most common neurologic disorder accompanying pregnancy.
Bell’s palsy is a form of facial paralysis. Epilepsy is the most common neurologic disorder accompanying pregnancy.
Epilepsy is the most common neurologic disorder accompanying pregnancy. The effects of pregnancy on epilepsy are unpredictable.
Multiple sclerosis is a patchy demyelinization of the spinal cord that does not affect the normal course of pregnancy or birth. However, epilepsy is the most common neurologic disorder accompanying pregnancy.

19. Less than 10% of women who are substance abusers receive treatment for their addiction during pregnancy.
A. True
B. False

A. True

This is a correct statement. Social stigma, labeling, and guilt are significant barriers. Women often do not seek help for substance abuse because of the fear of losing custody of their children or facing criminal prosecution.

20. A woman with severe preeclampsia is receiving a magnesium sulfate infusion. The nurse becomes concerned after assessment when the woman exhibits:
A. A sleepy, sedated affect.
B. A respiratory rate of 10 breaths/min.
C. Deep tendon reflexes of 2.
D. Absent ankle clonus.

B. A respiratory rate of 10 breaths/min.

Because magnesium sulfate is a central nervous system depressant, the woman will most likely become sedated when the infusion is initiated.
A respiratory rate of 10 breaths/min indicates that the woman is experiencing respiratory depression from magnesium toxicity.
Deep tendon reflexes of 2 is a normal finding.
Absent ankle clonus is a normal finding.

21. The nurse is preparing to discharge a 30-year-old woman who has experienced a miscarriage at 10 weeks of gestation. Which statement by the woman would indicate a correct understanding of the discharge instructions?
A. “I will not experience mood swings since I was only at 10 weeks of gestation.”
B. “I will avoid sexual intercourse for 6 weeks and pregnancy for 6 months.”
C. “I should eat foods that are high in iron and protein to help my body heal.”
D. “I should expect the bleeding to be heavy and bright red for at least 1 week.”

C. “I should eat foods that are high in iron and protein to help my body heal.”

After a miscarriage a woman may experience mood swings and depression as a result of the reduction of hormones and the natural grieving process.
Sexual intercourse should be avoided for 2 weeks or until the bleeding has stopped and pregnancy should be avoided for 2 months.
A woman who has experienced a miscarriage should be advised to eat foods that are high in iron and protein to help replenish her body after the loss.
The woman should not experience bright red, heavy, profuse bleeding; if such occurs, it should be reported to the health care provider.

22. Because pregnant women may need surgery during pregnancy, nurses should be aware that:
A. The diagnosis of appendicitis may be difficult to make, because the normal signs and symptoms mimic some normal changes in pregnancy.
B. Rupture of the appendix is less likely in pregnant women because of the close monitoring.
C. Surgery for intestinal obstructions should be delayed as long as possible because it usually affects the pregnancy.
D. When pregnancy takes over, a woman is less likely to have ovarian problems that require invasive responses.

A. The diagnosis of appendicitis may be difficult to make, because the normal signs and symptoms mimic some normal changes in pregnancy.

Both appendicitis and pregnancy are linked with nausea, vomiting, and increased white blood cell count.
Rupture of the appendix is two to three times more likely in pregnant women.
Surgery to remove obstructions should be done right away. It usually does not affect the pregnancy.
Pregnancy predisposes a woman to ovarian problems.

23. In caring for an immediate postpartum woman, you note petechiae and oozing from her IV site. You would monitor her closely for the clotting disorder:
A. Disseminated intravascular coagulation (DIC)
B. Amniotic fluid embolism (AFE)
C. Hemorrhage
D. HELLP syndrome

A. Disseminated intravascular coagulation (DIC)

The diagnosis of DIC is made according to clinical findings and laboratory markers. Physical examination reveals unusual bleeding. Petechiae may appear around a blood pressure cuff on the woman’s arm. Excessive bleeding may occur from the site of a slight trauma such as venipuncture sites.
These symptoms are not associated with AFE, nor is AFE a bleeding disorder.
Hemorrhage occurs for a variety of reasons in the postpartum woman. These symptoms are associated with DIC. Hemorrhage would be a finding associated with DIC and is not a clotting disorder in and of itself.
HELLP is not a clotting disorder, but it may contribute to the clotting disorder DIC.

24. A woman with severe preeclampsia has been receiving magnesium sulfate by intravenous infusion for 8 hours. The nurse assesses the woman and documents the following findings: temperature of 37.1° C, pulse rate of 96 beats/min, respiratory rate of 24 breaths/min, blood pressure (BP) of 155/112 mm Hg, 3+ deep tendon reflexes, and no ankle clonus. The nurse calls the physician, anticipating an order for:
A. Hydralazine.
B. Magnesium sulfate bolus.
C. Diazepam.
D. Calcium gluconate.

A. Hydralazine.

Hydralazine is an antihypertensive commonly used to treat hypertension in severe preeclampsia. Typically it is administered for a systolic BP over 160 mm Hg or a diastolic BP over 110 mm Hg.
An additional bolus of magnesium sulfate may be ordered for increasing signs of central nervous system irritability related to severe preeclampsia (e.g., clonus) or if eclampsia develops.
Diazepam sometimes is used to stop or shorten eclamptic seizures.
Calcium gluconate is used as the antidote for magnesium sulfate toxicity. The woman is not currently displaying any signs or symptoms of magnesium toxicity.

25. Nurses should be aware that HELLP syndrome:
A. Is a mild form of preeclampsia.
B. Can be diagnosed by a nurse alert to its symptoms.
C. Is characterized by hemolysis, elevated liver enzymes, and low platelets.
D. Is associated with preterm labor but not perinatal mortality.

C. Is characterized by hemolysis, elevated liver enzymes, and low platelets.

HELLP syndrome is a variant of severe preeclampsia.
HELLP syndrome is difficult to identify because the symptoms often are not obvious. It must be diagnosed in the laboratory.
The acronym HELLP stands for hemolysis (H), elevated liver enzymes (EL), and low platelets (LP).
Preterm labor is greatly increased in women with HELLP syndrome and so is perinatal mortality.

26. A woman at 39 weeks of gestation with a history of preeclampsia is admitted to the labor and birth unit. She suddenly experiences increased contraction frequency of every 1 to 2 minutes; dark red vaginal bleeding; and a tense, painful abdomen. The nurse suspects the onset of:
A. Eclamptic seizure.
B. Rupture of the uterus.
C. Placenta previa.
D. Placental abruption.

D. Placental abruption.

Eclamptic seizures are evidenced by the presence of generalized tonic-clonic convulsions.
Uterine rupture presents as hypotonic uterine activity, signs of hypovolemia, and in many cases the absence of pain.
Placenta previa presents with bright red, painless vaginal bleeding.
Uterine tenderness in the presence of increasing tone may be the earliest finding of premature separation of the placenta (abruptio placentae or placental abruption). Women with hypertension are at increased risk for an abruption.

27. Bleeding disorders in late pregnancy include all of the following except:
A. Placenta previa.
B. Abruptio placentae.
C. Spontaneous abortion.
D. Cord insertion.

C. Spontaneous abortion.

Placenta previa is a cause of bleeding disorders in later pregnancy.
Abruptio placentae is a cause of bleeding disorders in later pregnancy.
Spontaneous abortion is another name for miscarriage; by definition it occurs early in pregnancy.
Cord insertion is a cause of bleeding disorders in later pregnancy.

28. The nurse is caring for a woman who is at 24 weeks of gestation with suspected severe preeclampsia. Which signs and symptoms would the nurse expect to observe? Select all that apply.
A. Decreased urinary output and irritability
B. Transient headache and +1 proteinuria
C. Ankle clonus and epigastric pain
D. Platelet count of less than 100,000/mm3 and visual problems
E. Seizure activity and hypotension
A. Decreased urinary output and irritability
C. Ankle clonus and epigastric pain
D. Platelet count of less than 100,000/mm3 and visual problems
29. _________________________ is responsible for 10% to 15% of all maternal mortality and is the leading cause of infertility.
“Ectopic pregnancy”
30. The condition in which the placenta is implanted in the lower uterine segment near or over the internal cervical os is _________________________.
“placenta previa”
31. A laboring woman’s amniotic membranes have just ruptured. The immediate action of the nurse would be to:
A. Assess the fetal heart rate (FHR) pattern.
B. Perform a vaginal examination.
C. Inspect the characteristics of the fluid.
D. Assess maternal temperature.

A. Assess the fetal heart rate (FHR) pattern.

The first nursing action after the membranes are ruptured is to check the FHR. Compression of the cord could occur after rupture leading to fetal hypoxia as reflected in an alteration in FHR pattern, characteristically variable decelerations. The same initial action should follow artificial rupture of the membranes (amniotomy).
Performing a vaginal examination, inspecting the characteristics of the fluid, and assessing maternal temperature are all important and should be done after the FHR and pattern are assessed.

32. With regard to dysfunctional labor, nurses should be aware that:
A. Women who are underweight are more at risk.
B. Women experiencing precipitous labor are about the only “dysfunctionals” not to be exhausted.
C. Hypertonic uterine dysfunction is more common than hypotonic dysfunction.
D. Abnormal labor patterns are most common in older women.

B. Women experiencing precipitous labor are about the only “dysfunctionals” not to be exhausted.

Short women more than 30 pounds overweight are more at risk for dysfunctional labor.
Precipitous labor lasts less than 3 hours.
Hypotonic uterine dysfunction, in which the contractions become weaker, is more common.
Abnormal labor patterns are more common in women under 20 years of age.

33. A woman at 26 weeks of gestation is being assessed to determine whether she is experiencing preterm labor. What finding indicates that preterm labor is occurring?
A. Estriol is not found in maternal saliva.
B. Irregular, mild uterine contractions are occurring every 12 to 15 minutes.
C. Fetal fibronectin is present in vaginal secretions.
D. The cervix is effacing and dilated to 2 cm.

D. The cervix is effacing and dilated to 2 cm.

Estriol is a form of estrogen produced by the fetus that is present in plasma at 9 weeks of gestation. Levels of salivary estriol have been shown to increase before preterm birth.
Irregular, mild contractions that do not cause cervical change are not considered a threat.
The presence of fetal fibronectin in vaginal secretions between 24 and 36 weeks of gestation could predict preterm labor, but it has only a 20% to 40% positive predictive value. Of more importance are other physiologic clues of preterm labor such as cervical changes.
Cervical changes such as shortened endocervical length, effacement, and dilation are predictors of imminent preterm labor. Changes in the cervix accompanied by regular contractions indicate labor at any gestational age.

34. The nurse is caring for a woman whose labor is being augmented with oxytocin. The nurse recognizes that the oxytocin should be discontinued immediately if there is evidence of:
A. Uterine contractions occurring every 8 to 10 minutes.
B. A fetal heart rate (FHR) of 180 with absence of variability.
C. The woman needing to void.
D. Rupture of the woman’s amniotic membranes.

B. A fetal heart rate (FHR) of 180 with absence of variability.

The oxytocin should be discontinued if uterine hyperstimulation occurs. Uterine contractions that are occurring every 8 to 10 minutes do not qualify as hyperstimulation.
An FHR of 180 is nonreassuring. The oxytocin should be discontinued immediately, and the physician should be notified.
The woman needing to void is not an indication to discontinue the oxytocin induction immediately or to call the physician.
Unless a change occurs in the FHR pattern that is nonreassuring or the woman experiences uterine hyperstimulation, the oxytocin does not need to be discontinued. The physician should be notified that the woman’s membranes have ruptured.

35. With regard to the use of tocolytic therapy to suppress uterine activity, nurses should be aware that:
A. The drugs can be given efficaciously up to the designated beginning of term at 37 weeks.
B. There are no important maternal (as opposed to fetal) contraindications.
C. Its most important function is to afford the opportunity to administer antenatal glucocorticoids.
D. If the patient develops pulmonary edema while on tocolytics, intravenous (IV) fluids should be given.

C. Its most important function is to afford the opportunity to administer antenatal glucocorticoids.

Once the pregnancy has reached 34 weeks, the risks of tocolytic therapy outweigh the benefits.
There are important maternal contraindications to tocolytic therapy.
Buying time for antenatal glucocorticoids to accelerate fetal lung development might be the best reason to use tocolytics.
Tocolytic-induced edema can be caused by IV fluids.

36. The nurse providing care to a woman in labor should be aware that cesarean birth:
A. Is declining in frequency in the twenty-first century in the United States.
B. Is more likely to be done for the poor in public hospitals who do not get the nurse counseling that wealthier patients do.
C. Is performed primarily for the benefit of the fetus.
D. Can be either elected or refused by women as their absolute legal right.

C. Is performed primarily for the benefit of the fetus.

Cesarean births are increasing in the United States in this century.
Wealthier women who have health insurance and who give birth in a private hospital are more likely to experience cesarean birth.
The most common indications for cesarean birth are danger to the fetus related to labor and birth complications.
A woman’s right to elect cesarean surgery is in dispute, as is her right to refuse it if in doing so she endangers the fetus. Legal issues are not absolutely clear.

37. For a woman at 42 weeks of gestation, which finding would require more assessment by the nurse?
A. Fetal heart rate of 116 beats/min
B. Cervix dilated 2 cm and 50% effaced
C. Score of 8 on the biophysical profile
D. One fetal movement noted in 1 hour of assessment by the mother

D. One fetal movement noted in 1 hour of assessment by the mother

Fetal heart rate of 116 beats/min is a normal finding in a 42-week gestation.
A cervix dilated to 2 cm and 50% effaced is a normal finding in a 42-week gestation.
A score of 8 on the BPP is a normal finding in a 42-week gestation.
Self-care in a postterm pregnancy should include performing daily fetal kick counts three times per day. The mother should feel four fetal movements per hour. If fewer than four movements have been felt by the mother, she should count for 1 more hour. Fewer than four movements in that hour warrants evaluation.

38. ____________________ is defined as long, difficult, or abnormal labor. It is caused by various conditions associated with the five factors affecting labor.
“Dystocia”
39. Two hours after giving birth, a primiparous woman becomes anxious and complains of intense perineal pain with a strong urge to have a bowel movement. Her fundus is firm, at the umbilicus, and midline. Her lochia is moderate rubra with no clots. The nurse would suspect:
A. Bladder distention.
B. Uterine atony.
C. Constipation.
D. Hematoma formation.

D. Hematoma formation.

Bladder distension would result in an elevation of the fundus above the umbilicus and deviation to the right or left of midline.
Uterine atony would result in a boggy fundus.
Constipation is unlikely at this time.
Increasing perineal pressure along with a firm fundus and moderate lochial flow are characteristic of hematoma formation.

40. Postpartum women experience an increased risk for urinary tract infection. A prevention measure the nurse could teach the postpartum woman would be to:
A. Acidify the urine by drinking 3 glasses of orange juice each day.
B. Maintain a fluid intake of 1 to 2 L/day.
C. Empty bladder every 4 hours throughout the day.
D. Perform perineal care on a regular basis.

D. Perform perineal care on a regular basis.

Urine is acidified with cranberry juice.
The woman should drink at least 3 L of fluid each day.
The woman should empty her bladder every 2 hours to prevent stasis of urine.
Keeping the perineum clean will help prevent a urinary tract infection.

41. 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 on magnesium sulfate 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

B. A woman with severe preeclampsia on magnesium sulfate whose labor is being induced

Although many causes and risk factors are associated with PPH, a primiparous woman (G 2 P 1 0 0 1) being prepared for an emergency cesarean birth for fetal distress does not pose risk factors or causes of early PPH.
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, a multiparous woman (G 3 P 2 0 0 2) with an 8-hour labor does not pose risk factors or causes of early PPH.
Although many causes and risk factors are associated with PPH, a primigravida in spontaneous labor with preterm twins does not pose risk factors or causes of early PPH.

42. The first and most important nursing intervention when a nurse observes profuse postpartum bleeding is to:
A. Call the woman’s 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.

C. Palpate the uterus and massage it if it is boggy.

Calling the woman’s primary care provider is appropriate. However, the primary intervention should be to assess the uterus. Uterine atony is the leading cause of postpartum hemorrhage (PPH).
Administering a standing order for an oxytocic is appropriate. However, the primary intervention should be to assess the uterus. Uterine atony is the leading cause of PPH.
The initial management of excessive postpartum bleeding is firm massage of the uterine fundus.
Assessing maternal blood pressure and pulse is appropriate. However, the primary intervention should be to assess the uterus. Uterine atony is the leading cause of PPH.

43. 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 (ITP)
D. Uterine atony and disseminated intravascular coagulation (DIC)

A. Inversion of the uterus and hypovolemic shock

Inversion of the uterus and hypovolemic shock are considered medical emergencies.
Although a hypotonic uterus and coagulopathies are serious conditions, they do not necessarily constitute a medical emergency that requires immediate treatment.
Although subinvolution and ITP are serious conditions, they do not necessarily constitute a medical emergency that requires immediate treatment.
Although uterine atony and DIC are serious conditions, they do not necessarily constitute a medical emergency that requires immediate treatment.

44. What infection is contracted mostly by first-time mothers who are breastfeeding?
A. Endometritis
B. Wound infections
C. Mastitis
D. Urinary tract infections

C. Mastitis

Endometritis is an infection of the uterus and is not confined to first-time mothers.
Wound infections are most likely to occur after a cesarean birth and are not seen more often in first-time mothers.
Mastitis is infection in a breast, usually confined to a milk duct. Most women who suffer this are first-timers who are breastfeeding.
UTI can occur both during pregnancy and postpartum. Breastfeeding or being a first-time mother are not contributing factors.

45. A mother in late middle age who is certain she is not pregnant tells the nurse during an office visit that she has urinary problems and sensations of bearing down and of something in her vagina. The nurse would realize that the woman most likely is suffering from:
A. Pelvic relaxation.
B. Cystoceles and/or rectoceles.
C. Uterine displacement.
D. Genital fistulas.

B. Cystoceles and/or rectoceles.

Cystoceles are protrusions of the bladder downward into the vagina; rectoceles are herniations of the anterior rectal wall through a relaxed or ruptured vaginal fascia. Both can present as a bearing down sensation with urinary dysfunction. They occur more often in older women who have borne children.

46. To provide adequate postpartum care, the nurse should be aware that postpartum depression (PPD) with psychotic features:
A. Is more likely to occur in women with more than two children.
B. Is rarely delusional and then usually about someone trying to harm her (the mother).
C. Although serious, is not likely to need psychiatric hospitalization.
D. May include bipolar disorder (formerly called “manic depression”).

D. May include bipolar disorder (formerly called “manic depression”).

PPD is more likely to occur in first-time mothers.
Delusions may be present in 50% of women with PPD, usually involving something being wrong with the infant.
PPD with psychosis is a psychiatric emergency that requires hospitalization.
Manic mood swings are possible.

47. Possible alternative and complementary therapies for postpartum depression (PPD) for breastfeeding mothers include (choose all that apply):
A. Acupressure.
B. Aromatherapy.
C. St. John’s wort.
D. Wine consumption.
E. Yoga.
A. Acupressure.
B. Aromatherapy.
E. Yoga.
What are the goals for Healthy People 2020 (pediatrics)?
Framework for identifying essential components for child health promotion programs
Designed to prevent future health problems in children
Overarching goal: Increase quality and length of healthy life and eliminate health disparities.
What are the leading health indicators for Healthy People 2020?
Physical activity
Overweight and Obesity
Tobacco
Substance Abuse
Responsible Sexual behavior
List common childhood health problems
Obesity and Type 2 Diabetes
Childhood Injuries
Violence
Substance Abuse
Mental Health Problems
What is Morbidity?
Prevalence of disease
What is Mortality?
# of individuals who have died over time
What is Infant mortality?
# of deaths in infants <1 yr /1000 births
(Note racial differences in statistics)
What is the highest childhood morbidity?
50% are acute respiratory infections
Infections 11%
Injuries 15%
Chronic Illness
Asthma
Allergies
Behavior
What are the causes of death for neonatal (0-1 month)?
Gestation
Birth Weight
What are the causes of death for infant (1-12 month)?
Congenital anomalies
Gestational problems
SIDS
What are the causes of death for child (1-14 year)
Injuries
Motor Vehicle
Drowning
Burns
Cancer
Congenital anomalies
What are the causes of death for teens (>15 years)
Accidents
Homicides
Suicides
Cancer
What are the responsibilities of a Pediatric Nurse?
Family Centered Care
Promoting health and well being of child and family
Therapeutic Relationship
Embrace cultural diversity
What is atraumatic care?
Eliminate or minimize distress
Prevent or minimize separation from the family
Promote sense of control
Prevent or minimize bodily injury and pain
Examples:
– Foster the parent-child relationship
– Prepare child before any treatment or procedure
– Control pain
– Provide play activities for expression of fear and aggression
What are the key components of a cultural assessment?
Language
Diet
Childbearing/Childcare
Childrearing (Discipline, Training, Decisions)
Healing Beliefs
Religious/beliefs/rituals
What is the difference between enabling and empowerment?

Enabling: Strengthens current abilities and competencies it also aids in acquiring new abilities and competencies as needed

Empowerment: Interaction that allows the family to maintain or acquire a sense of control. Behaviors that foster family’s strengths, abilities, and actions

Why is important to understand causes of mortality in the pediatric population?
To address what the causes are, so that you can reduce that prevalence of pediatric mortality. So we know what kind of patients and issues we are dealing with.
Why do you think it is important for pediatric nurses to understand family function?
Nurses need to assess:
Communication
Flexibility and adaptability
Support systems
Respect and value of members
Coping mechanisms
Family rules
Common activities
What do you think the challenges would be to provide FCC in a pediatric unit?
Language, culture, family issues and involvement
What is the difference between growth and development?
Growth is orderly process and occurs in a systematic fashion.
Development more complex and subtle, proceeds from simple to complex and general to specific.
What are some influential factors of childhood development?
Nutrition most important influence
Other:
– Genetics
– Race
– Environment
– Affection
– Disease
– Stress
What are trends in physical development related to length?
Increases 50% by 1 year
Doubles by age 4y
1-3″ through adolescence
What are trends in physical development related to weight?
Birth weight doubles by 4-6mos
Triples by 1 year
4-6″ per year until adolescence
Explain some key indicators of physiologic development in children
BMR decreases as do caloric needs
Decrease in HR, RR (Adult values by adolescence)
Decrease in sleep needs
Neonatal reflexes extinguish by 6 months
In gross development at what time will there be no more head lag?
6 months
Name the progression of gross motor skills?
Roll over
Tripod
Sit by self
Crawl
Pull self up
Walk
Name the progression of fine motor development?
Grasp
Transfer
Pincer
Color
Write
Draw person
List the progression of depth in vision?
8-12in 9 mos
20/30 by 3 years
20/20 by 5 years
List the progression of auditory
Startle, localize 7 months
Follow directions 18 months
Name the developmental groups from neonatal to adolescent?
Neonatal (birth to 1 month)
Infant (1 month to 1 year)
Toddler (1 year to 3 years)
Preschooler (3 years to 6 years)
School-Age (6 years to 11-12 years)
Adolescent (12 years to 18 years)
What are Erickson’s developmental groups?
Trust vs Mistrust (birth to 1 yr)
Autonomy vs Shame and Doubt (1-3y)
Initiative vs Guilt (3 – 6y)
Industry vs Inferiority (6 – 12y)
Identity vs Role confusion (12- 18y)
What are the cognitive development stages of Piaget?
Sensorimotor (birth to 2 years)
Preoperational (2 to 7 years)
Concrete Operations (7 to 11 years)
Formal Operations (11 to 15 years)
Name the stages of Language Development
Newborn – cooing, crying
9 – 12months – “mama, dada”, “no”
18 – 24 months – 10-20 words, body parts
24 mos – 2-word phrases, 50% unintelligent
3 y – 3-4 word phrases, 75% intelligent, name
4 y – sentences, past tense, story, stutter
5 y- >5 word, future tense
What are some methods for nutritional assessments?
24 hour recall
Food diary
Food frequency
What are the physical parameters for nutritional assessment?
General Growth most sensitive
Skin
Hair
Mouth
Abdomen
Musculoskeletal
Neuro
What do morbidity rates measure?
A) Life span statistics
B) Acute illness, chronic disease, or disability
C) Cost-effective treatment for general population
D) Prevalence of a specific illness in a population
D) Prevalence of a specific illness in a population
Public health interventions that have had the greatest impact on world health include:
A) improved dental hygiene.
B) advances in prenatal care.
C) better methods of detection.
D) Clean drinking water and childhood vaccination programs.
D) Clean drinking water and childhood vaccination programs.
Which of the following is the leading cause of death from unintentional injuries in children?
A) Poisoning
B) Drowning
C) Motor vehicles
D) Fires and burns
C) Motor vehicles
Which of the following nursing interventions is most descriptive of atraumatic care of children?
A) Preparing child before any unfamiliar treatment or procedure
B) Preparing child for separation from parents during hospitalization
C) Helping child accept pain that is associated with a treatment or procedure
D) Helping child accept the loss of control associated with hospitalization
A) Preparing child before any unfamiliar treatment or procedure
Which of the following is most suggestive that a nurse has a nontherapeutic relationship with a patient or family?
A) Staff is concerned about the nurse’s actions with patient or family.
B) Staff assignments allow nurse to care for same patient or family over an extended time.
C) The nurse uses teaching skills to instruct the patient or family rather than doing everything for them.
D) The nurse is able to withdraw emotionally when emotional overload occurs but still remain committed.
A) Staff is concerned about the nurse’s actions with patient or family.
Which of the following is descriptive of nursing diagnoses?
A) They provide the basis for the selection of nursing interventions.
B) They should describe everything for which nursing is responsible.
C) The cause of the problem must be identified before a nursing diagnosis can be made.
D) The cause of the problem implies a cause-and-effect relationship in the nursing diagnosis
A) They provide the basis for the selection of nursing interventions.
Which of the following terms best describes a group of people who share a set of values, beliefs, practices, social relationships, law, politics, economics, and norms of behavior?
A) Race
B) Culture
C) Ethnicity
D) Social group
B) Culture
Currently, the fastest-growing segment of the homeless population in the United States consists of which of the following?
A) Families
B) “Runaway” adolescents
C) Migrant farm workers
D) Individuals with mental disorders
B) “Runaway” adolescents
Maria is a Spanish-speaking 5-year-old who has started kindergarten in an English-speaking school. Crying most of the time, she appears helpless and unable to function in this new situation. The best explanation for this is which of the following?
A) Lacks adequate maturity for attending school
B) Lacks the maturity needed in school
C) Is experiencing cultural shock
D) Is experiencing minority group discrimination
C) Is experiencing cultural shock
The father of a hospitalized child tells the nurse, “He can’t have meat. We are Buddhist and vegetarians.” The nurse’s best intervention is to:
A) Order the child a meatless tray.
B) ask a Buddhist priest to visit.
C) explain that hospital patients are exempt from dietary rules.
D) help the parent understand that meat provides protein needed for healing.
A) Order the child a meatless tray.
Which of the following statements is true concerning folk remedies?
A) They may be used to reinforce the treatment plan.
B) They are incompatible with modern medical regimens.
C) They are a leading cause of death in some cultural groups.
D) They are not a part of the culture in large, developed countries.
A) They may be used to reinforce the treatment plan
Which of the following is descriptive of family systems theory?
A) The family is viewed as the sum of individual members.
B) Change in one family member cannot create a change in other members.
C) Individual family members are readily identified as the source of a problem.
D) When the family system is disrupted, change can occur at any point in the system.
D) When the family system is disrupted, change can occur at any point in the system.
Dunst, Trivette, and Deal have identified the qualities of strong families that help them function effectively. These include which of the following?
A) Lack of congruence among family members
B) Clear set of family values, rules, and beliefs
C) Adoption of one coping strategy that always promotes positive functioning in dealing with life events
D) Sense of commitment toward growth of individual family members as opposed to that of the family unit
B) Clear set of family values, rules, and beliefs
Birth position of children affects their personalities. Which of the following is considered characteristic of children who are the youngest in their family?
A) More dependent than firstborn children
B) More affectionate than firstborn children
C) Identify more with parents than with peers
D) Are subject to greater parental expectations
B) More affectionate than firstborn children
The parents of a young child ask the nurse for suggestions about discipline. When discussing the use of “time-outs,” which of the following instructions should the nurse include?
A) Send child to his or her room, if child has one.
B) If child cries, refuses, or is more disruptive, try another approach.
C) Select an area that is safe and unstimulating, such as a hallway.
D) General rule for length of time is 1 hour per year of age.
C) Select an area that is safe and unstimulating, such as a hallway.
A parent of a school-age child tells the school nurse that the parents are going through a divorce. The child has not been doing well in school and sometimes has trouble sleeping. The nurse should recognize this as which of the following?
A) Indicative of maladjustment
B) Common reaction to divorce
C) Suggestive of lack of adequate parenting
D) Unusual response that indicates need for referral
B) Common reaction to divorce
List some ethical issues in Perinatal Nursing
Reproductive technology
Scarce resources
Older age pregnancies
Third-party payers
Induced ovulation and in vitro fertilization
Multifetal pregnancy reductionIntrauterine fetal surgery, Fetoscopy
Therapeutic insemination
Genetic engineering, Stem cell research
Surgery for infertility, “Test tube” babies
Treatment of very low-birth-weight (VLBW) infants

What are the overarching goals of Healthy People 2020
Increase quality/years of life and eliminate health disparities
Name some of the Healthy People 2020 perinatal proposed objectives?
– Reduce maternal deaths, illness, and complications r/t pregnancy
– Early and adequate prenatal care
– Reduce LBW and VLBW, and pre term births
– To decrease occurrence of SIDS have babies sleep on back
– Abstain from alcohol, cigarettes, and illicit drugs among pregnant women
– Reduce the occurrence of FAS
– Increase BF
– Quit smoking before, during and after pregnancy
– Increase preconception care services
– Increase work site lactation programs
– Increase 1 yr survival rate for babies with Down Syndrome
– Reduce the proportion of persons ages 18-44 who have impaired fecundity.
What are the key components of cultural competence?
– Recognize difference between own culture and client’s
– Understanding pt’s cultural background
– Recognize the importance of: communication styles, problem-solving techniques, concepts of space and time, desires to be involved with care decisions
– Anticipate language ability and literacy
Name the levels of preventative care, and list some examples?
Primary prevention: immunizations, car seats, etc.
Secondary prevention: screenings, testing, early treatments
Tertiary prevention: treatment and rehabilitation to prevent complications and further deterioration
Name 3 vulnerable populations?
Incarcerated women
Migrant women
Rural versus urban community settings
Homeless women and homeless families
Refugees and immigrants
Implications for nursing
Women
Racial and ethnic minorities
Adolescent girls
Older women
Low literacy
What does the US rank among industrialized nations in infant mortality rates despite HP2020 goals?
27th (book 29th), this is r/t LBW
Currently what is the focus of childbirth practices?
Family and alternatives
What are key factors influencing family health?
Key factors include: family socioeconomics, response to stress, and culture
In what part of culture would you find reproductive beliefs and practices?
They are found in economic, religious, kinship, and political structures
Define vulnerable populations
groups at higher risk for developing physical, mental, or social health problems
What are reasons for a woman to enter the healthcare system?
Preconception counseling (Ideal) and care
Pregnancy
Well-woman care (Ideal)
Fertility control and infertility
Menstrual problems (younger women especially)
Perimenopause
List some barriers to seeking health care (women)
Financial issues
Cultural issues
Gender issues
Name some health risks found in childbearing women?
Age
Socioeconomic
Substance use and abuse
Nutrition
Physical fitness and exercise
Stress
Sexual practices
Medical conditions
Gynecologic conditions
Environmental and workplace hazards
**Violence against women: women are more abused during the time of pregnancy**
What is included in a women’s health assessment?
Interview*
Women with special needs
History*
Physical examination*
Pelvic examination during pregnancy
Pelvic examination after hysterectomy
Laboratory and diagnostic procedures
As a nurse what are Anticipatory Guidance for Health Promotion and Illness Prevention?
Nutrition
Exercise
Stress management
Substance use cessation
Safer sexual practices
Health screening schedule
Health risk prevention
Health protection
List some complementary and alternative healing modalities?
Touch and energetic healing
Massage
Energy healing
Acupressure
Therapeutic touch (TT)
Reiki
Mind-body healing
Guided imagery
Meditation, prayer, reflection, and relaxation
Biofeedback
Alternative pharmacologic modalities
Homeopathy
Traditional Chinese Medicine (TCM)
Acupuncture
Nutrition and exercise
Applications in women’s health care
Pregnancy and maternity care
Gynecology
Why the big push for EBP?
– Reimbursement costs have decreased
– Patient population not willing to accept errors
– Professional organizations review/set standards
What is not a trend in the delivery of health care in the United States?
A. Greater emphasis has been placed on curing disease and disability than on preventing them.
B. Hospital stays for many conditions have been shortened.
C. Acute care increasingly is provided through home-based services.
D. Hospital-based nurses are increasingly involved in follow-up care after discharge.
A. Greater emphasis has been placed on curing disease and disability than on preventing them.
A 23-year-old African-American woman is pregnant with her first child. Based on the statistics for infant mortality, which plan is most important for the nurse to implement?
A. Perform a nutrition assessment.
B. Refer the woman to a social worker.
C. Advise the woman to see an obstetrician, not a midwife.
D. Explain to the woman the importance of keeping her prenatal care appointments.
D. Explain to the woman the importance of keeping her prenatal care appointments.
When a nurse is unsure about how to perform a client care procedure, the best action would be to:
A. Ask another nurse
B. Discuss the procedure with the client’s physician
C. Look up the procedure in a nursing textbook
D. Consult the agency procedure manual and follow the guidelines for the procedure
D. Consult the agency procedure manual and follow the guidelines for the procedure
When caring for pregnant women, the nurse should keep in mind that violence during pregnancy:
A. Affects more than 25% of pregnant women in the United States
B. Increases a pregnant woman’s risk for gestational hypertension
C. May be associated with substance abuse by both the pregnant woman and her partner
D. Has decreased in incidence as a result of better assessment techniques and record keeping
C. May be associated with substance abuse by both the pregnant woman and her partner
The following conditions have contributed to the increase in maternity-related health care costs except:
A. Early postpartum discharges
B. Maternal medical risk factors, such as diabetes
C. The use of high-tech equipment
D. The cost of care for low-birth-weight (LBW) infants
A. Early postpartum discharges
From the nurse’s perspective, what measure should be the focus of the health care system in order to reduce the rate of infant mortality further?
A. Implementing programs to ensure women’s early participation in ongoing prenatal care
B. Increasing the length of stay in a hospital after vaginal birth from 2 to 3 days
C. Expanding the number of neonatal intensive care units (NICUs)
D. Mandating that all pregnant women receive care from an obstetrician
A. Implementing programs to ensure women’s early participation in ongoing prenatal care
The term used to describe legal and professional responsibility for practice for maternity nurses is:
A. Collegiality
B. Ethics
C. Evaluation
D. Accountability
D. Accountability
The two most frequently reported maternal medical risk factors are:
A. Hypertension associated with pregnancy and diabetes
B. Drug use and alcohol abuse
C. Homelessness and lack of insurance
D. Behaviors and lifestyles
A. Hypertension associated with pregnancy and diabetes
Which statement made by the nurse would indicate that he or she is practicing appropriate family-centered care techniques?
A. The nurse encourages the mother and father to make choices whenever possible.
B. The nurse updates the family about what is going to happen but instructs the clients sister that she cannot be present in the room during the birth.
C. The nurse believes that he or she is acting in the best interest of the client and commands her what to do throughout labor.
D. The father is discouraged from accompanying his wife during a cesarean birth.
A. The nurse encourages the mother and father to make choices whenever possible.
The uterus is a muscular pear-shaped organ that is responsible for:
A. Cyclic menstruation
B. Sex hormone production
C. Fertilization
D. Sexual arousal
A. Cyclic menstruation
The hormone responsible for maturation of mammary gland tissue is:
A. Estrogen
B. Testosterone
C. Prolactin
D. Progesterone
D. Progesterone
Which statement about female sexual response is not accurate?
A. Women and men are more alike than different in their physiologic response to sexual arousal and orgasm.
B. Vasocongestion is the congestion of blood vessels.
C. The orgasmic phase is the final state of the sexual response cycle.
D. Facial grimaces and spasms of hands and feet are often part of arousal.
C. The orgasmic phase is the final state of the sexual response cycle.
The nurse who provides preconception care understands that it:
A. Is designed for women who have never been pregnant
B. Includes risk factor assessments for potential medical and psychologic problems but by law cannot consider finances or workplace conditions
C. Avoids teaching about safe sex to avoid political controversy
D. Could include interventions to reduce substance use and abuse
D. Could include interventions to reduce substance use and abuse
A 62-year-old woman has not been to the clinic for an annual examination for 5 years. The recent death of her husband reminded her that she should come for a visit. Her family doctor has retired, and she is going to see the women’s health nurse practitioner for her visit. To facilitate a positive health care experience, the nurse should:
A. Remind the woman that she is long overdue for her examination and that she should come in annually
B. Listen carefully and allow extra time for this woman’s health history interview
C. Reassure the woman that a nurse practitioner is just as good as her old doctor
D. Encourage the woman to talk about the death of her husband and her fears about her own death
B. Listen carefully and allow extra time for this woman’s health history interview
During a health history interview, a woman states that she thinks that she has “bumps” on her labia. She also states that she is not sure how to check herself. The correct response would be to:
A. Reassure the woman that the examination will not reveal any problems
B. Explain the process of vulvar self-examination to the woman and reassure her that she will become familiar with normal and abnormal findings during the examination
C. Reassure the woman that “bumps” can be treated
D. Reassure her that most women have “bumps” on their labia
B. Explain the process of vulvar self-examination to the woman and reassure her that she will become familiar with normal and abnormal findings during the examination
Which is correct concerning the performance of a Papanicolaou (Pap) test?
A. The woman should not douche, use vaginal medications, or have intercourse for at least 24 hours before the test.
B. It should be performed once a year beginning with the onset of puberty.
C. A lubricant such as Vaseline should be used to ease speculum insertion.
D. The specimen for the Pap test should be obtained after specimens are collected for cervical infection.
A. The woman should not douche, use vaginal medications, or have intercourse for at least 24 hours before the test.
The nurse-midwife is teaching a group of women who are pregnant, including instruction on Kegel exercises. Which statement by a participant would indicate a correct understanding of the instruction?
A. “I will only see results if I perform 100 Kegel exercises each day.”
B. “I should hold the Kegel exercise contraction for 10 seconds and rest for 10 seconds between exercises.”
C. “I should only perform Kegel exercises in the sitting position.”
D. “I will perform daily Kegel exercises during the last trimester of my pregnancy to achieve the best results.”
B. “I should hold the Kegel exercise contraction for 10 seconds and rest for 10 seconds between exercises.”
Article: As an RN what we qualified to do during epidurals for women?
Monitor the pt’s vital signs, mobility, level of consciousness, and perception if pain.
Monitor the status of the fetus
Replace empty infusion syringes or infusion bags with new, pre-prepared solutions containing the same medication and concentration, according to standing orders provided by the anesthesia care provider
Stop the continuous infusion if there is a safety concern or the woman has given birth
Remove the catheter, if educational criteria have been met and institutional policy and law allow.
Remo
Article: What is AWHONN’s position in regards to reproductive health care services or research activity?
AWHONN supports the protection of an individual RN’s right to choose to participate. RN’s have the right under federal law to refuse to assist in keeping with their personal moral, ethical, or religious beliefs.
LM Ch1: What do maternity nurse teach about pregnancy?
– Process of labor, birth and recovery
– Provide continuity of care through the childbirth cycle
LM Ch1: List some serious problems in the US related to healthcare of mothers and infants?
Lack of access to pregnancy
Pregnancy related care for all women
Lack of reproductive health services for adolescents
LM Ch1: Name the “never events” pertaining to maternal and child health?
– Infant discharged to the wrong person
– Maternal death or serious disability associated with labor or birth in a low risk pregnancy while being cared for in a health care facility
– Death or serious disability (kernicterus) associated with failure to identify and treat hyperbilirubinemia neonates
– Artificial insemination with the wrong donor sperm or donor egg
LM Ch 1: What are some factors associated with higher infant mortality rates?
Limited maternal education
Young maternal age
Unmarried status
Poverty
Lack of prenatal care
Smoking
Poor nutrition
Alcohol use
Maternal conditions: poor health, hypertension
LM Ch1: What is the leading cause death in the neonatal period?
Congenital anomalies
LM Ch1: What are the 3 leading causes of maternal death in the US?
gestational hypertension, PE, and hemorrhage
A woman’s cousin gave birth to an infant with a congenital heart anomaly. The woman asks the nurse when such anomalies occur during development. Which response by the nurse is most accurate?
A. “We don’t really know when such defects occur.”
B. “It depends on what caused the defect.”
C. “They occur between the third and fifth weeks of development.”
D. “They usually occur in the first 2 weeks of development.”
C. “They occur between the third and fifth weeks of development.”
A maternity nurse should be aware of which fact about the amniotic fluid?
A. It serves as a source of oral fluid and as a repository for waste from the fetus.
B. The volume remains about the same throughout the term of a healthy pregnancy.
C. A volume of less than 300 ml is associated with gastrointestinal malformations.
D. A volume of more than 2 L is associated with fetal renal abnormalities.
A. It serves as a source of oral fluid and as a repository for waste from the fetus.
The nurse caring for a pregnant woman knows that her health teaching regarding fetal circulation has been effective when the woman reports that she has been sleeping:
A. In a side-lying position
B. On her back with a pillow under her knees
C. With the head of the bed elevated
D. On her abdomen
A. In a side-lying position
A woman at 35 weeks of gestation has had an amniocentesis. The results reveal that surface-active phospholipids are present in the amniotic fluid. The nurse is aware that this finding indicates:
A. The fetus is at risk for Down syndrome
B. The woman is at high risk for developing preterm labor
C. Lung maturity
D. Meconium is present in the amniotic fluid
C. Lung maturity
Which time span delineates the appropriate length for a normal pregnancy?
A. 9 lunar months, 8.5 calendar months, 39 weeks, 272 days
B. 10 lunar months, 9 calendar months, 40 weeks, 280 days
C. 9 calendar months, 10 lunar months, 42 weeks, 294 days
D. 9 calendar months, 38 weeks, 266 days
B. 10 lunar months, 9 calendar months, 40 weeks, 280 days
A woman is 6 weeks pregnant. She has had a previous spontaneous abortion at 14 weeks of gestation and a pregnancy that ended at 38 weeks with the birth of a stillborn girl. What is her gravidity and parity using the GTPAL system?
A. 2-0-0-1-1
B. 2-1-0-1-0
C. 3-1-0-1-0
D. 3-0-1-1-0
C. 3-1-0-1-0
Over-the-counter (OTC) pregnancy tests usually rely on which technology to test for human chorionic gonadotropin (hCG)?
A. Radioimmunoassay
B. Radioreceptor assay
C. Latex agglutination test
D. Enzyme-linked immunosorbent assay (ELISA)
D. Enzyme-linked immunosorbent assay (ELISA)
A nurse teaches a pregnant woman about the presumptive, probable, and positive signs of pregnancy. The woman demonstrates understanding of the nurse’s instructions if she states that a positive sign of pregnancy is:
A. A positive pregnancy test
B. Fetal movement palpated by the nurse-midwife
C. Braxton Hicks contractions
D. Quickening
B. Fetal movement palpated by the nurse-midwife
During a client’s physical examination, the nurse notes that the lower uterine segment is soft on palpation. The nurse would document this finding as:
A. Hegar sign
B. McDonald sign
C. Chadwick sign
D. Goodell sign
A. Hegar sign
Cardiovascular system changes occur during pregnancy. Which finding would be considered normal for a woman in her second trimester?
A. Less audible heart sounds (S1, S2)
B. Increased pulse rate
C. Increased blood pressure
D. Decreased red blood cell (RBC) production
B. Increased pulse rate
A woman who has completed one pregnancy with a fetus (or fetuses) reaching the stage of fetal viability is called a:
A. Primipara
B. Primigravida
C. Multipara
D. Nulligravida
A. Primipara
Which presumptive sign (felt by woman) or probable sign (observed by the examiner) of pregnancy is not matched with another possible cause?
A. Amenorrhea-stress, endocrine problems
B. Quickening-gas, peristalsis
C. Goodell sign-cervical polyps
D. Chadwick sign-pelvic congestion
C. Goodell sign-cervical polyps
In order to reassure and educate pregnant clients about changes in their blood pressure, maternity nurses should be aware that:
A. A blood pressure cuff that is too small produces a reading that is too low; a cuff that is too large produces a reading that is too high
B. Shifting the client’s position and changing from arm to arm for different measurements produces the most accurate composite blood pressure reading at each visit
C. The systolic blood pressure increases slightly as pregnancy advances; the diastolic pressure remains constant
D. Compression of the iliac veins and inferior vena cava by the uterus contributes to hemorrhoids in the later stage of term pregnancy
D. Compression of the iliac veins and inferior vena cava by the uterus contributes to hemorrhoids in the later stage of term pregnancy
Which hematocrit (HCT) and hemoglobin (HGB) results represent the lowest acceptable values for a woman in the third trimester of pregnancy?
A. 38% HCT; 14 g/dl HGB
B. 35% HCT; 13 g/dl HGB
C. 33% HCT; 11 g/dl HGB
D. 32% HCT; 10.5 g/dl HGB
C. 33% HCT; 11 g/dl HGB
When the nurse is unsure how to perfor a client care procedure, which would be the best action for the nurse to take
Consult the agency procedure manual and follow the guidelines for the procedure
The National Quality Forum has issued a list of “never events” or “serious reportable events” pertaining specifically to maternal and child health. Which of the following is not included on this list?
Surgery performed on the wrong body part
Maternity nursing care that is based on knowledge gained through research and clinical trials, clinical expertise and patient/family preferences is which of the following?
Known as evidence-based practice
Which of the following was not discussed as a general category of errors and hazards in healthcare?
Near miss
According to QSEN, which of the following is not one of the six competencies all pre-licensure nursing students should learn while in school?
Effectiveness
Practices such as providing recommended immunizations, infant car seats and pre conceptual counseling are examples of what kind of care?
Primary preventive care
To provide culturally sensitive care to an Asian-American family, which of the following questions should the nurse include during the assessment interview?
Do you prefer hot or cold beverages?
A married couple lives in a single-family house with their newborn daughter and the husband’s daughter from a previous marriage. Which of the following family forms best describes this family?
Married-blended family
When the services of an interpreter are used, which of the following should the nurse do?
Use an interpreter who is certified and document the person’s name in the nursing notes
A woman at 25 weeks gestation tells the nurse that she dropped a pan last week and her baby jumped at the noised. Which response by the nurse is most accurate?
Babies respond to sound starting at around 24 weeks of gestation
A woman who is 14 weeks pregnant calls her obstetrician’s office with concerns about the development of a mask-like area on her face and a dark vertical line on her lower abdomen. What should the nurse tell the woman?
These are normal changes during pregnancy
Exposure to teratogens is most likely to adversely effect the fetus during which time of development?
First trimester
Which of the following is an accurate statement regarding a function of the placenta?
Secretes both estrogen and progesterone
The volume of amniotic fluid is an important factor in assessing fetal well-being. Oligohydramnios is associated with what kind of fetal anomalies
Renal
Sally comes in for her first prenatal examination. This is her first child. She asks the nurse, “How does my baby get air inside my uterus?” Which of the following is the correct response?
The placenta provides oxygen to the baby and excretes carbon dioxide into your blood stream
A maternity nurse should be aware of which fact regarding the amniotic fluid?
It serves as a source of oral fluid and as a repository for waste from the fetus
With regard to the structure and function of the placenta, which of the following statements is accurate?
As one of its early functions, the placenta acts as an endocrine gland
Which of the following is responsible for oxygen and carbon dioxide transport to and from the maternal bloodstream?
Chorionic villi
Which of the following statements about dizygotic twins are true?
1. … also known as fraternal twins
2. … develop from two fertilized ova
3. … can be different sexes
A woman is in her seventh month of pregnancy. She has been complaining of nasal congestion and occasional epistaxis. What should the nurse suspect?
This is normal respiratory change in pregnancy caused by elevated levels of estrogen
The diagnosis of pregnancy is based on which positive signs of pregnancy?
1. Identification of fetal heartbeat
2. Visualization of the fetus
3. Verification of fetal movements
A woman of normal weight asks you what an ideal weight gain is during pregnancy. Which of the following should be your best answer?
25-35 pounds is ideal
The various systems and organs develop at different times. Which of the following statements in accurate?
The cardiovascular system is the first organ system to function in the developing human
A woman is at 14 weeks gestation. The nurse would expect to palpate the fundus at which of the following levels?
Slightly above the symphysis pubis
Cardiovascular system changes occur during pregnancy. Which of the following findings would be considered normal for a woman in her second trimester?
Increased pulse rate
What is a woman who has completed one pregnancy with a fetus (or fetuses) reaching the state of fetal viability called?
Primipara
Which of the following statements about multifetal pregnancy is not accurate?
Twin pregnancies come to term with the same frequency as single pregnancies
A woman’s obstetric history is that she is pregnant for the fourth time and all her children are living. One was born 39 weeks, twins were born 34 weeks, and another child was born 35 weeks. What is her GTPAL?
4-1-2-0-4
In understanding and guiding a woman through her acceptance of pregnancy, which of the following statements is accurate?
Mood swings most likely are the result of worries about finances and a changed lifestyle, as well as profound hormonal changes
Which of the following hormones is essential for maintaining pregnancy by relaxing smooth muscle?
Progesterone
A multigravida reports she just started to feel the fetus move (quickening). This indicates she is most likely how many weeks pregnant?
16
A woman during her first trimester questions how much longer she will have urinary frequency. Which of the following statements would be the most accurate response?
Urinary frequency is a common complaint during the first trimester and again in the third
If constipation is a problem for a woman during pregnancy, which of the following measures would be best to recommend?
Increasing fluid intake
As a pregnant woman lies o the examining table, she grows very short of breath and dizzy. When you take her BP you note she is hypotensive. Why does this phenomenon probably happen?
The blood is trapped in the vena cava in a supine position
Which of the following statements is accurate for a pregnant woman experiencing nausea and vomiting?
Eat small, frequent meals (every 2-3 hours)
All of the following are considered normal gastrointestinal changes in pregnancy except which one? This condition can also be associated with anemia
Pica
Which of the following time-based descriptions of a state of development in pregnancy is accurate?
Term – pregnancy from the beginning of week 38 gestation to the end of week 42
Women with an inadequate weight gain during pregnancy are at higher risk of giving birth to an infant with which of the following conditions?
Intrauterine growth restriction
You encourage a pregnant woman to eat a diet high in complete protein. Assuming she likes all the following foods, which of them would you recommend?
A boiled egg
A woman has come to the clinic for preconception counseling because she wants to start trying to get pregnant in 3 months. Which of the following is the best advice to give to the woman?
Make sure you include folic acid into your diet
A woman in week 34 of pregnancy reports that she is very uncomfortable because of heartburn. Which of the following should the nurse suggest to the woman?
Eat five small meals daily
Prenatal testing for HIV is recommended for which of the following women?
All women, regardless of risk factors
A woman arrives at the clinic for a pregnancy test. Her LMP was February 14, 2007. What is her EDB?
November 21, 2007
Which of the following signs and symptoms should a woman report immediately to her health care provider? (select all that apply)
Vaginal bleeding, vaginal fluid leakage (water breaks or rupture of membranes), epigastric discomfort accompanied by severe headache
A woman who is 32 weeks pregnant is informed by the nurse that a danger sign of pregnancy could be which of the following?
Alteration in the pattern of fetal movements
For which of the following reasons would breastfeeding be contraindicated?
HIV positive
A woman is 3 months pregnant. At her prenatal visit, she tells the nurse that she doesn’t know what is happening: one minute she is happy that she is pregnant and the next minute she cries. Which of the following responses by the nurse is most appropriate?
Hormone changes during pregnancy commonly result in mood swings
With regard to the follow-up visits for women receiving prenatal care, which of the following statements is accurate?
During the abdominal examinations, the nurse should be alert to supine hypotension
A woman with preeclampsia has a seizure. The nurse’s duties include which of the following interventions? Select all the apply
1. Ensure an open airway
2. Turn her to her side to prevent aspiration
3. Stay with the client and call for help
A woman at 39 weeks with a hx of preeclampsia is admitted to L&D. She suddenly experiences increased contraction frequency of every 1-2 minutes, dark red vaginal bleeding and a tense painful abdomen. What onset should the nurse suspect?
Abruptio placenta
A woman with severe preeclampsia is receiving magnesium sulfate infusion. The nurse becomes concerned when the woman exhibits which of the following symptoms?
A respiratory rate of 10 breaths/minute.
(NOT: sleepy, sedated but responsive, DTR +2, and absent ankle clonus)
Which of the following nursing diagnoses would be the most appropriate for a client experiencing severe preeclampsia?
Risk for injury to mother and fetus related to CNS irritability
A primigravida is being monitored in her prenatal clinical for preeclampsia. What finding would concern her nurse?
A dipstick value of 3+ in her urine
With regard to preeclampsia and eclampsia, nurses should be aware which of the following statements is accurate?
Preeclampsia results in decreased function of 40-60% in such organs such as the placenta, kidneys, liver, and brain as a result of vasospasm which impedes blood flow
Why is magnesium sulfate given to women with preeclampsia and eclampsia?
Prevent convulsion
A woman is being admitted for severe preeclampsia. When deciding on where to place her, which of the following areas would be most appropriate?
In a quiet, private room away from the hustle and bustle of the unit
What is the antidote to reverse the effects of magnesium sulfate?
Calcium gluconate
The labor of a preeclamptic woman is going to be induced. Before initiating the oxytocin infusion, the nurse reviews the woman’s labs and finds a platelet count of 90,000, an elevated AST level and a falling hematocrit. The nurse should tell the Dr because it indicates?
HELLP
The perinatal nurse is giving discharge instructions to a woman, status post suction curettage secondary to a hydatidiform mole. The woman asks why she must take oral contraceptives for 12 months. Which is the best response?
The major risk to you after a molar pregnancy is a type of cancer that can be diagnoses only by measuring the same hormone that your body produces during pregnancy. If you were to get pregnant it would make the diagnosis of this cancer more difficult
What is the most distinguishing clinical manifestation of abuptio placenta as opposed to placenta previa?
Abdominal pain and increased uterine tone
Methotrexate is recommended as part of the treatment plan for which of the following obstetric complications?
Unruptured ectopic pregnancy
A woman arrives for evaluation of her symptoms which include a missed period, adnexal fullness, tenderness and dark red vaginal bleeding. Upon examination, the nurse notices ecchymotic blueness around the umbilicus. The nurse recognizes this assessment finding as:
Cullen’s sign associated with a ruptured ectopic pregnancy
After reporting to the unit, you are assigned the patients listed below. Which of the patients should be evaluated first?
A woman at 11 weeks gestation with suspected ectopic pregnancy complaining of should and abdominal pain
Which of the following statements regarding women with hyperemesis gravidarum is accurate?
Have vomiting severe and persistent enough to cause weight loss, dehydration, and electrolyte imbalance.
In assessing the knowledge of pregestational woman with type 1 diabetes concerning changing insulin needs during pregnancy, the nurse recognizes that further teaching is warrented when the client says:

“I will need to increase my insulin dosage during the first 3 months of pregnancy”

(Correct: “insulin dosage will likely need to be increased during 2nd and 3rd”, “episodes of hypoglycemia are more likely in first 3 months”, “insulin needs should return to normal within 7-10 days after birth if I am bottle feeding”

Preconception counseling is critical to the outcome of diabetic pregnancies because poor glycemic control before and during early pregnancy is associated with which of the following?
Congenital abnormalities or malformation of the fetus
Screening at 24 weeks gestation reveals that a pregnant woman has gestational diabetes. In planning her care, the nurse and the woman mutually agree that an expected outcome is to prevent injury to the fetus. What is the fetus at greatest risk for developing?
Macrosomia
In planning the care of a 30 year old woman with pregestational diabetes, the nurse recognizes that the most important factor affecting pregnancy outcome would be which of the following?
Degree of glycemic control during pregnancy
During a prenatal visit, the nurse is explaining dietary management to a woman with pregestational diabetes. The nurse evaluates that teaching has been effective when the woman says:
Diet and insulin needs change during pregnancy
Metabolic changes throughout pregnancy that affect glucose and insulin in the mother and the fetus are complicated. Nurses should know which of the following statements is accurate?
During the second and third trimester, pregnancy exerts a diabetogenic effect that ensures an abundant supply of glucose for the fetus
What would the nurse caring for a woman with hyperemesis gravidarum expect the initial treatment to involve?
IV therapy to correct fluid and electrolyte imbalances
As a powerful CNS stimulant, which of these substances can lead to a miscarriage, preterm labor, abruptio placenta, and stillbirth?
Cocaine
Which of the following use/abuse during pregancny causes vasoconstriction and decreased placental perfusion, resulting in maternal and neonatal complications?
Tobacco
Which of the following is an opiate the causes euphoria, relaxation, drowsiness, and detachment from reality and has possible effects on the pregnancy, including preeclampsia, IUGR, and premature rupture of membranes. Methadone may be given as treatment
Heroin
During pregnancy, physiologic changes can alter the pharmacokinetics of medications. What contributes to the decreased predictability of medications? (Select all that apply)
1, Increased elimination by the kidneys
2. Plasma volume expansion
3. Increased metabolism by the liver
Which of the following statements are true? (select all that apply)
1. The use of any drug should be avoided during pregnancy, unless its use is necessary
2. If meds need to be used, the lowest dose for the shortest duration should be chosen
3. Pregnant women should receive the flu vaccine if pregnant during flu season
Which statement about family systems theory is inaccurate?
A family as a whole is EQUAL to the sum of the individual members
Team member for: a patient who tests positive for cocaine
Social worker
Team member for: newly diagnosed gestational diabetic
Dietician
Team member for: Newly diagnosed pregnant woman who has a family history of Down’s syndrome
Genetic counselor
When providing care for a pregnant woman, the nurse should be aware that one of the most frequently reported maternal medical risk factors is:
Diabetes mellitus.
To ensure optimal outcomes for the patient, the contemporary maternity nurse must incorporate both teamwork and communication with clinicians into her care delivery, The SBAR technique of communication is an easy-to-remember mechanism for communication. Which of the following correctly defines this acronym?
Situation, background, assessment, recommendation
The role of the professional nurse caring for childbearing families has evolved to emphasize:
Practice using an evidence-based approach.
A 23-year-old African-American woman is pregnant with her first child. Based on the statistics for infant mortality, which plan is most important for the nurse to implement?
Explain to the woman the importance of keeping her prenatal care appointments.
During a prenatal intake interview, the nurse is in the process of obtaining an initial assessment of a 21-year-old Hispanic patient with limited English proficiency. It is important for the nurse to:
Assess whether the patient understands the discussion.
When managing health care for pregnant women at a prenatal clinic, the nurse should recognize that the most significant barrier to access to care is the pregnant woman’s:
Inability to pay.
What is the primary role of practicing nurses in the research process?
Identifying researchable problems
When the nurse is unsure about how to perform a patient care procedure, the best action would be to:
Consult the agency procedure manual and follow the guidelines for the procedure.
From the nurse’s perspective, what measure should be the focus of the health care system to reduce the rate of infant mortality further?
Implementing programs to ensure women’s early participation in ongoing prenatal care
Alternative and complementary therapies:
Recognize the value of clients’ input into their health care.
A 38-year-old Hispanic woman delivered a 9-pound, 6-ounce girl vaginally after being in labor for 43 hours. The baby died 3 days later from sepsis. On what grounds would the woman potentially have a legitimate legal case for negligence?
The standards of care were not met.
A newly graduated nurse is attempting to understand the reason for increasing health care spending in the United States. Her research finds that these costs are much higher compared with other developed countries as a result of:
A higher rate of obesity among pregnant women.
The term used to describe legal and professional responsibility for practice for maternity nurses is:
Accountability.
Through the use of social media technology, nurses can link with other nurses who may share similar interests, insights about practice, and advocate for patients. The most concerning pitfall for nurses using this technology is:
Violation of patient privacy and confidentiality.
An important development that affects maternity nursing is integrative health care, which:
Blends complementary and alternative therapies with conventional Western treatment.
Recent trends in childbirth practices in the United States indicate that:
Births occurring in the hospital accounted for 99% of births.
Recent trends in childbirth practice indicate that:
Newborn infants remain with the mother and are encouraged to breastfeed.
The nurse caring for a pregnant client should be aware that the U.S. birth rate shows which trend?
Births to unmarried women are more likely to have less favorable outcomes.
Maternity nursing care that is based on knowledge gained through research and clinical trials is:
Known as evidence-based practice.
The level of practice a reasonably prudent nurse provides is called:
The standard of care.
During a prenatal intake interview, the client informs the nurse that she would prefer a midwife to provide her care during pregnancy and deliver her infant. What information would be most appropriate for the nurse to share with this patient?
The client will receive fewer interventions during the birth process.
While obtaining a detailed history from a woman who has recently emigrated from Somalia, the nurse realizes that the client has undergone female genital mutilation (FGM). The nurse’s best response to this patient is:
“The extent of your circumcision will affect the potential for complications.”
To ensure patient safety, the practicing nurse must have knowledge of the current Joint Commission’s “Do Not Use” list of abbreviations. Which of the following is acceptable for use?
MSO4 or MgSO4
Healthy People 2020 has established national health priorities that focus on a number of maternal-child health indicators. Nurses are assuming greater roles in assessing family health and providing care across the perinatal continuum. Therefore it is important for the nurse to be aware that significant progress has been made in:
The reduction of fetal deaths and use of prenatal care.
Which interventions would help alleviate the problems associated with access to health care for maternity patients (Select all that apply)?
Provide transportation to prenatal visits.
Provide childcare so that a pregnant woman may keep prenatal visits.
Provide low-cost or no-cost health care insurance.
Which of the following statements indicate that the nurse is practicing appropriate family-centered care techniques (Select all that apply)?
The nurse allows time for the partner to ask questions
The nurse allows the mother and father to make choices when possible.
Hand hygiene:
Comply with CDC guidelines.
Informed consent:
Ask the patient to “teach back.”
Culture measurement, feedback, and intervention:
Promote interventions that will reduce patient risk.
Pediatric imaging:
Reduce exposure to radiation.
Patient care information:
Ensure that information is documented in a timely manner.
A married couple lives in a single-family house with their newborn son and the husband’s daughter from a previous marriage. On the basis of the information given, what family form best describes this family?
Married-blended family
In what form do families tend to be most socially vulnerable?
Single-parent family
Health care functions carried out by families to meet their members’ needs include:
Meeting nutritional requirements.
The nurse should be aware that the criteria used to make decisions and solve problems within families are based primarily on family:
Values and beliefs.
Using the family stress theory as an intervention approach for working with families experiencing parenting, the nurse can help the family change internal context factors. These include:
The family’s perception of the event.
While working in the prenatal clinic, you care for a very diverse group of patients. When planning interventions for these families, you realize that acceptance of the interventions will be most influenced by:
Individual beliefs.
The nurse’s care of a Hispanic family includes teaching about infant care. When developing a plan of care, the nurse bases interventions on the knowledge that in traditional Hispanic families:
The maternal grandmother participates in the care of the mother and her infant.
The woman’s family members are present when the home care maternal-child nurse arrives for a postpartum and newborn visit. What should the nurse do?
Observe the family members’ interactions with the newborn and one another.
The nurse should be aware that during the childbearing experience an African-American woman is most likely to:
Arrive at the hospital in advanced labor.
To provide competent care to an Asian-American family, the nurse should include which of the following questions during the assessment interview?
“Do you prefer hot or cold beverages?”
The patient’s family is important to the maternity nurse because:
The family culture and structure will influence nursing care decisions.
A mother’s household consists of her husband, his mother, and another child. She is living in a(n):
Extended family.
A traditional family structure in which male and female partners and their children live as an independent unit is known as a(n):
Nuclear family.
Which statement about family systems theory is inaccurate?
A family as a whole is equal to the sum of the individual members.
A pictorial tool that can assist the nurse in assessing aspects of family life related to health care is the:
Genogram.
The process by which people retain some of their own culture while adopting the practices of the dominant society is known as:
Acculturation.
When attempting to communicate with a patient who speaks a different language, the nurse should:
Provide as much privacy as possible.
In which culture is the father more likely to be expected to participate in the labor and delivery?
European-American
Which statement about cultural competence is not accurate?
Nursing care is delivered in the context of the client’s culture but not in the context of the nurse’s culture.
The nurse is preparing for a home visit to complete a newborn wellness checkup. The neighborhood has a reputation for being dangerous. Identify which precautions the nurse should take to ensure her safety (Select all that apply).
Having access to a cell phone at all times.
Carrying an extra set of car keys.
Avoiding groups of strangers hanging out in doorways.
The two primary functions of the ovary are:
Ovulation and hormone production.
The uterus is a muscular, pear-shaped organ that is responsible for:
Cyclic menstruation.
Unique muscle fibers make the uterine myometrium ideally suited for:
The birth process.
The hormone responsible for maturation of mammary gland tissue is:
Progesterone.
Because of the effect of cyclic ovarian changes on the breast, the best time for breast self-examination (BSE) is:
5 to 7 days after menses ceases.
Menstruation is periodic uterine bleeding:
That is regulated by ovarian hormones.
Individual irregularities in the ovarian (menstrual) cycle are most often caused by:
Variations in the follicular (preovulatory) phase.
Prostaglandins are produced in most organs of the body, including the uterus. Other source(s) of prostaglandins is/are:
Menstrual blood.
Physiologically, sexual response can be characterized by:
Myotonia and vasocongestion.
The long-term treatment plan for an adolescent with an eating disorder focuses on:
Restructuring perception of body image.
The nurse guides a woman to the examination room and asks her to remove her clothes and put on an examination gown with the front open. The woman states, “I have special undergarments that I do not remove for religious reasons.” The most appropriate response from the nurse would be:
“Tell me about your undergarments. I’ll explain the examination procedure, and then we can discuss how you can have your examination comfortably.”
A 62-year-old woman has not been to the clinic for an annual examination for 5 years. The recent death of her husband reminded her that she should come for a visit. Her family doctor has retired, and she is going to see the women’s health nurse practitioner for her visit. To facilitate a positive health care experience, the nurse should:
Listen carefully and allow extra time for this woman’s health history interview.
During a health history interview, a woman states that she thinks that she has “bumps” on her labia. She also states that she is not sure how to check herself. The correct response would be to:
Explain the process of vulvar self-examination to the woman and reassure her that she should become familiar with normal and abnormal findings during the examination.
A woman arrives at the clinic for her annual examination. She tells the nurse that she thinks she has a vaginal infection and she has been using an over-the-counter cream for the past 2 days to treat it. The nurse’s initial response should be to:
Ask the woman to describe the symptoms that indicate to her that she has a vaginal infection.
The transition phase during which ovarian function and hormone production decline is called:
The climacteric.
Which statement would indicate that the client requires additional instruction about breast self-examination?
“Yellow discharge from my nipple is normal if I’m having my period.”
A woman who is 6 months pregnant has sought medical attention, saying she fell down the stairs. What scenario would cause an emergency department nurse to suspect that the woman has been a victim of intimate partner violence (IPV)?
The woman has injuries on various parts of her body that are in different stages of healing.
A 20-year-old patient calls the clinic to report that she has found a lump in her breast. The nurse’s best response is:
“Many women have benign lumps and bumps in their breasts. However, to make sure that it’s benign, you should come in for an examination by your physician.”
The female reproductive organ(s) responsible for cyclic menstruation is/are the:
Uterus.
The body part that both protects the pelvic structures and accommodates the growing fetus during pregnancy is the:
Bony pelvis.
A fully matured endometrium that has reached the thickness of heavy, soft velvet describes the _____ phase of the endometrial cycle.
Secretory
The stimulated release of gonadotropin-releasing hormone and follicle-stimulating hormone is part of the:
Hypothalamic-pituitary cycle.
Certain fatty acids classified as hormones that are found in many body tissues and that have roles in many reproductive functions are known as:
Prostaglandins (PGs).
Which statement regarding female sexual response is inaccurate?
The orgasmic phase is the final state of the sexual response cycle.
As part of their participation in the gynecologic portion of the physical examination, nurses should:
Help the woman relax through proper placement of her hands and proper breathing during the examination.
During which phase of the cycle of violence does the batterer become contrite and remorseful?
Honeymoon phase
A patient at 24 weeks of gestation says she has a glass of wine with dinner every evening. The nurse will counsel her to eliminate all alcohol intake because:
The fetus is placed at risk for altered brain growth.
As a powerful central nervous system stimulant, which of these substances can lead to miscarriage, preterm labor, placental separation (abruption), and stillbirth?
Cocaine
The microscopic examination of scrapings from the cervix, endocervix, or other mucous membranes to detect premalignant or malignant cells is called:
A Papanicolaou (Pap) test.
As a girl progresses through development, she may be at risk for a number of age-related conditions. While preparing a 21-year-old client for her first adult physical examination and Papanicolaou (Pap) test, the nurse is aware of excessiveness shyness. The young woman states that she will not remove her bra because, “There is something wrong with my breasts; one is way bigger.” What is the best response by the nurse in this situation?
“I will explain normal growth and breast development to you.”
Which statement by the patient indicates that she understands breast self-examination?
“I will perform breast self-examination 1 week after my menstrual period starts.”
A pregnant woman who abuses cocaine admits to exchanging sex for her drug habit. This behavior places her at a greater risk for:
Sexually transmitted diseases
A woman who is older than 35 years may have difficulty achieving pregnancy primarily because:
Her ovaries may be affected by the aging process
The most dangerous effect on the fetus of a mother who smokes cigarettes while pregnant is:
Intrauterine growth restriction
Despite warnings, prenatal exposure to alcohol continues to exceed by far exposure to illicit drugs. A diagnosis of fetal alcohol syndrome (FAS) is made when there are visible markers in each of three categories. Which is category is not associated with a diagnosis of FAS?
Respiratory conditions
When the nurse is alone with a battered patient, the patient seems extremely anxious and says, “It was all my fault. The house was so messy when he got home and I know he hates that.” The best response by the nurse is:
“No one deserves to be hurt. It’s not your fault. How can I help you?”
A common effect of both smoking and cocaine use in the pregnant woman is:
Vasoconstriction
Many pregnant teens wait until the second or third trimester to seek prenatal care. The nurse should understand that the reasons behind this delay include:
Lack of realization that they are pregnant.
Uncertainty as to where to go for care.
Continuing to deny the pregnancy.
Continuing to deny the pregnancy.
Human papillomavirus (HPV):
Three injections for girls between the ages 9 to 26
Hepatitis B:
Primary series of three injections
Influenza:
Annually
Tetanus-diphtheria-pertussis (Tdap):
Once and then a booster every 10 years
Herpes Zoster:
One dose after age 65
Measles, mumps, rubella:
Once if born after 1956
Maternal and neonatal risks associated with gestational diabetes mellitus are:
Maternal preeclampsia and fetal macrosomia.
Women with gestational diabetes have twice the risk of developing hypertensive disorders such as preeclampsia, and the baby usually has macrosomia.
The nurse is caring for a woman with mitral stenosis who is in the active stage. Which action should the nurse take to promote cardiac function?
Maintain the woman in a side-lying position with the head and shoulders elevated to facilitate hemodynamics
During the first trimester the pregnant woman would be most motivated to learn about
Measures to reduce nausea and fatigue so she can feel better.
During the first trimester a woman is egocentric and concerned about how she feels. She is working on the task of accepting her pregnancy.
An expectant father confides in the nurse that his pregnant wife, 10 weeks of gestation, is driving him crazy. “One minute she seems happy, and the next minute she is crying over nothing at all. Is there something wrong with her?” The nurse’s best response would be:
“This is called emotional liability and is related to hormone changes and anxiety during pregnancy. The mood swings will eventually subside as she adjusts to being pregnant.”
This is the most appropriate response since it gives an explanation and a time frame for when the mood swings may stop.
If exhibited by an expectant father, what would be a warning sign of ineffective adaptation to his partner’s first pregnancy?
Consistently changes the subject when the topic of the fetus/newborn is raised
What laboratory results would be a cause for concern if exhibited by a woman at her first prenatal visit during the second month of her pregnancy?
Rubella titre 1:6
A maternal serum alpha-fetoprotein (MsAFP) test is performed at 16 to 18 weeks of gestation. An elevated level has been associated with:
Open neural tube defects such as spina bifida.
Low levels of MsAFP are associated with Down syndrome.
A pregnant woman at 32 weeks of gestation complains of feeling dizzy and light-headed while her fundal height is being measured. Her skin is pale and moist. The nurse’s initial response would be to:
Turn the woman on her side.
A pregnant woman demonstrates understanding of the nurse’s instructions regarding relief of leg cramps if she:
Extends her leg and dorsiflexes her foot during the cramp.
When planning a diet with a pregnant woman, the nurse’s first action would be to
Review the woman’s current dietary intake
A pregnant woman with a body mass index (BMI) of 22 asks the nurse how she should be gaining weight during pregnancy. The nurse’s best response would be to tell the woman that her pattern of weight gain should be approximately
2 to 5 pounds during the first trimester, then a pound each week until the end of pregnancy.
A pregnant woman at 7 weeks of gestation complains to her nurse midwife about frequent episodes of nausea during the day with occasional vomiting. She asks what she can do to feel better. The nurse midwife could suggest that the woman:
Eat a high-protein snack before going to bed.
The nurse is preparing to discharge a 30-year-old woman who has experienced a miscarriage at 10 weeks of gestation. Which statement by the woman would indicate a correct understanding of the discharge instructions?
“I should eat foods that are high in iron and protein to help my body heal.”
The nurse is caring for a woman who is at 24 weeks of gestation with suspected severe preeclampsia. Which signs and symptoms would the nurse expect to observe? Select all that apply.
Decreased urinary output and irritability
C. Ankle clonus and epigastric pain
D. Platelet count of less than 100,000/mm3 and visual problems
A primigravida asks the nurse about signs she can look for that would indicate that the onset of labor is getting closer. The nurse should describe:
Bloody show.
Passage of the mucous plug (operculum) also termed pink/bloody show occurs as the cervix ripens.
The nurse should tell a primigravida that the definitive sign indicating that labor has begun would be
Progressive uterine contractions
On completion of a vaginal examination on a laboring woman, the nurse records: 50%, 6 cm, -1. What is a correct interpretation of the data?
The fetal presenting part is 1 cm above the ischial spines.
A laboring woman becomes anxious during the transition phase of the first stage of labor and develops a rapid and deep respiratory pattern. She complains of feeling dizzy and light-headed. The nurse’s immediate response would be to:
Help the woman breathe into a paper bag
A woman is in the second stage of labor and has a spinal block in place for pain management. The nurse obtains the woman’s blood pressure and notes that it is 20% lower than the baseline level. Which action should the nurse take?
Turn the woman to the left lateral position or place a pillow under her hip.
When assessing a fetal heart rate (FHR) tracing, the nurse notes a decrease in the baseline rate from 155 to 110. The rate of 110 persists for more than 10 minutes. The nurse could attribute this decrease in baseline to:
Initiation of epidural anesthesia that resulted in maternal hypotension. Fetal bradycardia is the pattern described and results from the hypoxia that would occur when uteroplacental perfusion is reduced by maternal hypotension. The woman receiving epidural anesthesia needs to be well hydrated before and during induction of the anesthesia to maintain an adequate cardiac output and blood pressure.
On review of a fetal monitor tracing, the nurse notes that for several contractions the fetal heart rate decelerates as a contraction begins and returns to baseline just before it ends. The nurse should:
Describe the finding in the nurse’s notes.
An early deceleration pattern from head compression is described. No action other than documentation of the finding is required since this is an expected reaction to compression of the fetal head as it passes through the cervix.
Which finding meets the criteria of a reassuring fetal heart rate (FHR) pattern?
Variability averages between 6 to 10 beats/min.
Baseline range for the FHR is 120 to 160 beats/min.
Late deceleration patterns are noted when assessing the monitor tracing of a woman whose labor is being induced with an infusion of Pitocin. The woman is in a side-lying position, and her vital signs are stable and fall within a normal range. Contractions are intense, last 90 seconds, and occur every 1½ to 2 minutes. The nurse’s immediate action would be to:
Stop the Pitocin.
Which characteristic is associated with false labor contractions?
Decrease in intensity with ambulation.
Although false labor contractions decrease with activity, true labor contractions are enhanced or stimulated with activity such as ambulation.
A pregnant couple has formulated a birth plan and is reviewing it with the nurse at an expectant parent’s class. Which aspect of their birth plan would be considered unrealistic and require further discussion with the nurse?
“We do not want the fetal monitor used during labor since it will interfere with movement and doing effleurage.”
Since monitoring is essential to assess fetal well-being, it is not a factor that can be determined by the couple. The nurse should fully explain its importance. The option for intermittent electronic monitoring could be explored if this is a low risk pregnancy and as long as labor is progressing normally.
When performing vaginal examinations on laboring women, the nurse should be guided by what principle?
Cleanse the vulva and perineum before and after the examination as needed
The nurse should realize that the most common and potentially harmful maternal complication of epidural anesthesia is:
Hypotension.
Epidural anesthesia can lead to vasodilation and a drop in blood pressure that could interfere with adequate placental perfusion. The woman must be well hydrated before and during epidural anesthesia to prevent this problem and maintain an adequate blood pressure.
A laboring woman’s amniotic membranes have just ruptured. The immediate action of the nurse would be to:
Assess the fetal heart rate (FHR) pattern.
A woman is evaluated to be using an effective bearing-down effort if she:
Takes two deep, cleansing breaths at the onset of a uterine contraction and at the end of the contraction. Cleansing breaths at the onset of a contraction allow it to build to a peak before pushing begins. They also enhance gas exchange in the alveoli and help the woman relax after the uterine contraction subsides.
Following rupture of membranes, a prolapse of the cord was noted on vaginal examination. A recommended action to prevent cord compression would be to:
Keep the protruding cord moist with warm sterile normal saline compresses.
When palpating the fundus of a woman 18 hours after birth, the nurse notes that it is firm, 2 fingerbreadths above the umbilicus, and deviated to the left of midline. The nurse should:
Assist the woman to empty her bladder.
A firm fundus should not be massaged since massage could overstimulate the fundus and cause it to relax.
Which finding would be a source of concern if noted during the assessment of a woman who is 12 hours’ postpartum?
Pain in left calf with dorsiflexion of left foot
A temperature of 100.4° F in the first 24 hours most likely indicates dehydration, which is easily corrected by increasing oral fluid intake.
The nurse examines a woman 1 hour after birth. The woman’s fundus is boggy, midline, and 1 cm below the umbilicus. Her lochial flow is profuse, with two plum-sized clots. The nurse’s initial action would be to:
Massage her fundus. A boggy or soft fundus indicates that uterine atony is present. This is confirmed by the profuse lochia and passage of clots. The first action would be to massage the fundus until firm.
Perineal care is an important infection control measure. When evaluating a postpartum woman’s perineal care technique, the nurse would recognize the need for further instruction if the woman:
Uses the peribottle to rinse upward into her vagina.
Which measure would be least effective in preventing postpartum hemorrhage?
Massage the fundus every hour for the first 24 hours following birth
When making a visit to the home of a postpartum woman 1 week after birth, the nurse should recognize that the woman would characteristically:
Vacillate between the desire to have her own nurturing needs met and the need to take charge of her own care and that of her newborn.
Four hours after a difficult labor and birth, a primiparous woman refuses to feed her baby, stating that she is too tired and just wants to sleep. The nurse should:
Take the baby back to the nursery, reassuring the woman that her rest is a priority at this time.
Parents can facilitate the adjustment of their other children to a new baby by:
Having the children choose or make a gift to give to the new baby on its arrival home.
A primiparous woman is in the taking-in stage of psychosocial recovery and adjustment following birth. Recognizing the needs of women during this stage, the nurse should:
Provide time for the mother to reflect on the events of and her behavior during childbirth.
Two hours after giving birth, a primiparous woman becomes anxious and complains of intense perineal pain with a strong urge to have a bowel movement. Her fundus is firm, at the umbilicus, and midline. Her lochia is moderate rubra with no clots. The nurse would suspect:
Hematoma formation.
Postpartum women experience an increased risk for urinary tract infection. A prevention measure the nurse could teach the postpartum woman would be to:
Perform perineal care on a regular basis.
RN examining a woman who gave birth 5 hours ago, the nurse finds that the woman has completely saturated a perineal pad within 15 minutes. The nurse’s priority would be to
Massage the fundus
A woman gave birth vaginally to a 9-pound, 12 ounce girl yesterday. Her primary health care provider has written orders for perineal ice packs, use of a sitz bath tid, and a stool softener. What information is most closely correlated with these orders?
She has an episiotomy
The laboratory results for a postpartum woman are as follows; blood type A; Rh status positive; rubella titer, 1:8 (EIA 0.8); hematocrit, 30%. How would the nurse best interpret these data:
Rubella vaccine should be given
Part of the health assessment of newborn is observing the infant’s breathing pattern. A full-term newborn’s breathing pattern is predominantly
Abdominal with synchronous chest
A first time father is changing the diaper of his 1 day old daughter. He asks the nurse, “What is this black sticky stuff in her diaper?
Meconium
An African-American woman noticed some bruises on her newborn girl’s buttocks. She asked the nurse who spanked her daughter the nurse explains that it is
Mongolian Spot
The parents of a newborn ask the nurse how much the newborn can see the parents specifically want to know what type of visual stimuli they should provide for their newborn the nurse responds to the parents by telling them
The infant can track their parent’s eyes and distinguish patterns, they prefer complex patterns
An infant body was just born a few minutes ago. The nurse is conducting the initial assessment. Part of the assessment includes the Apgar score. The apgar assessment is performed
at least twice, 1 minute and 5 minutes after birth
The normal term infant has little difficulty clearing its airway at birth. Most secretions are brought up to the oropharynx by the cough reflex. However, if the infant has excess secretion, the mouth and nasal passages can be cleared easily with a bulb syringe. When instructing the parents on the correct use of the piece of equipment it is important to teach the parents to suction
mouth first
A new father wants to know what medication was put into his infants eyes and why it was needed. The nurse explains to the father that the purpose of the ophthalmic ointment is to
prevent gonorrhea and chlamydia infection of the infant’s eyes potentially from the birth canal
In the classification of newborns by gestational age and birth weight, the appropriate gestation age (AGA) weight would
fall between the 10th and 90th percentiles for the infant’s age
A newborn is jaundices and receiving phototherapy via ultraviolet bank lights. An appropriate nursing intervention when caring for an infant with hyperbilirubinemia and receiving phototherapy by this method would be to
place eye shields over the newborn’s eyes
A mother expresses fear about changing her infant’s diaper after he is circumcised. What does the woman need to be taught to take care of the infant when she gets home?
Cleanse the penis gently with water and put petroleum jelly around the glans after each diaper change
With regard to fetal positioning during labor, nurses should be away that: birth is imminent at
4+ or 5+
With regard to primary and secondary powers, the maternity nurse should know that:
Primary powers are responsible for effacement and dilation of the cervix
To adequately care for a laboring woman, the nurse should know which state of labor varies the most in length
First stage
How do you assess cervical change
Vaginal Exam
The nurse providing care for the laboring woman should understand that late fetal heart rate (FHR) decelerations are caused by
uteroplacental insufficiency
The nurse providing care for the laboring woman should understand that variable fetal heart rate (FHR) decelerations are caused by
umbilical cord compression
A nurse might be called on to stimulate the fetal scalp
to elicit an acceleration in FHR
When using intermittent auscultation IA for fetal heart rate nurses should be aware that:
you can order an ultrasound and look for the best place to listen for FHR
According to standard professional thinking, nurses should auscultate the fetal heart rate (FHR):
In the active phase of the first stage of labor, the FHR should be auscultated every 30 min if no risk factors are involved
To help patients manage discomfort and pain during labor, nurses should be aware
the predominant pain of the first stage of labor is the visceral pain located in the lower portion of the abdomen- this pain comes from cervical changes, distention of the lower uterine segment, and uterine ischemia
Referred pain occurs when
the pain that originates in the uterus radiates into the abdomen
Nursing care measures are commonly offered to women labor, which nursing measure reflects application of the gate-control theory
massaging the women’s back
A first-time mother is concerned about the type of medications she will received during labor she is in a fair amount of pain
sedatives can be used to reduce the n/v that often accompany opioid use in addition some ataractics reduce anxiety and apprehension and potentiate the opioid analgesic affects
A woman in labor has just received spinal anesthesia. The most important nursing intervention is to:
Monitor the maternal blood pressure for possible hypotension
A woman has requested an epidural for her pain. She is 5 cm dilated and 100% effaced. The baby is in a vertex position and is engaged. The nurse increases the woman’s IV fluid for a preprocedural bolus. She reviews her lab values and noes her hemoglobin is 12 g/dl hematocrit is 38% and platelets are 67,000 and white
thrombocytopenia
Several changes in the integumentary system that appear during pregnancy disappear after birth, although not always completely. What change is almost certain to be completely reversed?
Nail brittleness disappears
Excessive blood loss after child birth can have several causes, the most common is:
Failure of the uterine muscle to contract firmly-atony
With regard to the newborn’s developing cardiovascular system, nurses should be aware that:
The point of maximal impulse (PMI) often is visible on the chest wall
At 1 min after birth the nurse assesses the infant and notes: a HR of 80 beats/min, some flexion of extremities, a weak cry, grimacing, and a pink body but blue extremities. The nurse would calculate and Apgar score of:
5
• When planning care for a laboring woman whose membranes have ruptured, the nurse recognizes that the woman’s risk for ___ has increased
Intrauterine Infection
After an emergency birth (birth may be unexpected place, not in typical facility with things you would normally have to deal with the birth) , the nurse encourages the woman to breastfeed her newborn. The primary purpose of this activity is to:
Stimulate the uterus to contract
In helping the breastfeeding mother position the baby, nurses should keep in mind that:
Whatever the position used, the infant is “belly to belly” with the mother/Don’t want to have the baby’s head turned, this can cause latching problems
Which description of the phases of the second stage of labor is accurate:
Descent phase: Significant increase in contractions, Ferguson reflex activated, average duration varies
While evaluating an external monitor tracing of a woman in active labor who is being induced, the nurse notes that the fetal heart rate (FHR) begins to decelerate at the onset of several contractions and returns to baseline before each contraction ends. The nurse should:
Document the finding in the patients records
The nurse providing care for the laboring woman should understand that amnioinfusion is used to treat:
o Variable decelerations- caused by cord pressure, used to help when there is no amniotic fluid to relieve that pressure
After change of shift report, the nurse assumes care of a multiparous patient in labor. The woman is complaining of pain that radiates to her abdominal wall, lower back, and buttocks and down her thighs. Before implementing a plan of care the nurse should understand that this type of pain is
Referred
As part of standard precautions, nurses wear gloves when handling the newborn, The chief reason is:
To protect the nurse from contamination by the newborn
A woman arrives at the clinic seeking confirmation that she is pregnant. The following info is obtained; 24 years old, BMI-17.5, she admits to having used cocaine several times during the past year and drinks alcohol occasionally. BP 108/70, pulse 72 bpm, resp. 16 bpm, family history diabetes mellitus and cancer. her sister recently gave birth to an infant with neural tube defect NTD Which characteristics place her at a high risk category
Family history of NTD, low BMI, and substance abuse are all high risk factors
When nurses help their expectant mother assess the daily fetal movement counts, they should be aware that:
the fetal alarm signal should go off when the fetal movements stop entirely for 12 hours
In 1st trimesters ultrasonography can be used to gain information on
Uterine Abnormalities
A 39 year old primagravida thinks she is about 8 weeks pregnant although she has had irregular menstrual periods her life history of smoking approx. one pack of cigarette a day tell you she trying to cut down, lab within normal limits
Ultrasound
41 week pregnant multigravida present in labor and delivery unit after a non-stress test indicated that her fetus could be experiencing some difficulties in utero, which diagnostic tool would yield more detailed info about the fetus:
Biophysical Profile
Preconception counseling is critical to the outcome of diabetic pregnancies because poor glycemic control before and during early pregnancy is associated with
congenital anomalies in the fetus
In assessing knowledge of pregestational woman with type I diabetes concerning changing insulin needs during pregnancy the nurse recognizes that further teaching is warranted when the woman states
I will need to increase my insulin dosage during the first 3 months of pregnancy
Screening at 24 weeks of gestation reveals that a normal weight pregnant woman has gestational diabetes mellitus (GDM) in planning her care nurse and woman mutually agree that an expected outcome is to prevent injury to the fetus as a result of GDM the nurse identifies that the fetus is at greatest risk for
Macrosomia
• A 26 year old primigravida comes to clinic for regular prenatal visit at 12 weeks appears thin nervous, reports eats well balanced diet, although her weight is 5 pounds less than it was at her last visit, lab studies confirm she has a hyperthyroid condition, based on data from the nurse formulate a plan of care, what nursing diagnosis is most appropriate for the woman at this time
Imbalanced nutrition: less than body
In caring for a pregnant women with sickle cell crisis, the nurse understands that management of this patient includes all except
Antibiotics
Screening questions for alcohol and drug abuse should be included in the overall assessment during the first prenatal visit for all women the 4 P’s plus is a screening tool designed specifically or identify when there is a need of a more in depth assessment the 4 Ps include all except:
Present
A primigravida is being monitored in her prenatal clinic for preeclampsia, which finding should concern her nurse
A dipstick value of 3+ for protein in her urine
A pregnant woman has been receiving magnesium sulfate infusion for tx. of preeclampsia for 24 hr., on assessment temp 37.3 degree c, pulse rate 88 bpm respiratory rate of 10 breaths/min blood pressure of 128/90 mm hg absent deep tendon reflexes and no ankle clonus the pt. complains I’m so thirsty and warm”
Discontinue the magnesium sulfate infusion
The perinatal nurse is giving instructions to a woman, stay she must take two post-suction curettage secondary to a hydatidiform mole, the woman asks why she must take oral contraceptives for 12 months the best response
The major risk to you after a molar pregnancy is a type of cancer that can be diagnosed only by measuring the same hormone that your body produced during pregnancy, if you were to get pregnant it would make the diagnosis of this cancer more difficult
The most prevalent clinical manifestation of abruptio placenta as opposed to placenta previa is
Abdominal pain
In caring for the woman with disseminated intravascular coagulation (DIC) what order should the nurse anticipate
Administration of blood
In planning for home care of a woman with preterm labor, the nurse needs to address what concern:
prolonged bed rest may cause negative physiological effects
A woman in preterm labor at 30 weeks of gestation receives 2 12 mg doses of betamethasone intramuscularly, The purpose of this pharmacologic treatment is to:
antenatal glucocorticoids given as intramuscular injections to the mother to stimulates fetal lung maturation (surfactant)
A primigravida 40 weeks gestational is having uterine contractions every 1 ½ to 2 minutes and says that they are very painful, her cervix is dilated 2 cm and has not changes in 3 hours. The woman is crying and wants an epidural what is likely status of this woman’s labor
hypertonic
A woman is having her first child. She has been in labor for 15 hours, 2 hours ago her vaginal examination revealed the cervix to be dilated to 5 cm and 100% effaced, and the presenting part was at station 0, 5 mins ago her vaginal examination indicated that there had been no change what abnormal labor pattern is associated with this description
Secondary arrest
A pregnant woman’s amniotic membranes have ruptured prolapsed cord is suspected. What intervention would be the top priority
Placing the woman in knee to chest position
Premature infants who exhibit 5-10 seconds of resp. pauses followed by 10-15 seconds of compensatory rapid respiration are:
breathing in a respiratory pattern common to premature infants
An infant is to receive gastronomy feeding what intervention should the nurse institute to prevent bloating, GI reflux into the esophagus. Vomiting, and respiratory compromise
slow small warm bolus feedings over 20-30 mins
NEC inflammatory disease of the GI mucosa, the signs of NEC are nonspecific some generalized signs are:
abdominal distention, temp instability and grossly bloody stools
Nurse practicing in perinatal setting should promote kangaroo care regardless of infants gestational age, this intervention should
help infants to interact directly with their parents and enhances their temperature regulation
A woman arrives at the clinic for a pregnancy test, Last Menstrual period was Feb 14, 2012, her expected date of birth would be
Nov 21
Which blood pressure finding during 2nd trimester indicates risk for pregnancy induced hypertension
100/70 –> 130/85
Prenatal testing for the human immunodeficiency virus HIV is recommended for which women
all women regardless of risk factors
With regard to work and travel during pregnancy nurses should be aware that: while working or traveling in a car or on a plane
women should arranged to walk around at least every hour or so
A woman is recovering at the gynecologists office following a late first trimester spontaneous abortion, at this time it is essential for the nurse too check which of the following:
Maternal blood type
A newborn admitted to nursery has a positive direct Coomb’s test. Which of the following is an appropriate action by the nurse?
Monitor baby for jaundice
A 36-week gestation woman lies flat on her back. Which of the following maternal signs/ symptoms would not be unanticipated?
Diziness
A baby was just born to a mother who had positive vaginal cultures for group B strep. The mother was admitted to labor 2 hours before the birth. Which of the following should the nurse closely observe for in this baby
Hypothermia
4 babies are in the newborn nursery. The nurse pages the neonatologist to see that baby who exhibits what?
o Intercostal retractions
o Erythema toxicum
o Pseudostrabismus
o Vernix caseousa
Intercostal retractions
A pregnant woman informs the nurse that her last normal menstrual period was on Sep 20, 2012, using Nagele’s rule the nurse calculates the clients EDD as:
June 27, 2013
A nurse suspects that a client has been physically abused. The woman refuses to report the abuse to the police. Which statement by the client suggests to the nurse that the relationship may be in the “honeymoon phase’
My partner said that he will never hurt me again
Four 38 gestation woman have just deliver. Which of the babies should be monitored closely for respiratory distress
o Baby whose mother has DM (diabetes mellitus)
o Baby whose mother has lung cancer
o Baby whose mother has hyperthyroidism
o Baby whose mother has asthma
Baby whose mother has DM (diabetes mellitus)
A patient has been diagnoses with gestational diabetes! I will never be able to give myself shots!” Which response by the nurse is most appropriate?
If you exercise and follow your diet your will probably not need insulin
A 24 week pregnant client is being seeing the prenatal client. She states, “I’ve had a terrible headache for the past few days, Which is the priority assessment
Take her BP
A pregnant woman, 36 weeks gestation with DM 1 has just had a BPP (biophysical profile). Which of the following results should be reported?
One fetal heart acceleration in 20 mins
A gravid woman with sickle cell anemia is admitted in vaso-occlusive crisis. Which of the following is the priority intervention that the nurse must perform
Infuse IV hydration
A lecithin; sphignomyelin (L/S) ratio has been ordered, What will be learned from the test?
Maturation of fetal lungs
A 26-week gestation woman is diagnosed with severe preeclampsia with HELLP syndrome. The nurse will assess for which of the following signs/symptoms
Epigastric pain
Which finding should nurse expect when assessing a client with placenta previa
Painless, vaginal bleeding
A woman has just been admitted to the ER subsequent to head-on automobile accident. Her body appears to be uninjured. The nurse monitor for which complications of pregnancy
Placental Abruption
Type I diabetic is being seen for preconception counseling. The nurse should emphasize that during the first trimester the woman may experience which of the following
Need for less insulin that she normally injects
A nurse is performing an assessment on four 22-week pregnant clients. The nurse reports to the OB that which of the clients may be carrying twins:
Fundal height measurement 26
The perinatal nurse is caring for a woman in the immediate post birth period. Assessment reveals that the woman is experiencing profuse bleeding. The most likely etiology for the bleeding is
Uterine Atony
The perinatal nurse assisting with establishing lactation is aware that acute mastitis can be minimized by
Using proper breastfeeding techniques
The prevalence of urinary incontinence increases as women age, with more than 1/3 of women in the US suffering from some form of this disorder. The symptoms of mild to moderate-to-mild UI can be successfully decreased by a number of strategies, which of these should the nurse instruct the patient to do first
bladder training and pelvic floor exercises
When a woman is diagnosed with PPD with psychotic features, one of the major concerns is that she may
Harm her infant
At 35 weeks of pregnancy a women experiences preterm labor, tocolytics administer, placed on bed rest, experiences regular uterine contractions, her cervix is beginning to dilate and efface, what would be an important test for fetal well- being at this time:
Amniocentesis for L/S ratio to assess fetal lung maturity
A 39 year old primagravida thinks she is about 8 weeks pregnant although she has had irregular MP her entire life, history of smoking one pack of cigarettes a day, she tells you that she is trying to cut down. Her lab data are within normal limits what diagnostic (should be screening) technique could be used with this pregnant woman at this time
Ultrasound
With what heart conditions is pregnancy not usually contraindicated
Heart transplant
When caring for a pregnant woman with cardiac problems the nurse must be alert for s/sx of cardiac decompensation, which are
Dyspnea, crackles, an irregular weak pulse
The nurse providing care for woman with gestational diabetes understands that a lab test for glycosated hemoglobin A1C:
Would be considered evidence of good diabetes control with a result of 2.5%-5.9%
A woman presents to ED complaining of bleeding and cramping, the initial nursing history is significant for a last menstrual period of 6 weeks ago, on sterile speculum examination the primary care provider finds cervix is closed. The anticipated plan of care for this woman is based on probable diagnosis of which of the following types of spontaneous abortion
Threatened
Nurses should be aware chronic hypertension
Can occur simultaneously with gestational hypertension
A PHYSICIAN ORDERED Pitocin for induction of 4 women, in which of the following situations should the nurse refuse to comply with the order
Primigravida with a transverse lie
A woman is 36 weeks gestation, which of the following tests should be done during her next prenatal visit
Vaginal and rectal cultures
Pregnant for the 3rd time, all of her children are living, 1 child born at 39 weeks, twins born at 34 weeks, another child born at 35 weeks of gestation
4-1-2-0-4
A woman is at 14 weeks gestation, the nurse would expect to palpate the fundus at which level
Slightly above pubic symphisis
Cardiovascular system changes in pregnancy, which finding would be normal of a woman in her second trimester
Increased pulse rate
Appendicitis may be difficult to diagnose in pregnancy because the appendix is
Displaced upward and laterally, high and to the right
The nurse must be cognizant that an individual’s genetic makeup is known as
Genotype
Regarding the estimation and interpretation of the recurrence of risks for genetic disorders, nurses should be aware that
The risk factor remains the same no matter how many affected children are in the family
A father and a mother are carriers of phyneulketonuria (PKU). Their 2 year old daughter has PKU. The couples tell the nurse that they are planning to have a second baby. Because their daughter has PKU, they are sure that their next baby won’t be affected what response by the nurse is most accurate
You are both carriers, so each baby has 25% of being affected
A woman’s cousin gave birth to an infant with a congenital heart anomaly. The woman asks the nurse when such anomalies occur. Which response by the nurse is most accurate
They occur between the 3rd and 5th weeks of development
With regard to the structure and function of the placenta the nurse should be aware
As one of its early functions, the placenta acts as an endocrine gland
The nurse is providing genetic counseling to an expectant couples who already gave a child with trisomy 18, the nurse should
Discuss options with the couple, including amniocentesis to determine whether the fetus is affected
The nurse caring for a laboring women should know that meconium is produced by
Fetal intestines
In practical terms regarding genetic health care, nurses should be aware that
The most important of all nursing function is providing support to the family during counseling
With regard to prenatal genetic testing, nurses should be aware
Maternal serum screening can determine whether a pregnant woman is at risk of carrying a fetus with down syndrome
The ___ is/are responsible for oxygen and carbon dioxide transport to and from the maternal bloodstream
Chorionic villi
With regard to follow-up visits for women receiving prenatal care, nurses should be aware that:
During the abdominal examination, the nurse should be alert for supine hypotension
Which symptom is considered a first-trimester warning sign and should be reported immediately by the pregnancy woman to her health care provider
Vaginal bleeding
While evaluating an external monitoring tracing and in active labor, the nurse notes that the fetal heart rate (FHR) for 5 sequential contractions begins to decelerate late in the contraction with nadir of the decelerations occurring after the peak of contraction, the nurse’s first concern is
Change the women’s position
The nurse caring for a laboring women should understand that early decelerations are caused by
Altered fetal cerebral blood flow
During labor a fetus with an average heart rate of 135 beat/min over a 10 min period would be considered to have
A normal baseline heart rate
Nurse teaches pregnancy women about characteristics of true labor contractions, the nurse evaluated the woman understands
True labor contractions will continue and get stronger even if I relax and even if I relax and take a shower
Nulliparous woman telephones the hospital to report that she is in labor, the nurse should initially
Ask the women to describe why she believes she is in labor
A new mother states that her infant must be cold because the baby’s hands and feet are blue, The nurse explains that this is a common and temporary condition called
Acrocyanosis
While evaluating reflex of newborn, nurse notes with loud noise the newborn systemically abducts and extends his arms, his fingers fan out and forma a C with the thumb and forefinger, and he has a slight tremor, the nurse would document positive
Moro reflex
While assessing skin of 24 h old newborn, the nurse notes a pink popular rash with vesicles superimposed on the thorax, back and abdomen, the nurse should
Document the finding as erythema toxicum
With regard to the functioning of the renal system in newborns, nurses should be aware that
The pediatrician should be notified if the newborn has not voided in 24 hours
A collection of blood between the skull bone and its periosteum is known as cephalohematoma. To reassure the new parents infants develops such a soft bulge it is important that the nurse be aware
May occur with spontaneous vaginal birth
A woman gave birth to an infant boy 10 hours ago, Where would the nurse expect to locate this woman’s fundus
One centimeter above the umbilicus
Which woman is most likely to experience strong after pains
Gravida 4, para 4-0-0-4
2 days ago a woman gave birth to a full term infant, Last night she awakened several times to urinate and notes that her gown and bedding were wet from profuse diaphoresis. One mechanism for the diaphoresis and diuresis that this woman is experiencing during the early postpartum periods is
Loss of increased blood volume associated with pregnancy
All of these statements indicate impacts of breastfeeding on the family or society at large except
Breast feeding costs employers in terms of time lost from work
With regard to the care management of preterm labor, nurses should be aware
The diagnosis of preterm labor is based on gestational age, uterine activity, and progressive cervical change
Nurses should be aware that induction of labor
Is rated for viability by a bishop score
• A woman who has recently given birth complains of pain and tenderness in her leg. On physical examination, the nurse notices warmth and redness
Thrombopheltbitis
What statement about multifetal pregnancy is not accurate
Twin pregnancies come to term with the same frequency as single pregnancies
With regard to medications, herbs, shots, and other substances normally encountered
Both prescription and OTC drugs that otherwise are harmless can be made hazardous by metabolic deficiencies of the fetus
Which statement about pregnancy is accurate
A normal pregnancy lasts about 10 lunar months
When assessing a women in first stage of labor the nurse recognizes that the most conclusive sign that uterine contraction are effective would be
Dilation of cervix
With regard to use of intrauterine devices (IUD) nurse should be aware
IUDs containing cooper can provide an emergency contraception option if inserted within a few days of unprotected intercourse
When assessing a women in labor, the nurse is aware that the relationship of the fetal body parts to one another is called fetal
Attitude
The most critical nursing action in caring for the newborn immediately after birth is
Keeping the newborn’s airway clear
On vaginal examination of 30 year old women nurse documents the following findings: profuse, thin, grayish white vaginal discharge with a “fishy” odor, complaints of pruritus, On the basis of these findings the nurse suspects that this women has
Bacterial vaginitis (BV)
With regard to hemolytic disease of the newborn, nurses should be aware that
The indirect Coombs test is done on the mother on the cord blood after birth
While assessing the newborn he nurse should be aware that the average expected apical pulse range of a full-term quiet/alert newborn is
120-140 bpm
A woman has thick, white lumpy cottage cheese like discharge, with patches on her labia and in her vagina. She complains of intense pruritus the nurse practitioner would order which preparation for treatment
Fluconazole
Which condition not uncommon in pregnancy is likely to require careful medical assessment during puerperium
Headaches
Which viral sexually transmitted infection is characterized by a primary infection followed by recurrent episodes?
Herpes simplex virus
A woman will be taking oral contraceptive using s 28-day pack. The nurse should advice this women to protect against pregnancy by
Taking one pill at the same time every day
The 2 primary areas of risk for sexually transmitted infections (STIs) are
Risky sexual behavior and inadequate preventive health behaviors
A man smokes 2 packs of cigarettes a day, he wants to know if smoking is contributing to the difficulty he and his wife are having getting pregnant, the nurse’s most appropriate response is
Smoking can reduce the quality of your sperm
When evaluating women for STIs, the nurse should be aware the most common bacterial sexually transmitted infection is
Chlamydia
To adequately care for laboring women the nurse should know which stage of labor varies the most in length
first
26 year old women G2 P1 is 28 weeks pregnancy when she experiences bright red, painless vaginal bleeding. She has not previously had any prenatal care for this pregnancy. Upon arrival at the hospital what would be an expected diagnostic procedure:
Ultrasounds for placental location
Which contraceptive method protects against sexually transmitted infections and HIV
Barrier methods
RN examining a woman who gave birth 5 hours ago, the nurse finds that the woman has completely saturated a perineal pad within 15 minutes. The nurse’s priority would be to
Massage the fundus
A woman gave birth vaginally to a 9-pound, 12 ounce girl yesterday. Her primary health care provider has written orders for perineal ice packs, use of a sitz bath tid, and a stool softener. What information is most closely correlated with these orders?
She has an episiotomy
The laboratory results for a postpartum woman are as follows; blood type A; Rh status positive; rubella titer, 1:8 (EIA 0.8); hematocrit, 30%. How would the nurse best interpret these data:
Rubella vaccine should be given
Part of the health assessment of newborn is observing the infant’s breathing pattern. A full-term newborn’s breathing pattern is predominantly
Abdominal with synchronous chest
A first time father is changing the diaper of his 1 day old daughter. He asks the nurse, “What is this black sticky stuff in her diaper?
Meconium
An African-American woman noticed some bruises on her newborn girl’s buttocks. She asked the nurse who spanked her daughter the nurse explains that it is
Mongolian Spot
The parents of a newborn ask the nurse how much the newborn can see the parents specifically want to know what type of visual stimuli they should provide for their newborn the nurse responds to the parents by telling them
The infant can track their parent’s eyes and distinguish patterns, they prefer complex patterns
An infant body was just born a few minutes ago. The nurse is conducting the initial assessment. Part of the assessment includes the Apgar score. The apgar assessment is performed
at least twice, 1 minute and 5 minutes after birth
The normal term infant has little difficulty clearing its airway at birth. Most secretions are brought up to the oropharynx by the cough reflex. However, if the infant has excess secretion, the mouth and nasal passages can be cleared easily with a bulb syringe. When instructing the parents on the correct use of the piece of equipment it is important to teach the parents to suction
mouth first
A new father wants to know what medication was put into his infants eyes and why it was needed. The nurse explains to the father that the purpose of the ophthalmic ointment is to
prevent gonorrhea and chlamydia infection of the infant’s eyes potentially from the birth canal
In the classification of newborns by gestational age and birth weight, the appropriate gestation age (AGA) weight would
fall between the 10th and 90th percentiles for the infant’s age
A newborn is jaundices and receiving phototherapy via ultraviolet bank lights. An appropriate nursing intervention when caring for an infant with hyperbilirubinemia and receiving phototherapy by this method would be to
place eye shields over the newborn’s eyes
A mother expresses fear about changing her infant’s diaper after he is circumcised. What does the woman need to be taught to take care of the infant when she gets home?
Cleanse the penis gently with water and put petroleum jelly around the glans after each diaper change
With regard to fetal positioning during labor, nurses should be away that: birth is imminent at
4+ or 5+
With regard to primary and secondary powers, the maternity nurse should know that:
Primary powers are responsible for effacement and dilation of the cervix
To adequately care for a laboring woman, the nurse should know which state of labor varies the most in length
First stage
How do you assess cervical change
Vaginal Exam
The nurse providing care for the laboring woman should understand that late fetal heart rate (FHR) decelerations are caused by
uteroplacental insufficiency
The nurse providing care for the laboring woman should understand that variable fetal heart rate (FHR) decelerations are caused by
umbilical cord compression
A nurse might be called on to stimulate the fetal scalp
to elicit an acceleration in FHR
When using intermittent auscultation IA for fetal heart rate nurses should be aware that:
you can order an ultrasound and look for the best place to listen for FHR
According to standard professional thinking, nurses should auscultate the fetal heart rate (FHR):
In the active phase of the first stage of labor, the FHR should be auscultated every 30 min if no risk factors are involved
To help patients manage discomfort and pain during labor, nurses should be aware
the predominant pain of the first stage of labor is the visceral pain located in the lower portion of the abdomen- this pain comes from cervical changes, distention of the lower uterine segment, and uterine ischemia
Referred pain occurs when
the pain that originates in the uterus radiates into the abdomen
Nursing care measures are commonly offered to women labor, which nursing measure reflects application of the gate-control theory
massaging the women’s back
A first-time mother is concerned about the type of medications she will received during labor she is in a fair amount of pain
sedatives can be used to reduce the n/v that often accompany opioid use in addition some ataractics reduce anxiety and apprehension and potentiate the opioid analgesic affects
A woman in labor has just received spinal anesthesia. The most important nursing intervention is to:
Monitor the maternal blood pressure for possible hypotension
A woman has requested an epidural for her pain. She is 5 cm dilated and 100% effaced. The baby is in a vertex position and is engaged. The nurse increases the woman’s IV fluid for a preprocedural bolus. She reviews her lab values and noes her hemoglobin is 12 g/dl hematocrit is 38% and platelets are 67,000 and white
thrombocytopenia
Several changes in the integumentary system that appear during pregnancy disappear after birth, although not always completely. What change is almost certain to be completely reversed?
Nail brittleness disappears
Excessive blood loss after child birth can have several causes, the most common is:
Failure of the uterine muscle to contract firmly-atony
With regard to the newborn’s developing cardiovascular system, nurses should be aware that:
The point of maximal impulse (PMI) often is visible on the chest wall
At 1 min after birth the nurse assesses the infant and notes: a HR of 80 beats/min, some flexion of extremities, a weak cry, grimacing, and a pink body but blue extremities. The nurse would calculate and Apgar score of:
5
• When planning care for a laboring woman whose membranes have ruptured, the nurse recognizes that the woman’s risk for ___ has increased
Intrauterine Infection
After an emergency birth (birth may be unexpected place, not in typical facility with things you would normally have to deal with the birth) , the nurse encourages the woman to breastfeed her newborn. The primary purpose of this activity is to:
Stimulate the uterus to contract
In helping the breastfeeding mother position the baby, nurses should keep in mind that:
Whatever the position used, the infant is “belly to belly” with the mother/Don’t want to have the baby’s head turned, this can cause latching problems
Which description of the phases of the second stage of labor is accurate:
Descent phase: Significant increase in contractions, Ferguson reflex activated, average duration varies
While evaluating an external monitor tracing of a woman in active labor who is being induced, the nurse notes that the fetal heart rate (FHR) begins to decelerate at the onset of several contractions and returns to baseline before each contraction ends. The nurse should:
Document the finding in the patients records
The nurse providing care for the laboring woman should understand that amnioinfusion is used to treat:
o Variable decelerations- caused by cord pressure, used to help when there is no amniotic fluid to relieve that pressure
After change of shift report, the nurse assumes care of a multiparous patient in labor. The woman is complaining of pain that radiates to her abdominal wall, lower back, and buttocks and down her thighs. Before implementing a plan of care the nurse should understand that this type of pain is
Referred
As part of standard precautions, nurses wear gloves when handling the newborn, The chief reason is:
To protect the nurse from contamination by the newborn
A woman arrives at the clinic seeking confirmation that she is pregnant. The following info is obtained; 24 years old, BMI-17.5, she admits to having used cocaine several times during the past year and drinks alcohol occasionally. BP 108/70, pulse 72 bpm, resp. 16 bpm, family history diabetes mellitus and cancer. her sister recently gave birth to an infant with neural tube defect NTD Which characteristics place her at a high risk category
Family history of NTD, low BMI, and substance abuse are all high risk factors
When nurses help their expectant mother assess the daily fetal movement counts, they should be aware that:
the fetal alarm signal should go off when the fetal movements stop entirely for 12 hours
In 1st trimesters ultrasonography can be used to gain information on
Uterine Abnormalities
A 39 year old primagravida thinks she is about 8 weeks pregnant although she has had irregular menstrual periods her life history of smoking approx. one pack of cigarette a day tell you she trying to cut down, lab within normal limits
Ultrasound
41 week pregnant multigravida present in labor and delivery unit after a non-stress test indicated that her fetus could be experiencing some difficulties in utero, which diagnostic tool would yield more detailed info about the fetus:
Biophysical Profile
Preconception counseling is critical to the outcome of diabetic pregnancies because poor glycemic control before and during early pregnancy is associated with
congenital anomalies in the fetus
In assessing knowledge of pregestational woman with type I diabetes concerning changing insulin needs during pregnancy the nurse recognizes that further teaching is warranted when the woman states
I will need to increase my insulin dosage during the first 3 months of pregnancy
Screening at 24 weeks of gestation reveals that a normal weight pregnant woman has gestational diabetes mellitus (GDM) in planning her care nurse and woman mutually agree that an expected outcome is to prevent injury to the fetus as a result of GDM the nurse identifies that the fetus is at greatest risk for
Macrosomia
• A 26 year old primigravida comes to clinic for regular prenatal visit at 12 weeks appears thin nervous, reports eats well balanced diet, although her weight is 5 pounds less than it was at her last visit, lab studies confirm she has a hyperthyroid condition, based on data from the nurse formulate a plan of care, what nursing diagnosis is most appropriate for the woman at this time
Imbalanced nutrition: less than body
In caring for a pregnant women with sickle cell crisis, the nurse understands that management of this patient includes all except
Antibiotics
Screening questions for alcohol and drug abuse should be included in the overall assessment during the first prenatal visit for all women the 4 P’s plus is a screening tool designed specifically or identify when there is a need of a more in depth assessment the 4 Ps include all except:
Present
A primigravida is being monitored in her prenatal clinic for preeclampsia, which finding should concern her nurse
A dipstick value of 3+ for protein in her urine
A pregnant woman has been receiving magnesium sulfate infusion for tx. of preeclampsia for 24 hr., on assessment temp 37.3 degree c, pulse rate 88 bpm respiratory rate of 10 breaths/min blood pressure of 128/90 mm hg absent deep tendon reflexes and no ankle clonus the pt. complains I’m so thirsty and warm”
Discontinue the magnesium sulfate infusion
The perinatal nurse is giving instructions to a woman, stay she must take two post-suction curettage secondary to a hydatidiform mole, the woman asks why she must take oral contraceptives for 12 months the best response
The major risk to you after a molar pregnancy is a type of cancer that can be diagnosed only by measuring the same hormone that your body produced during pregnancy, if you were to get pregnant it would make the diagnosis of this cancer more difficult
The most prevalent clinical manifestation of abruptio placenta as opposed to placenta previa is
Abdominal pain
In caring for the woman with disseminated intravascular coagulation (DIC) what order should the nurse anticipate
Administration of blood
In planning for home care of a woman with preterm labor, the nurse needs to address what concern:
prolonged bed rest may cause negative physiological effects
A woman in preterm labor at 30 weeks of gestation receives 2 12 mg doses of betamethasone intramuscularly, The purpose of this pharmacologic treatment is to:
antenatal glucocorticoids given as intramuscular injections to the mother to stimulates fetal lung maturation (surfactant)
A primigravida 40 weeks gestational is having uterine contractions every 1 ½ to 2 minutes and says that they are very painful, her cervix is dilated 2 cm and has not changes in 3 hours. The woman is crying and wants an epidural what is likely status of this woman’s labor
hypertonic
A woman is having her first child. She has been in labor for 15 hours, 2 hours ago her vaginal examination revealed the cervix to be dilated to 5 cm and 100% effaced, and the presenting part was at station 0, 5 mins ago her vaginal examination indicated that there had been no change what abnormal labor pattern is associated with this description
Secondary arrest
A pregnant woman’s amniotic membranes have ruptured prolapsed cord is suspected. What intervention would be the top priority
Placing the woman in knee to chest position
Premature infants who exhibit 5-10 seconds of resp. pauses followed by 10-15 seconds of compensatory rapid respiration are:
breathing in a respiratory pattern common to premature infants
An infant is to receive gastronomy feeding what intervention should the nurse institute to prevent bloating, GI reflux into the esophagus. Vomiting, and respiratory compromise
slow small warm bolus feedings over 20-30 mins
NEC inflammatory disease of the GI mucosa, the signs of NEC are nonspecific some generalized signs are:
abdominal distention, temp instability and grossly bloody stools
Nurse practicing in perinatal setting should promote kangaroo care regardless of infants gestational age, this intervention should
help infants to interact directly with their parents and enhances their temperature regulation
A woman arrives at the clinic for a pregnancy test, Last Menstrual period was Feb 14, 2012, her expected date of birth would be
Nov 21
Which blood pressure finding during 2nd trimester indicates risk for pregnancy induced hypertension
100/70 –> 130/85
Prenatal testing for the human immunodeficiency virus HIV is recommended for which women
all women regardless of risk factors
With regard to work and travel during pregnancy nurses should be aware that: while working or traveling in a car or on a plane
women should arranged to walk around at least every hour or so
A woman is recovering at the gynecologists office following a late first trimester spontaneous abortion, at this time it is essential for the nurse too check which of the following:
Maternal blood type
A newborn admitted to nursery has a positive direct Coomb’s test. Which of the following is an appropriate action by the nurse?
Monitor baby for jaundice
A 36-week gestation woman lies flat on her back. Which of the following maternal signs/ symptoms would not be unanticipated?
Diziness
A baby was just born to a mother who had positive vaginal cultures for group B strep. The mother was admitted to labor 2 hours before the birth. Which of the following should the nurse closely observe for in this baby
Hypothermia
4 babies are in the newborn nursery. The nurse pages the neonatologist to see that baby who exhibits what?
o Intercostal retractions
o Erythema toxicum
o Pseudostrabismus
o Vernix caseousa
Intercostal retractions
A pregnant woman informs the nurse that her last normal menstrual period was on Sep 20, 2012, using Nagele’s rule the nurse calculates the clients EDD as:
June 27, 2013
A nurse suspects that a client has been physically abused. The woman refuses to report the abuse to the police. Which statement by the client suggests to the nurse that the relationship may be in the “honeymoon phase’
My partner said that he will never hurt me again
Four 38 gestation woman have just deliver. Which of the babies should be monitored closely for respiratory distress
o Baby whose mother has DM (diabetes mellitus)
o Baby whose mother has lung cancer
o Baby whose mother has hyperthyroidism
o Baby whose mother has asthma
Baby whose mother has DM (diabetes mellitus)
A patient has been diagnoses with gestational diabetes! I will never be able to give myself shots!” Which response by the nurse is most appropriate?
If you exercise and follow your diet your will probably not need insulin
A 24 week pregnant client is being seeing the prenatal client. She states, “I’ve had a terrible headache for the past few days, Which is the priority assessment
Take her BP
A pregnant woman, 36 weeks gestation with DM 1 has just had a BPP (biophysical profile). Which of the following results should be reported?
One fetal heart acceleration in 20 mins
A gravid woman with sickle cell anemia is admitted in vaso-occlusive crisis. Which of the following is the priority intervention that the nurse must perform
Infuse IV hydration
A lecithin; sphignomyelin (L/S) ratio has been ordered, What will be learned from the test?
Maturation of fetal lungs
A 26-week gestation woman is diagnosed with severe preeclampsia with HELLP syndrome. The nurse will assess for which of the following signs/symptoms
Epigastric pain
Which finding should nurse expect when assessing a client with placenta previa
Painless, vaginal bleeding
A woman has just been admitted to the ER subsequent to head-on automobile accident. Her body appears to be uninjured. The nurse monitor for which complications of pregnancy
Placental Abruption
Type I diabetic is being seen for preconception counseling. The nurse should emphasize that during the first trimester the woman may experience which of the following
Need for less insulin that she normally injects
A nurse is performing an assessment on four 22-week pregnant clients. The nurse reports to the OB that which of the clients may be carrying twins:
Fundal height measurement 26
The perinatal nurse is caring for a woman in the immediate post birth period. Assessment reveals that the woman is experiencing profuse bleeding. The most likely etiology for the bleeding is
Uterine Atony
The perinatal nurse assisting with establishing lactation is aware that acute mastitis can be minimized by
Using proper breastfeeding techniques
The prevalence of urinary incontinence increases as women age, with more than 1/3 of women in the US suffering from some form of this disorder. The symptoms of mild to moderate-to-mild UI can be successfully decreased by a number of strategies, which of these should the nurse instruct the patient to do first
bladder training and pelvic floor exercises
When a woman is diagnosed with PPD with psychotic features, one of the major concerns is that she may
Harm her infant
At 35 weeks of pregnancy a women experiences preterm labor, tocolytics administer, placed on bed rest, experiences regular uterine contractions, her cervix is beginning to dilate and efface, what would be an important test for fetal well- being at this time:
Amniocentesis for L/S ratio to assess fetal lung maturity
A 39 year old primagravida thinks she is about 8 weeks pregnant although she has had irregular MP her entire life, history of smoking one pack of cigarettes a day, she tells you that she is trying to cut down. Her lab data are within normal limits what diagnostic (should be screening) technique could be used with this pregnant woman at this time
Ultrasound
With what heart conditions is pregnancy not usually contraindicated
Heart transplant
When caring for a pregnant woman with cardiac problems the nurse must be alert for s/sx of cardiac decompensation, which are
Dyspnea, crackles, an irregular weak pulse
The nurse providing care for woman with gestational diabetes understands that a lab test for glycosated hemoglobin A1C:
Would be considered evidence of good diabetes control with a result of 2.5%-5.9%
A woman presents to ED complaining of bleeding and cramping, the initial nursing history is significant for a last menstrual period of 6 weeks ago, on sterile speculum examination the primary care provider finds cervix is closed. The anticipated plan of care for this woman is based on probable diagnosis of which of the following types of spontaneous abortion
Threatened
Nurses should be aware chronic hypertension
Can occur simultaneously with gestational hypertension
A PHYSICIAN ORDERED Pitocin for induction of 4 women, in which of the following situations should the nurse refuse to comply with the order
Primigravida with a transverse lie
A woman is 36 weeks gestation, which of the following tests should be done during her next prenatal visit
Vaginal and rectal cultures
Pregnant for the 3rd time, all of her children are living, 1 child born at 39 weeks, twins born at 34 weeks, another child born at 35 weeks of gestation
4-1-2-0-4
A woman is at 14 weeks gestation, the nurse would expect to palpate the fundus at which level
Slightly above pubic symphisis
Cardiovascular system changes in pregnancy, which finding would be normal of a woman in her second trimester
Increased pulse rate
Appendicitis may be difficult to diagnose in pregnancy because the appendix is
Displaced upward and laterally, high and to the right
The nurse must be cognizant that an individual’s genetic makeup is known as
Genotype
Regarding the estimation and interpretation of the recurrence of risks for genetic disorders, nurses should be aware that
The risk factor remains the same no matter how many affected children are in the family
A father and a mother are carriers of phyneulketonuria (PKU). Their 2 year old daughter has PKU. The couples tell the nurse that they are planning to have a second baby. Because their daughter has PKU, they are sure that their next baby won’t be affected what response by the nurse is most accurate
You are both carriers, so each baby has 25% of being affected
A woman’s cousin gave birth to an infant with a congenital heart anomaly. The woman asks the nurse when such anomalies occur. Which response by the nurse is most accurate
They occur between the 3rd and 5th weeks of development
With regard to the structure and function of the placenta the nurse should be aware
As one of its early functions, the placenta acts as an endocrine gland
The nurse is providing genetic counseling to an expectant couples who already gave a child with trisomy 18, the nurse should
Discuss options with the couple, including amniocentesis to determine whether the fetus is affected
The nurse caring for a laboring women should know that meconium is produced by
Fetal intestines
In practical terms regarding genetic health care, nurses should be aware that
The most important of all nursing function is providing support to the family during counseling
With regard to prenatal genetic testing, nurses should be aware
Maternal serum screening can determine whether a pregnant woman is at risk of carrying a fetus with down syndrome
The ___ is/are responsible for oxygen and carbon dioxide transport to and from the maternal bloodstream
Chorionic villi
With regard to follow-up visits for women receiving prenatal care, nurses should be aware that:
During the abdominal examination, the nurse should be alert for supine hypotension
Which symptom is considered a first-trimester warning sign and should be reported immediately by the pregnancy woman to her health care provider
Vaginal bleeding
While evaluating an external monitoring tracing and in active labor, the nurse notes that the fetal heart rate (FHR) for 5 sequential contractions begins to decelerate late in the contraction with nadir of the decelerations occurring after the peak of contraction, the nurse’s first concern is
Change the women’s position
The nurse caring for a laboring women should understand that early decelerations are caused by
Altered fetal cerebral blood flow
During labor a fetus with an average heart rate of 135 beat/min over a 10 min period would be considered to have
A normal baseline heart rate
Nurse teaches pregnancy women about characteristics of true labor contractions, the nurse evaluated the woman understands
True labor contractions will continue and get stronger even if I relax and even if I relax and take a shower
Nulliparous woman telephones the hospital to report that she is in labor, the nurse should initially
Ask the women to describe why she believes she is in labor
A new mother states that her infant must be cold because the baby’s hands and feet are blue, The nurse explains that this is a common and temporary condition called
Acrocyanosis
While evaluating reflex of newborn, nurse notes with loud noise the newborn systemically abducts and extends his arms, his fingers fan out and forma a C with the thumb and forefinger, and he has a slight tremor, the nurse would document positive
Moro reflex
While assessing skin of 24 h old newborn, the nurse notes a pink popular rash with vesicles superimposed on the thorax, back and abdomen, the nurse should
Document the finding as erythema toxicum
With regard to the functioning of the renal system in newborns, nurses should be aware that
The pediatrician should be notified if the newborn has not voided in 24 hours
A collection of blood between the skull bone and its periosteum is known as cephalohematoma. To reassure the new parents infants develops such a soft bulge it is important that the nurse be aware
May occur with spontaneous vaginal birth
A woman gave birth to an infant boy 10 hours ago, Where would the nurse expect to locate this woman’s fundus
One centimeter above the umbilicus
Which woman is most likely to experience strong after pains
Gravida 4, para 4-0-0-4
2 days ago a woman gave birth to a full term infant, Last night she awakened several times to urinate and notes that her gown and bedding were wet from profuse diaphoresis. One mechanism for the diaphoresis and diuresis that this woman is experiencing during the early postpartum periods is
Loss of increased blood volume associated with pregnancy
All of these statements indicate impacts of breastfeeding on the family or society at large except
Breast feeding costs employers in terms of time lost from work
With regard to the care management of preterm labor, nurses should be aware
The diagnosis of preterm labor is based on gestational age, uterine activity, and progressive cervical change
Nurses should be aware that induction of labor
Is rated for viability by a bishop score
• A woman who has recently given birth complains of pain and tenderness in her leg. On physical examination, the nurse notices warmth and redness
Thrombopheltbitis
What statement about multifetal pregnancy is not accurate
Twin pregnancies come to term with the same frequency as single pregnancies
With regard to medications, herbs, shots, and other substances normally encountered
Both prescription and OTC drugs that otherwise are harmless can be made hazardous by metabolic deficiencies of the fetus
Which statement about pregnancy is accurate
A normal pregnancy lasts about 10 lunar months
When assessing a women in first stage of labor the nurse recognizes that the most conclusive sign that uterine contraction are effective would be
Dilation of cervix
With regard to use of intrauterine devices (IUD) nurse should be aware
IUDs containing cooper can provide an emergency contraception option if inserted within a few days of unprotected intercourse
When assessing a women in labor, the nurse is aware that the relationship of the fetal body parts to one another is called fetal
Attitude
The most critical nursing action in caring for the newborn immediately after birth is
Keeping the newborn’s airway clear
On vaginal examination of 30 year old women nurse documents the following findings: profuse, thin, grayish white vaginal discharge with a “fishy” odor, complaints of pruritus, On the basis of these findings the nurse suspects that this women has
Bacterial vaginitis (BV)
With regard to hemolytic disease of the newborn, nurses should be aware that
The indirect Coombs test is done on the mother on the cord blood after birth
While assessing the newborn he nurse should be aware that the average expected apical pulse range of a full-term quiet/alert newborn is
120-140 bpm
A woman has thick, white lumpy cottage cheese like discharge, with patches on her labia and in her vagina. She complains of intense pruritus the nurse practitioner would order which preparation for treatment
Fluconazole
Which condition not uncommon in pregnancy is likely to require careful medical assessment during puerperium
Headaches
Which viral sexually transmitted infection is characterized by a primary infection followed by recurrent episodes?
Herpes simplex virus
A woman will be taking oral contraceptive using s 28-day pack. The nurse should advice this women to protect against pregnancy by
Taking one pill at the same time every day
The 2 primary areas of risk for sexually transmitted infections (STIs) are
Risky sexual behavior and inadequate preventive health behaviors
A man smokes 2 packs of cigarettes a day, he wants to know if smoking is contributing to the difficulty he and his wife are having getting pregnant, the nurse’s most appropriate response is
Smoking can reduce the quality of your sperm
When evaluating women for STIs, the nurse should be aware the most common bacterial sexually transmitted infection is
Chlamydia
To adequately care for laboring women the nurse should know which stage of labor varies the most in length
first
26 year old women G2 P1 is 28 weeks pregnancy when she experiences bright red, painless vaginal bleeding. She has not previously had any prenatal care for this pregnancy. Upon arrival at the hospital what would be an expected diagnostic procedure:
Ultrasounds for placental location
Which contraceptive method protects against sexually transmitted infections and HIV
Barrier methods
Chapter 8: Maternal and Fetal Nutrition
Adequate Intakes (AIs)
Recommended nutrient intakes estimated to meet the needs of almost all healthy people in the population; provided for nutrients or age-group categories for which the available information is not sufficient to warrant establishing recommended dietary allowances
anthropometric measurements
Body measurements, such as height and weight
body mass index (BMI)
Method of calculating appropriateness of weight for height (BMI = weight/height2)
Dietary Reference Intakes (DRIs)
Nutritional recommendations for the United States, consisting of the recommended dietary allowances, adequate intakes, and tolerable upper intake levels; the upper limit of intake associated with low risk in almost all members of a population
intrauterine growth restriction (IUGR)
Fetal undergrowth from any cause
kcal
Kilocalorie; unit of heat content or energy equal to 1000 small calories
lactose intolerance
Inherited absence of the enzyme lactase
physiologic anemia
Relative excess of plasma leading to a decrease in hemoglobin concentration and hematocrit; normal adaptation during pregnancy
pica
Unusual oral craving during pregnancy (e.g., for laundry starch, dirt, red clay)
pyrosis
A burning sensation in the epigastric and sternal region from stomach acid (heartburn)
Recommended Dietary Allowances (RDAs)
Recommended nutrient intakes estimated to meet the needs of almost all (97%-98%) of the healthy people in the population
• Good nutrition before and during pregnancy helps prevent neonatal problems, such as low birth weight and prematurity.
• Nutritional care during the preconception period and pregnancy includes nutrition assessment, diagnosis of nutrition-related problems or risk factors (such as diabetes, phenylketonuria, and obesity), intervention based on the dietary goals and plan, and evaluation.
• If the mother is significantly underweight or overweight when pregnancy begins, maternal and fetal risks are increased.
• During pregnancy, physiologic changes influence the need for additional nutrients.
• The optimal rate of weight gain depends on the stage of pregnancy. Total maternal weight gain and the pattern of weight gain affect the pregnancy outcome.
• Nutritional risk factors include adolescent pregnancy, multifetal pregnancy, frequent pregnancies, previous poor fetal outcome, poverty, nicotine use, alcohol or drug use, poor diet habits, problems with weight gain, and weight loss.
• By 12 weeks of gestation, the pregnant woman should start taking 30 mg of ferrous iron daily. Depending on nutritional risk factors, a woman may need other supplements.
• Moderate exercise during pregnancy improves muscle tone, which may shorten the course of labor, and promotes a sense of well-being.
• Chronic conditions, such as diabetes mellitus, renal disease, liver disease, cystic fibrosis, seizure disorders, hypertension, and phenylketonuria, may affect a woman’s nutritional status and dietary needs.
• The only nutrition-related laboratory test most women need is a hematocrit or hemoglobin measurement to screen for anemia.
• Nutrition-related discomforts of pregnancy include nausea and vomiting, constipation, and heartburn. Dietary adaptation can help ease these discomforts.

Critical Thinking/Clinical Decision Making

Nutrition and the Overweight Pregnant Woman

Tamara, of African-American and Asian heritage, is 3 months pregnant and comes to her initial appointment for diagnosis and care. She appears to be overweight for her height. To provide optimal care for her, you plan to calculate her prepregnancy body mass index. When her pregnancy is confirmed, you are asked to plan a diet with Tamara that meets the minimum daily requirements and allows for growth of the pregnancy. You know the importance of including consideration of personal preferences and cultural factors in your plan. With Tamara, identify barriers to implementing the plan.

1. Evidence—Is evidence sufficient to draw conclusions about an appropriate nutrition plan, taking into consideration personal preferences and cultural factors?
Yes. A dietary assessment using a food intake questionnaire should be conducted and a physical assessment of nutritional status performed. Based on these data, the desired pattern of weight gain during pregnancy, and a knowledge of characteristic food patterns of African-American and Asian people, planning can begin.
2. Assumptions—Describe the underlying assumptions about each of the following issues:
a. Dietary reference intakes for pregnancy and lactation
b. Indicators of nutritional risk in pregnancy
c. Daily food guide for pregnancy and lactation
d. Sources of calcium for women who do not drink milk
Assumptions.
a. A list of dietary reference intakes (RDIs) for pregnancy and lactation can be shared with Tanisha. Through discussion, you can determine whether Tanisha is ingesting adequate amounts of these important elements and whether supplementation of vitamins and minerals is necessary.
b. While reviewing indicators of nutritional risk in pregnancy with Tanisha, problem areas can be identified, and recommendations for change provided as needed.
c. The daily food guide for pregnancy and lactation can be shared with Tanisha. It can provide a basis for planning appropriate menus to provide the necessary nutrients and avoid consuming more energy (calories) than is desired.
d. As someone of African-American and Asian heritage, Tanisha may be lactose intolerant and may need sources of calcium other than milk. Through careful questioning, her lactose status can be determined and counseling can be provided about nonmilk sources of calcium.
3. What implications and priorities for nursing care can be drawn at this time?
As part of her prenatal care, Tanisha (and all pregnant women) should receive nutrition counseling. Tanisha is currently overweight. Although reduction diets may be contraindicated in pregnancy, Tamara can be assisted to plan menus that allow a slow but adequate weight gain to support growth of the pregnancy and the fetus and avoid excess weight gain.
4. Does the evidence objectively support your conclusion?
Yes, there is ample evidence about DRIs in pregnancy and lactation. Nutrition counseling should be part of the plan of care for Tanisha.
5. Do alternative perspectives to your conclusion exist?
Tanisha could have metabolic problems, including diabetes mellitus, that contribute to her weight. Ethnic and cultural patterns of eating and fast food choices could also be factors. Enlisting the support of her family would likely be helpful in planning appropriate meals.
1. When planning a diet with a pregnant woman, the nurse’s first action would be to:
A. Review the woman’s current dietary intake.
B. Teach the woman about the food pyramid.
C. Caution the woman to avoid large doses of vitamins, especially those that are fat-soluble.
D. Instruct the woman to limit the intake of fatty foods.

A. Review the woman’s current dietary intake.

Reviewing the woman’s dietary intake as the first step will help to establish whether she has a balanced diet or whether changes in the diet are required. Teaching about the food pyramid is a correct action on the part of the nurse, but the first action should be to assess the woman’s current dietary pattern and practices because instruction should be geared to what she already knows and does. Cautioning the woman to avoid large doses of vitamins is a correct action on the part of the nurse, but the first action should be to assess the woman’s current dietary pattern and practices because instruction should be geared to what she already knows and does. Instructing the woman to limit intake of fatty foods is a correct action on the part of the nurse, but the first action should be to assess the woman’s current dietary pattern and practices because instruction should be geared to what she already knows and does.

2. A pregnant woman with a body mass index (BMI) of 22 asks the nurse how much weight she should be gaining during pregnancy. The nurse’s best response would be to tell the woman that her pattern of weight gain should be approximately:
A. A pound a week throughout pregnancy.
B. 2 to 5 pounds during the first trimester, then a pound each week until the end of pregnancy.
C. A pound a week during the first two trimesters, then 2 pounds per week during the third trimester.
D. A total of 25 to 35 pounds.

B. 2 to 5 pounds during the first trimester, then a pound each week until the end of pregnancy.

A pound a week is not the correct guideline during pregnancy. A BMI of 22 represents a normal weight. Therefore, a total weight gain for pregnancy would be about 25 to 35 pounds or about 2 to 5 pounds in the first trimester and about 1 pound per week during the second and third trimesters. A pound per week the first two trimesters and 2 pounds per week the third trimester are not accurate guidelines for weight gain during pregnancy. The total weight gain of 25 to 35 pounds is correct, but the pattern of weight gain needs to be explained.

3. A pregnant woman at 7 weeks of gestation complains to her nurse midwife about frequent episodes of nausea during the day with occasional vomiting. She asks what she can do to feel better. The nurse midwife could suggest that the woman:
A. Drink warm fluids with each of her meals.
B. Eat a high-protein snack before going to bed.
C. Keep crackers and peanut butter at her bedside to eat in the morning before getting out of bed.
D. Schedule three meals and one mid-afternoon snack a day.

B. Eat a high-protein snack before going to bed.

Fluids should be taken between (not with) meals to provide for maximum nutrient uptake in the small intestine. A bedtime snack of slowly digested protein is especially important to prevent the occurrence of hypoglycemia during the night that would contribute to nausea. Dry carbohydrates such as plain toast or crackers are recommended before getting out of bed. Adding peanut butter would not be helpful. Eating small, frequent meals (about five or six each day) with snacks helps to avoid a distended or empty stomach, both of which contribute to the development of nausea and vomiting.

4. A pregnant woman’s diet consists almost entirely of whole grain breads and cereals, fruits, and vegetables. The nurse would be most concerned about this woman’s intake of:
A. Calcium.
B. Protein
C. Vitamin B12.
D. Folic acid.

C. Vitamin B12.

This diet is consistent with that followed by a strict vegetarian (vegan). Vegans consume only plant products. Because vitamin B12 is found in foods of animal origin, this diet is deficient in vitamin B12.

5. A pregnant woman reports that she is still playing tennis at 32 weeks of gestation. The nurse would be most concerned that during and after tennis matches this woman consumes:
A. Several glasses of fluid.
B. Extra protein sources such as peanut butter.
C. Salty foods to replace lost sodium.
D. Easily digested sources of carbohydrate.

A. Several glasses of fluid.

If no medical or obstetric problems contraindicate physical activity, pregnant women should get 30 minutes of moderate physical exercise daily. Liberal amounts of fluid should be consumed before, during, and after exercise, because dehydration can trigger premature labor. The woman’s calorie intake should be sufficient to meet the increased needs of pregnancy and the demands of exercise. Extra protein would not be needed. The woman’s calorie intake should be sufficient to meet the increased needs of pregnancy and the demands of exercise. It would not be necessary to replace lost sodium. The woman’s calorie intake should be sufficient to meet the increased needs of pregnancy and the demands of exercise. Adding easily digested carbohydrate sources would not be necessary.

6. Women with an inadequate weight gain during pregnancy are at higher risk of giving birth to an infant with:
A. Spina bifida.
B. Intrauterine growth restriction.
C. Diabetes mellitus.
D. Down syndrome.

B. Intrauterine growth restriction.

Spina bifida is not associated with inadequate maternal weight gain. Both normal-weight and underweight women with inadequate weight gain have an increased risk of giving birth to an infant with intrauterine growth restriction. Diabetes mellitus is not associated with inadequate maternal weight gain. Down syndrome is not associated with inadequate maternal weight gain.

7. Which minerals and vitamins usually are recommended to supplement a pregnant woman’s diet?
A. Fat-soluble vitamins A and D
B. Water-soluble vitamins C and B6
C. Iron and folate
D. Calcium and zinc

C. Iron and folate

Fat-soluble vitamins should be supplemented as a medical prescription, because vitamin D might be needed for lactose-intolerant women. Water-soluble vitamin C sometimes is consumed in excess naturally; vitamin B6 is prescribed only if the woman has a very poor diet. Iron generally should be supplemented during pregnancy, and folic acid supplements often are needed because folate is so important to the growing fetus. Zinc is sometimes supplemented during pregnancy. Most women get enough calcium.

8. With regard to nutritional needs during lactation, a maternity nurse should be aware that:
A. The mother’s intake of vitamin C, zinc, and protein can be lower than during pregnancy.
B. Caffeine consumed by the mother accumulates in the infant, who therefore may be unusually active and wakeful.
C. Critical iron and folic acid levels, higher than during pregnancy, must be maintained to ensure the health of the infant.
D. Lactating women can go back to their prepregnant calorie intake.

B. Caffeine consumed by the mother accumulates in the infant, who therefore may be unusually active and wakeful.

Vitamin C, zinc, and protein levels need to be moderately higher during lactation than during pregnancy. A lactating woman needs to avoid consuming too much caffeine. The recommendations for iron and folic acid are somewhat lower during lactation. Lactating women should consume about 500 kcal more than their prepregnancy intake, at least 1800 kcal daily overall.

9. When counseling a patient about getting enough iron in her diet, the maternity nurse should tell her that:
A. Milk, coffee, and tea aid iron absorption if consumed at the same time as iron.
B. Iron absorption is inhibited by a diet rich in vitamin C.
C. Iron supplements are permissible for children in small doses.
D. Constipation is common with iron supplements.

D. Constipation is common with iron supplements.

The beverages listed inhibit iron absorption when consumed at the same time as iron. Vitamin C promotes iron absorption. Children who ingest iron can get very sick and even die. Constipation can be a problem when iron intake is increased.

10. After you complete your nutritional counseling for a pregnant woman, you ask her to repeat your instructions so you can assess her understanding of the instructions given. Which statement indicates that she understands the role of protein in her pregnancy?
A. “Protein will help my baby grow.”
B. “Eating protein will prevent me from becoming anemic.”
C. “Eating protein will make my baby have strong teeth after he is born.”
D. “Eating protein will prevent me from being diabetic.”

A. “Protein will help my baby grow.”

Protein is the nutritional element basic to growth. An adequate protein intake is essential to meeting the increasing demands of pregnancy. These demands arise from the rapid growth of the fetus; the enlargement of the uterus, mammary glands, and placenta; the increase in the maternal blood volume; and the formation of amniotic fluid. Iron intake prevents anemia. Calcium intake is needed for fetal bone and tooth development. Glycemic control is needed in diabetics; protein is one nutritional factor to consider, but this is not the primary role of protein intake.

11. Obstetricians today are seeing more morbidly obese pregnant women (those that weigh 400 pounds or greater). A new medical subspecialty referred to as __________ obstetrics has subsequently arisen.

Bariatric

To manage the conditions of morbidly obese pregnant women and to meet their logistical needs, the subspecialty of bariatric obstetrics has been developed. Extra wide BP cuffs, surgical tables and scales that can hold these patients are necessary to deliver safe patient care. Special techniques for ultrasound and longer surgical instruments are also required.

Chapter 10: Management of Discomfort
analgesia
Absence of pain without loss of consciousness
anesthesia
Partial or complete absence of sensation with or without loss of consciousness
counterpressure
Pressure applied to the sacral area of the back during uterine contractions
effleurage
Gentle stroking used in massage, usually on the abdomen
epidural block
Type of regional anesthesia produced by injection of a local anesthetic alone or in combination with a narcotic analgesic into the epidural (peridural) space
epidural blood patch
A patch formed by a few milliliters of the mother’s blood occluding a tear in the dura mater around the spinal cord that occurs during induction of spinal or epidural block; its purpose is to relieve headache associated with leakage of spinal fluid
gate-control theory of pain
Pain theory used to explain the neurophysiologic mechanism underlying the perception of pain: the capacity of nerve pathways to transmit pain is reduced or completely blocked by using distraction techniques
local perineal infiltration anesthesia
Process by which a local anesthetic medication is deposited within the tissue to anesthetize a limited region of the body
neonatal narcosis
Central nervous system depression in the newborn caused by an opioid (narcotic); may be signaled by respiratory depression, hypotonia, lethargy, and delay in temperature regulation
opioid (narcotic) agonist analgesics
Medications that relieve pain by activating opioid receptors
opioid (narcotic) agonist-antagonist analgesics
Medications that combine agonist activity (activates or stimulates a receptor to perform a function) and antagonist activity (blocks a receptor or medication designed to activate a receptor) to relieve pain without causing significant maternal or fetal or newborn respiratory depression
opioid (narcotic) antagonists
Medications used to reverse the central nervous system depressant effects of an opioid, especially respiratory depression
pudendal nerve block
Injection of a local anesthetic at the pudendal nerve root to produce numbness of the genital and perianal region
spinal anesthesia (block)
Regional anesthesia induced by injection of a local anesthetic agent into the subarachnoid space at the level of the third, fourth, or fifth lumbar interspace
systemic analgesia
Pain relief induced when an analgesic is administered parenterally (e.g., subcutaneous [SC], intramuscular [IM], or intravenous [IV] route) and crosses the blood-brain barrier to provide central analgesic effects
• The way each woman perceives or interprets the pain of childbirth is influenced by physical, emotional, psychosocial, cultural, and environmental factors.
• The gate-control theory of pain helps explain how the pain-relief techniques taught in childbirth preparation classes work.
• Effective nonpharmacologic techniques for managing discomfort include focusing and relaxation, breathing techniques, and water therapy.
• Used together, pharmacologic and nonpharmacologic measures increase pain relief and create a more positive labor experience for the woman and her family.
• A woman who experiences a prolonged latent phase of labor and needs to decrease anxiety or promote sleep may be given a sedative.
• Analgesic drugs used for the pain of childbirth include opioid (narcotic) agonists and opioid (narcotic) agonist-antagonists.
• Opioid agonist analgesics relieve severe, persistent, or recurrent pain.
• In appropriate doses, opioid agonist-antagonist analgesics provide adequate analgesia without causing significant respiratory depression in the mother or neonate.
• Opioid agonist-antagonist analgesics are not suitable for women with an opioid dependence because the antagonist activity could precipitate withdrawal symptoms in both the mother and her newborn.
• Opioid antagonists, such as naloxone (Narcan), can reverse opioid effects, especially respiratory depression.
• The nurse must understand the expected effects, adverse reactions, and methods of administration of the drugs given to the mother.
• During spinal and epidural nerve blocks, the mother’s fluid balance must be maintained.
• Using epidural anesthesia and analgesia is the most effective pharmacologic method for relieving the pain of labor. In the United States, it is the most commonly used method.
• General anesthesia is rarely used for vaginal birth but may be used for cesarean birth.

Critical Thinking/Clinical Decision Making

Laboring Without an Epidural
Jamie is a 16-year-old G1 P0 who has been admitted with severe preeclampsia (HELLP syndrome) at 34 weeks of gestation. Jamie’s physician plans to induce labor and anticipates a vaginal birth. Jamie has not attended any childbirth preparation classes and has been planning to have an epidural for labor and birth. Unfortunately, because her platelet count is very low (28,000), the anesthesia care provider refuses to place an epidural block. Jamie bursts into tears and says, “I can’t make it through labor without an epidural! It’s going to hurt too much! Help me!!

1. Evidence—Is evidence sufficient to support the anesthesia care provider’s decision to avoid epidural anesthesia for Jamie?
Yes. Jamie’s platelet count of 28,000 is considered very low. Because of her thrombocytopenia Jamie is at risk for excessive bleeding if a blood vessel were to be damaged during insertion of the epidural catheter. Bleeding in the epidural space could cause the formation of a hematoma that might compress the cauda equina or the spinal cord and lead to serious CNS complications.

2. Assumptions—What assumptions can be made about the following methods for relieving pain during labor that would likely be available to Jamie?

a. Breathing and relaxation techniques
b. Application of heat and cold
c. Intradermal water block
d. Systemic analgesia

Assumptions.
a. Breathing techniques provide distraction, thereby reducing the perception of pain and helping Jamie maintain control throughout contractions. In the first stage of labor, such breathing techniques can promote relaxation of the abdominal muscles and thereby increase the size of the abdominal cavity. This lessens discomfort generated by friction between the uterus and abdominal wall during contractions. Because the muscles of the genital area also become more relaxed, they do not interfere with fetal descent. Although Jamie has had no prior preparation, she can be given instruction in simple breathing and relaxation techniques early in labor and will likely find these techniques to be helpful.
b. Warmed blankets, warm compresses, heated rice bags, a warm bath or shower, or a moist heating pad can enhance relaxation and reduce pain during labor. Heat relieves muscle ischemia and increases blood flow to the area of discomfort. Cold application such as cool cloths or ice packs applied to the back, the chest, and/or the face during labor may be effective in increasing comfort when the woman feels warm. They may also be applied to areas of pain. Cooling relieves pain by reducing the muscle temperature and relieving muscle spasms. Heat and cold may be used alternately for a greater effect.
c. An intradermal water block involves the injection of small amounts of sterile water into four locations on the lower back to relieve back pain. It is simple to perform and is effective in early labor and in an effort to delay the initiation of pharmacologic pain relief measures. Relief of back pain for up to 2 hours has been reported. Effectiveness of this method is probably related to the mechanism of counterirritation.
d. Systemic analgesics cross the maternal blood-brain barrier to provide central analgesic effects. They also cross the placenta and are transferred to the fetus. Effects on the fetus and newborn can be profound (e.g., respiratory depression, decreased alertness, delayed sucking), depending on the characteristics of the specific systemic analgesic used, the dosage given, and the route and timing of administration. Intravenous (IV) administration is preferred to intramuscular (IM) administration because the medication’s onset of action is faster and more predictable; as a result, a higher level of pain relief usually occurs with smaller doses. Ideally, birth should occur less than 1 hour or more than 4 hours after administration of systemic analgesia so that neonatal CNS depression is minimized.
3. What implications and priorities for nursing care can be drawn at this time?
The nurse’s priority at this time is to do everything possible to keep Jamie comfortable during labor and assist her in achieving a satisfying birth experience, even though she will not be able to use her desired method of pain relief. Jamie can be informed that there are many methods for relieving pain in labor other than epidural anesthesia, and that we will keep trying until we find the methods that work best for her. Jamie’s satisfaction with her labor and birth experience will be determined in large part by the quality of support and interaction she receives from her caregivers. Therefore, it is critical that the nurse, along with any support persons present, remains at the bedside to provide assistance in coping with each contraction. The nurse may need to try a variety of nonpharmacologic methods of pain relief in order to identify those that are most effective for Jamie.
4. Does the evidence objectively support your conclusion?
Yes. Many studies done over the years have shown that there are many nonpharmacologic methods available to effectively relieve labor pain.
5. Do alternative perspectives to your conclusion exist?
Yes. Although there are many nonpharmacologic methods that effectively relieve labor pain, epidural anesthesia and analgesia is the most effective pharmacologic pain relief method for labor that is currently available. As a result, it is the most commonly used method for relieving pain during labor in the United States, and its use has been increasing. Currently, nearly two thirds of American women giving birth choose epidural analgesia.

1. A laboring woman becomes anxious during the transition phase of the first stage of labor and develops a rapid and deep respiratory pattern. She complains of feeling dizzy and light-headed. The nurse’s immediate response would be to:

A. Encourage the woman to breathe more slowly.
B. Help the woman breathe into a paper bag.
C. Turn the woman on her side.
D. Administer a sedative.

B. Help the woman breathe into a paper bag.

Just telling her to breathe more slowly does not ensure a change in respirations. The woman is exhibiting signs of hyperventilation. This leads to a decreased carbon dioxide level and respiratory alkalosis. Rebreathing her exhaled air would increase the carbon dioxide level. Turning her on her side would not solve this problem. The side-lying position would be appropriate for supine hypotension. Administration of a sedative could lead to neonatal respiratory depression because this woman, being in the transition phase, is nearing the birth process.

2. A woman in active labor receives an analgesic, an opioid agonist. Which medication relieves severe, persistent, or recurrent pain; creates a sense of well-being; overcomes inhibitory factors; and may even relax the cervix but should be used cautiously in women with cardiac disease?

A. Meperidine (Demerol)
B. Promethazine (Phenergan)
C. Butorphanol tartrate (Stadol)
D. Nalbuphine (Nubain)

A. Meperidine (Demerol)

Meperidine used to be the most commonly used opioid agonist analgesic for women in labor throughout the world. It overcomes inhibitory factors in labor and may even relax the cervix. Because tachycardia is a possible adverse reaction, meperidine is used cautiously in women with cardiac disease. Other medication options with fewer side effects are now available for use during labor. Promethazine is an ataractic (tranquilizer) that may be used to augment the desirable effects of the opioid analgesics but has few of the undesirable effects of those drugs. Butorphanol tartrate is an opioid agonist-antagonist analgesic. Nalbuphine is an opioid agonist-antagonist analgesic.

3. A woman is experiencing back labor and complains of intense pain in her lower back. An effective relief measure would be to use:

A. Counterpressure against the sacrum.
B. Pant-blow (breaths and puffs) breathing techniques.
C. Effleurage.
D. Conscious relaxation or guided imagery.

A. Counterpressure against the sacrum.

Counterpressure is steady pressure applied by a support person to the sacral area with the fist or heel of the hand. This technique helps the woman cope with the sensations of internal pressure and pain in the lower back. Breathing techniques are usually helpful during contractions because they provide distraction; they are not necessarily targeted at back pain. Effleurage is usually helpful for relieving pain from contractions per the gate-control theory. Conscious relaxation or guided imagery techniques are usually helpful during contractions because they provide the opportunity to focus on a more pleasant situation; they are not targeted specifically toward back pain.

4. Nurses should be aware of the differences experience can make in how labor pain is perceived, such as:

A. Sensory pain for nulliparous women often is greater than for multiparous women during early labor.
B. Affective pain for nulliparous women usually is less than for multiparous women throughout the first stage of labor.
C. Women with a history of substance abuse experience more pain during labor.
D. Multiparous women have more fatigue from labor and therefore experience more pain.

A. Sensory pain for nulliparous women often is greater than for multiparous women during early labor.

Sensory pain is greater for nulliparous women because their reproductive tract structures are less supple. Affective pain is greater for nulliparous women during the first stage but decreases for both nulliparous and multiparous women during the second stage. Women with a history of substance abuse experience the same amount of pain as those without such a history. Nulliparous women have longer labors and therefore experience more fatigue.

5. With regard to breathing techniques used by a woman during labor, maternity nurses should be aware that:

A. Breathing techniques used in the first stage of labor are designed to increase the size of the abdominal cavity to reduce friction.
B. By the time labor has begun, it is too late for instruction in breathing and relaxation.
C. Controlled breathing techniques are most difficult to adhere to near the end of the second stage of labor.
D. The patterned-paced breathing technique can help prevent hyperventilation.

A. Breathing techniques used in the first stage of labor are designed to increase the size of the abdominal cavity to reduce friction.

First-stage breathing techniques promote relaxation of abdominal muscles, thereby increasing the size of the abdominal cavity. Providing instruction in simple breathing and relaxation techniques early in labor is possible and effective. Controlled breathing techniques are most difficult to adhere to in the transition phase at the end of the first stage of labor when the cervix is dilated 8 to 10 cm. Patterned-paced breathing sometimes can lead to hyperventilation.

6. With regard to systemic analgesics administered during labor, nurses should be aware that:

A. Systemic analgesics cross the maternal blood-brain barrier as easily as they do the fetal blood-brain barrier.
B. Effects on the fetus and newborn can include decreased alertness and delayed sucking.
C. Intramuscular administration (IM) is preferred over intravenous (IV) administration.
D. IV patient-controlled analgesia (PCA) results in increased use of an analgesic.

B. Effects on the fetus and newborn can include decreased alertness and delayed sucking.

Systemic analgesics cross the fetal blood-brain barrier more readily than the maternal blood-brain barrier. Effects depend on the specific drug given, the dosage, and the timing. IV administration is preferred over IM administration because the drug acts faster and more predictably. PCA results in decreased use of an analgesic.

7. With regard to spinal and epidural (block) anesthesia, nurses should know that:

A. This type of anesthesia is commonly used for cesarean births but is not suitable for vaginal births.
B. A high incidence of after-birth headache is seen with spinal blocks.
C. Epidural blocks allow the woman to move freely.
D. Spinal and epidural blocks are never used together.

B. A high incidence of after-birth headache is seen with spinal blocks.

Spinal blocks may be used for vaginal births, but the woman must be assisted while she is in labor. A high incidence of after-birth headache can occur; headaches may be prevented or mitigated to some degree by a number of methods. Epidural blocks limit the woman’s ability to move freely. Combined use of spinal and epidural blocks is becoming increasingly popular.

8. Maternal hypotension is a potential side effect of regional anesthesia and analgesia. What nursing interventions could you use to raise the patient’s blood pressure if hypotension occurs? Choose all that apply.

A. Place the woman in a supine position.
B. Place the woman in a lateral position.
C. Increase intravenous (IV) fluids.
D. Administer oxygen.
E. Perform a vaginal examination.

B. Place the woman in a lateral position.
C. Increase intravenous (IV) fluids.
D. Administer oxygen.Placing the woman in a supine position would cause venous compression, thereby limiting blood flow to and oxygenation of the placenta and fetus. Nursing interventions for maternal hypotension arising from analgesia or anesthesia include turning the woman to a lateral position, increasing IV fluids, administering oxygen via face mask, elevating the woman’s legs, notifying the physician, administering an IV vasopressor, and monitoring the maternal and fetal status at least every 5 minutes until these are stable. A sterile vaginal examination has no bearing on maternal blood pressure.

Chapter 13: Maternal Physiologic Changes
afterpains (afterbirth pains)
Painful uterine cramps that occur intermittently for approximately 2 or 3 days after birth and that result from contractile efforts of the uterus to return to its normal involuted condition
autolysis
The self-destruction of excess hypertrophied tissue
diastasis recti abdominis
Separation of the two rectus muscles along the median line of the abdominal wall
involution
Return of the uterus to a nonpregnant state after birth
lochia
Vaginal discharge during the puerperium consisting of blood, tissue, and mucus
lochia alba
Thin, yellowish to white, vaginal discharge that follows lochia serosa on approximately the tenth day after birth and that may last from 2 to 6 weeks postpartum
lochia rubra
Red, distinctly blood-tinged vaginal flow that follows birth and lasts 2 to 4 days
lochia serosa
Serous, pinkish brown, watery vaginal discharge that follows lochia rubra until approximately the tenth day after birth
pelvic relaxation
Lengthening and weakening of the fascial supports of pelvic structures
puerperium
Period between the birth of the newborn and the return of the reproductive organs to their normal nonpregnant state; fourth trimester of pregnancy
subinvolution
Failure of the uterus to reduce to its normal size and condition after pregnancy
• The time between birth and the return of the reproductive organs to their nonpregnant state is called the postpartum period, the puerperium, or the fourth trimester of pregnancy.
• Involution, the process of returning the uterus to its nonpregnant state, begins immediately after placental expulsion.
• The most common causes of subinvolution, the failure of the uterus to return to a nonpregnant state, are retained placental fragments and infection.
• During the first 2 hours after birth, the amount of uterine discharge, called lochia, should be similar to the amount during a heavy menstrual period.
• After placental expulsion, estrogen and progesterone levels decrease dramatically, triggering anatomic and physiologic changes.
• In women who breastfeed, ovulation may be delayed for a long period of time.
• After childbirth, total blood volume declines by about 16%, resulting in transient anemia.
• Vessel damage, immobility, and elevated levels of coagulation factors during the immediate postpartum period predispose the woman to thromboembolism, especially after a cesarean birth.
• Normally, few changes in vital signs occur after birth.
• Kidney function returns to normal within 1 month after birth.
• Pregnancy-induced hypervolemia allows most women to tolerate considerable blood loss during childbirth.
Critical Thinking/Clinical Decision Making
Assessment of Postpartum BleedingYou are the nurse assigned to care for Margarita, a G9 P9 who gave birth vaginally 1 hour ago to twins. Twin A weighed 7 pounds, 4 ounces, and Twin B weighed 6 pounds, 12 ounces. Margarita did not have an episiotomy and sustained no lacerations requiring repair. You are at the nurse’s station when Margarita calls and asks for her nurse to “come quick!” When you arrive in her room, you find Margarita lying in a puddle of blood. The disposable pad underneath her, as well as Margarita’s perineal pad, are completely soaked with blood.

1. What other immediate assessment is necessary to determine the cause and management of Margarita’s excessive bleeding?
The most likely cause of Margarita’s excessive bleeding is uterine atony. Therefore, the nurse’s first assessment is to palpate Margarita’s uterus. If the uterine fundus initially feels boggy rather than firm and well-contracted, uterine atony is confirmed as the probable cause of the excessive bleeding.
2. What assumptions can be made about the following issues:
a. Normal amount of lochia expected at this time (1 hour after birth)
b. Margarita’s risk factors for uterine atony
c. Immediate nursing interventions for Margarita
d. Other possible causes for Margarita’s excessive bleeding
Assumptions:
a. For the first 2 hours after birth, the amount of lochial flow should be approximately that of a heavy menstrual period. If Maria is lying in a puddle of blood and both the disposable pad underneath her and her perineal pad are completely soaked, she is obviously bleeding excessively.
b. Margarita has at least two risk factors for uterine atony. She is a grand multipara (G9 P9). She has also given birth to twins whose combined birthweight is 14 pounds.
c. Once uterine atony is confirmed, the nurse should continue to massage Margarita’s fundus until it feels firm, like a hard ball. If an IV is already in place, the rate should be increased to provide additional volume. The intravenous fluid should contain oxytocin to further encourage uterine contraction. Next, vital signs should be obtained, especially blood pressure and heart rate. While obtaining vital signs, the nurse will also assess Margarita’s skin temperature and mental status.
d. Other possible causes for Margarita’s excessive bleeding include retained placental fragments or membranes or undiscovered, and thus unrepaired, genital tract lacerations.
3. Using the situation-background-assessment-recommendation (SBAR) technique, how would you report to Margarita’s health care provider about her current status?
S: Margarita H., in Room 312, has excessive vaginal bleeding. Her underpad and perineal pad are both completely soaked, and she is lying in a puddle of blood.
B: Margarita is a G9 P9. She gave birth vaginally 1 hour ago to twins with a combined birthweight of 14 pounds. Margarita did not have an episiotomy and sustained no lacerations requiring repair.
A: Margarita’s uterus was initially boggy to palpation, but firmed after fundal massage. Her bleeding has now decreased. Her most recent vital signs are BP 110/50, pulse 100, rate 22, temp 36.8° C. Her skin feels cool and dry. She is alert and oriented. An intravenous infusion of 500 ml D5LR with 30 units of oxytocin added is currently running at 50 ml per hour. I have just changed her underpad and perineal pad.
R: Please come ASAP to evaluate this patient for other sources of bleeding. In the meantime, do you want her to receive any other medications? Do you want to order a stat hematocrit or hemoglobin?
4. Does the evidence objectively support your conclusion?
Yes. Margarita’s excessive bleeding was likely the result of uterine atony, probably caused by the huge expansion of her uterus necessary for her to give birth to two normal-sized term babies. Also, because Margarita is a grand multipara, her uterus will most likely not contract postpartum as well as it would if she had only given birth once or twice before.
5. Do alternative perspectives to your conclusion exist?
Uterine atony is the most likely cause of Margarita’s excessive bleeding. However, other possible causes of postpartum hemorrhage such as retained placental fragments or membranes or unrepaired genital tract lacerations need to be ruled out.

1. As part of the postpartum assessment, the nurse examines the breasts of a primiparous breastfeeding woman who is 1 day postpartum. An expected finding would be:

A. Presence of soft, nontender colostrum.
B. Leakage of milk at let-down
C. Swollen, warm, and tender on palpation.
D. A few blisters and a bruise on each areola.

A. Presence of soft, nontender colostrum.

Breasts are essentially unchanged for the first 2 to 3 days after birth. Colostrum is present and may leak from the nipples.
Leakage of milk occurs around day 2 or 3. Engorgement occurs at day 2 or 3 postpartum. A few blisters and a bruise indicate problems with the breastfeeding techniques being used.

2. A woman gave birth to a 7-pound, 3-ounce infant boy 2 hours ago. The nurse determines that the woman’s bladder is distended because her fundus is now 3 cm above the umbilicus and to the right of the midline. In the immediate postpartum period, the most serious consequence likely to occur from bladder distention is:

A. Urinary tract infection.
B. Excessive uterine bleeding.
C. A ruptured bladder.
D. Bladder wall atony.

B. Excessive uterine bleeding.

A urinary tract infection may result from overdistention of the bladder, but it is not the most serious consequence. Excessive bleeding can occur immediately after birth if the bladder becomes distended because it pushes the uterus up and to the side and prevents it from contracting firmly. A ruptured bladder may result from a severely overdistended bladder. However, vaginal bleeding most likely would occur before the bladder reaches this level of overdistention. Bladder distention may result from bladder wall atony. The most serious concern associated with bladder distention is excessive uterine bleeding.

3. Which statement by a newly delivered woman indicates that she knows what to expect about her menstrual activity after childbirth?

A. “My first menstrual cycle will be lighter than normal and then will get heavier every month thereafter.”
B. “My first menstrual cycle will be heavier than normal, and my period will return to my prepregnant volume within three or four cycles.”
C. “I will not have a menstrual cycle for 6 months after childbirth.”
D. “My first menstrual cycle will be heavier than normal and then will be light for several months after.”

B. “My first menstrual cycle will be heavier than normal, and my period will return to my prepregnant volume within three or four cycles.”

She can expect her first menstrual cycle to be heavier than normal, and the volume of her subsequent cycles to return to prepregnant levels within three or four cycles. Saying the first menstrual cycle will be heavier than normal and the subsequent three or four cycles will return to prepregnant volume is an accurate statement and indicates her understanding of her expected menstrual activity. Most women experience a heavier than normal flow during the first menstrual cycle, which occurs by 3 months after childbirth. She can expect her first menstrual cycle to be heavier than normal, and the volume of her subsequent cycles to return to prepregnant levels within three or four cycles.

4. Which description of postpartum restoration or healing times is accurate?

A. The cervix shortens, becomes firm, and returns to form within a month postpartum.
B. The vagina gradually returns to prepregnancy size by 6 to 10 weeks after childbirth.
C. Most episiotomies heal within a week.
D. Hemorrhoids usually decrease in size within 2 weeks of childbirth.

B. The vagina gradually returns to prepregnancy size by 6 to 10 weeks after childbirth.

The cervix regains its form within days; the cervical os may take longer to return to form. The vagina returns to prepregnancy size by 6 to 10 weeks; however, lubrication may take longer to return to prepregnancy level. Most episiotomies take 2 to 3 weeks to heal. Hemorrhoids can take 6 weeks to decrease in size.

5. The breasts of a bottle-feeding woman are engorged. The nurse should tell her to:

A. Wear a snug, supportive bra.
B. Allow warm water to soothe the breasts during a shower.
C. Express milk from breasts occasionally to relieve discomfort.
D. Place absorbent pads with plastic liners into her bra to absorb leakage.

A. Wear a snug, supportive bra.

A snug, supportive bra limits milk production and reduces discomfort by supporting the tender breasts and limiting their movement. Cold packs reduce tenderness, whereas warmth would increase circulation, thereby increasing discomfort. Expressing milk results in continued milk production. Plastic liners keep the nipples and areola moist, leading to excoriation and cracking.

6. With regard to afterbirth pains, nurses should be aware that these pains are:

A. Caused by mild, continuous contractions for the duration of the postpartum period.
B. More common in first-time mothers.
C. More noticeable in births in which the uterus was overdistended.
D. Alleviated somewhat when the mother breastfeeds.

C. More noticeable in births in which the uterus was overdistended.

The cramping that causes afterbirth pains arises from periodic, vigorous contractions and relaxations, which persist throughout the first part of the postpartum period. Afterbirth pains are more common in multiparous women because first-time mothers have better uterine tone. A large baby or multiple babies overdistend the uterus and this accounts for afterbirth pains. Breastfeeding intensifies afterbirth pain because it stimulates contractions.

7. Postbirth uterine/vaginal discharge, called lochia:

A. Is similar to a light menstrual period for the first 6 to 12 hours.
B. Is usually greater after cesarean births.
C. Will usually decrease with ambulation and breastfeeding.
D. Should smell like normal menstrual flow unless an infection is present.

D. Should smell like normal menstrual flow unless an infection is present.

Lochia flow should approximate a heavy menstrual period for the first 2 hours and then steadily decrease. Less lochia usually is seen after cesarean births. Lochia usually increases with ambulation and breastfeeding. An offensive odor usually indicates an infection.

8. Although all other joints return to their normal prepregnancy state, those in the parous woman’s feet do not. The new mother may notice a permanent increase in her shoe size. True or False?
True
9. Changes in the maternal immune system during the postpartum period account for the profuse diaphoresis that new mothers experience. True or False?
False
Chapter 14: Nursing Care of the Family during the Fourth Trimester
couplet care
One nurse, educated in both maternal and newborn care, functions as the primary nurse for both mother and neonate (also known as mother-baby care or single-room maternity care)
engorgement
Swelling of the breast tissue brought about by an increase in blood and lymph supplied to the breast, occurring as early milk (colostrum) transitions to mature milk, at approximately 72 to 96 hours after birth
uterine atony
Relaxation of uterine muscle possibly leading to excessive postpartum bleeding and postpartum hemorrhage
warm line
A help line, or consultation service, for families to access, most often for support of newborn care and postpartum care after hospital discharge
• Postpartum care is family-centered.
• Nursing care in the early postpartum period includes helping the mother rest and recover, assessing her physiologic and psychologic adaptation, preventing complications, teaching self-care and infant care, and supporting the mother and her partner as they make the transition to parenthood.
• The nurse starts preparing the new mother for discharge at their first postpartum contact.
• The care plan includes periodic assessments to detect deviations from normal physical changes, measures to relieve discomfort, and safety measures to prevent injury and infection.
• In the postpartum period, nursing interventions include preventing excessive bleeding, bladder distention, and infection; relieving pain and discomfort; and promoting or suppressing lactation.
• The most important interventions for preventing excessive bleeding are maintaining good uterine tone and preventing bladder distention.
• Common causes of discomfort include pain from uterine contractions (afterpains), perineal lacerations, episiotomy, hemorrhoids, sore nipples, and breast engorgement.
• Early ambulation is associated with a reduced incidence of venous thromboembolism.
• The mother should void spontaneously within 6 to 8 hours after giving birth.
• To help meet the psychosocial needs of a new mother, the nurse assesses the parents’ reactions to the birth experience, feelings about themselves, and interactions with the baby and other family members.
• A woman’s cultural background strongly influences her behavior during the postpartum period.
• After uncomplicated vaginal births, women are commonly scheduled for a 6-week postpartum follow-up examination.
• Early discharge classes, telephone follow-up, home visits, warm lines, and support groups can facilitate physiologic and psychologic adjustments in the postpartum period.
Critical Thinking/Clinical Decision Making
Cultural Influences during the Postpartum PeriodMingyu is a 29 year old from China who gave birth to her first child last evening. Her husband is completing postdoctoral study at the local university. Both Mingyu and her husband speak some English, although he is more fluent than she is. Her mother and father have come from China to be with her for 3 months. When the nurse enters the room, she notices immediately that the room temperature is rather warm and Mingyu is lying in bed with several layers of covers pulled up to her neck. She also has a blanket around her head. She has eaten nothing from the breakfast tray. The nursing assistant had reported that Mingyu refused to shower this morning. Although Mingyu’s chart indicates that she intends to breastfeed, she requests formula for her baby.

1. Evidence—Is evidence sufficient to draw conclusions about the cultural beliefs of Asians as they relate to the postpartum period and breastfeeding?
Yes. Potential sources of information include journal articles, books, and interviews with women who are members of that cultural group. Information regarding how traditional Asian beliefs may be adapted by women who immigrate to other countries is also available from these sources.
2. Assumptions—What assumptions can be made about the following issues?
a. Culturally appropriate diet, activity, and hygiene for the postpartum Asian woman
b. Providing appropriate care for the newborn, including breastfeeding, in the Asian culture
c. Role of other family members and friends in providing care to the postpartum woman and newborn
d. Difficulty in establishing lactation if breastfeeding is not begun immediately
Assumptions.
a. In the postpartum period, Asian women are concerned with maintaining balance between hot and cold within the body and in the environment. Blood is considered “hot,” so when blood is lost through childbirth, she is considered to be in a “cold” state. A major focus in the postpartum period is keeping the new mother warm. Asian women typically prefer warm foods and hot drinks after giving birth and refuse anything cold. Warm food and drinks help to restore balance in the woman’s body by facilitating the return of the “hot” state. The environmental temperature is kept warm; even in summer, the air conditioning is turned off and windows are closed. The postpartum woman is expected to stay in bed to prevent cold air from entering her body. Baths, showers, or washing hair are not permitted. During the 30-day confinement period after birth, the new mother is not to be walking about and cannot leave her home. She is expected to take a passive role. Household tasks are done by female relatives or live-in helpers.
b. Because of the prevalent belief among Asians that the mother should rest and remain in bed to protect herself immediately after childbirth, routine baby care is usually provided by another female. In several cultures, including Asian cultures, colostrum is viewed as unnecessary and unhealthy for newborns. Breastfeeding is begun only several days after birth, when the “true milk” has come in. Before that time, babies may be fed prelacteal food. Asian parents often request infant formula for their infant while they are in the hospital.
c. In many cultures, female family members and friends play an essential role in providing care for the new mother and baby immediately after birth. In the Asian culture, new mothers observe specific diet and activity restrictions for several weeks. Following these traditional cultural practices in a different country may prove to be extremely difficult if family members or friends are not available. In the home country, males are often not expected to assist in caring for new mothers and babies. Even if a woman’s husband is willing to do so, he may need much instruction and encouragement to provide even minimal care for his wife and baby.
d. Women are routinely taught that the ideal time to initiate breastfeeding is within the first hour after birth. During this time the baby is usually in the quiet alert state. However, women from cultures that wait hours or days to initiate breastfeeding are able to do so successfully.
3. What implications and priorities for nursing care can be drawn at this time?

The priority for nursing care at this time is to assist Mingyu in recovering from childbirth in a way that is congruent with her cultural beliefs. Every effort should be made to determine Mingyu’s preferences with regard to diet, activity, and hygiene, and to honor them as much as possible. Although Mingyu’s beliefs may seem unusual, they should be encouraged as long as she wants to conform to them and she and the baby suffer no ill effects. Culturally appropriate accommodations that can be made for Mingyu on the postpartum unit include providing a sponge bath if desired, offering only warm food and drink, and encouraging family members or friends to bring in especially desired foods if the hospital’s dietary department is unable to provide them. If Mingyu desires, family members or friends can be encouraged to stay with her as much as possible to assist with her care and the baby’s care.

Breastfeeding will also need to be addressed with Mingyu. A good way to determine the information Mingyu needs is to discover why she prefers to feed her baby infant formula. Discussing the benefits of colostrum for newborns may cause Mingyu to change her mind about delaying breastfeeding. Asian women may decide to breastfeed and offer formula as a supplement after breastfeeding. It is helpful for the nurse or lactation consultant to observe a breastfeeding session to identify any potential issues.

4. Does the evidence objectively support your conclusion?
There is a significant amount of information available concerning culturally appropriate care during the postpartum period for Asian women. Women who receive culturally appropriate care during this time will likely be more satisfied with their care. They will also be better able to assume care for themselves and their babies in the future if their early needs for passive nurturing are met.
5. Do alternative perspectives to your conclusion exist?
Not all women belonging to a particular cultural group will desire to use the traditional health practices that represent that group. Many young women who are first- or second-generation Americans follow their cultural traditions only when older family members are present or not at all. Adherents to the “melting pot” theory of acculturation in the United States would assert that women, regardless of their cultural heritage, should “act like Americans” if they live in America.
Critical Thinking/Clinical Decision Making
Weight Loss after BirthWendy, a primipara, is postpartum 3 days after giving birth by cesarean to a 9-pound son. She has had an uncomplicated recovery thus far, and breastfeeding is going well. During a discharge teaching session, Wendy expresses concern to the nurse about regaining her figure after childbirth and states that she is worried that she cannot fit into her business clothes when she returns to her job as an administrative assistant in 6 weeks. Before pregnancy, her weight was appropriate for her height. However, during pregnancy, she gained 46 pounds.

1. Evidence—Is evidence sufficient to draw conclusions about counseling women with regard to regaining their nonpregnant appearance?
Yes. Normal weight gain during pregnancy is approximately 25 pounds. Because Wendy gained almost twice that much weight during her pregnancy, she will need to make changes in her diet and exercise regularly in order to reach her prepregnant weight. There are multiple sources of information about diet and exercise during the postpartum period, including health care professionals, dietitians, web sites, television programs, and magazines available to Wendy. Although making changes in her diet and exercise regimen will not be easy, with determination and persistence Wendy can certainly succeed at regaining her prepregnant appearance.
2. Assumptions—What assumptions can be made about the following issues?
a. Appropriate diet for the postpartum mother who wants to improve her appearance
b. The relationship between breastfeeding and postpartum weight loss
c. Exercises for the postpartum woman who wants to improve her appearance
d. The relationship between perceived body image and self-esteem in postpartum women
Assumptions.
a. The postpartum woman will lose weight gradually if she consumes a balanced diet that provides slightly fewer calories than her daily energy expenditure. Most women rapidly lose several pounds during the month after birth. Because fat is the most concentrated source of calories in the diet, the first step in weight reduction is to identify sources of fat in the diet and explore ways to reduce them.
b. In general, the breastfeeding mother should eat a healthy, well-balanced diet that includes an extra 200 to 500 calories per day over nonpregnant requirements. According to the Institute of Medicine (IOM) (2005), the estimated energy requirement (EER) for a lactating woman during the first 6 months is 2700 kcal/day; during the next 6 months, the EER is 2768 kcal/day. Even with the increased caloric intake, women who are breastfeeding tend to lose weight more quickly than those who are formula feeding (Becker & Scott, 2008). Rapid weight reduction while breastfeeding may result in decreased milk supply; it is best to lose weight gradually while consuming a nutritious, well-balanced diet.
c. Women can begin exercising soon after birth, although they are encouraged to begin with simple exercises and gradually progress to more strenuous ones. Because Wendy has had a cesarean birth, she should not be doing any strenuous exercise for at least 4 to 6 weeks and has been cleared by her health care provider. The nurse might recommend walking as a beneficial form of exercise for Wendy during the next few weeks.
d. A woman’s self-esteem is often related to her perceived body image. How a new mother feels about herself and her body may affect her behavior and adaptation to parenting.
3. What implications and priorities for nursing care can be drawn at this time?

Priority for nursing care at this time is to educate Wendy regarding a weight reduction diet for a breastfeeding woman and a sensible exercise plan for a postpartum cesarean mother. She should be encouraged to follow the same balanced diet recommended during pregnancy and urged to avoid overly strict dieting. In addition, Wendy can be encouraged to eliminate “empty” calories, such as sugar-sweetened drinks, desserts, and chips from her diet. She will likely be surprised and pleased to learn that she will burn about 500 calories per day through milk production. Wendy’s individual dietary preferences should also be considered. It is important to inform Wendy that dieting can cause her milk supply to decrease; she should monitor the baby’s intake and output to see whether the infant is receiving adequate nutrition. If her milk production is declining, she may need to add more calories to her diet.

Wendy can be encouraged to begin simple nonstrenuous exercises after discharge, waiting to begin more strenuous exercises until she sees the health care provider at her 6-week follow-up visit. Taking the baby for a walk each day would provide both an opportunity for exercise and help in regaining a normal routine.

In terms of body image and self-esteem, if Wendy voiced concerns about feeling unable to cope, having no support, or perceiving that things are now very different and will “never return to normal,” a referral for more extensive evaluation and counseling would be warranted.

4. Does the evidence objectively support your conclusion?
There is a significant amount of information available concerning diet and exercise for the postpartum woman who is breastfeeding. Data regarding self-esteem in new mothers also exist.
5. Do alternative perspectives to your conclusion exist?
Most postpartum women are eager to regain their nonpregnant figures quickly. It can be discouraging when diet and exercise efforts fail to produce the desired results immediately.

1. When palpating the fundus of a woman 18 hours after birth, the nurse notes that it is firm, 2 fingerbreadths above the umbilicus, and deviated to the left of midline. The nurse should:

A. Massage the fundus.
B. Administer Methergine, 0.2 mg PO, that has been ordered prn.
C. Assist the woman to empty her bladder
D. Recognize this as an expected finding during the first 24 hours following birth

C. Assist the woman to empty her bladder

A firm fundus should not be massaged because massage could overstimulate the fundus and cause it to relax. Methergine is not indicated in this case because it is an oxytocic and the fundus is already firm. The findings indicate a full bladder, which pushes the uterus up and to the right or left of midline. The recommended action would be to empty the bladder. If the bladder remains distended, uterine atony could occur, resulting in a profuse flow. A Firm fundus that is 2 fingerbreadths above the umbilicus and deviated to the left of midline is not a normal finding, and an action is required.

2. Which finding would be a source of concern if noted during the assessment of a woman who is 12 hours’ postpartum?

A. Postural hypotension
B. Temperature of 100.4° F
C. Bradycardia—pulse rate of 55 beats/min
D. Pain in left calf with dorsiflexion of left foot

D. Pain in left calf with dorsiflexion of left foot

Postural hypotension is an expected finding related to circulatory changes after birth. A temperature of 100.4° F in the first 24 hours most likely indicates dehydration, which is easily corrected by increasing oral fluid intake. A heart rate of 55 beats/min is an expected finding in the initial postpartum period. Findings of pain in the left calf with dorsiflexion of the left foot indicate a positive Homan’s sign and are suggestive of thrombophlebitis and should be investigated.

3. The nurse examines a woman 1 hour after birth. The woman’s fundus is boggy, midline, and 1 cm below the umbilicus. Her lochial flow is profuse, with two plum-sized clots. The nurse’s initial action would be to:

A. Place her on a bedpan to empty her bladder.
B. Massage her fundus.
C. Call the physician.
D. Administer Methergine, 0.2 mg IM, which has been ordered prn.

B. Massage her fundus.

There is no indication of a distended bladder; thus having the woman urinate will not alleviate the problem. A boggy or soft fundus indicates that uterine atony is present. This is confirmed by the profuse lochia and passage of clots. The first action would be to massage the fundus until firm. The physician can be called after massaging the fundus, especially if the fundus does not become or remain firm with massage. Methergine can be administered after massaging the fundus, especially if the fundus does not become or remain firm with massage.

4. Perineal care is an important infection control measure. When evaluating a postpartum woman’s perineal care technique, the nurse would recognize the need for further instruction if the woman:

A. Uses soap and warm water to wash the vulva and perineum.
B. Washes from symphysis pubis back to episiotomy.
C. Changes her perineal pad every 2 to 3 hours.
D. Uses the peribottle to rinse upward into her vagina.

D. Uses the peribottle to rinse upward into her vagina.

Washing the vulva and perineum with soap and water is an appropriate measure. Washing from symphysis pubis back toward episiotomy is an appropriate measure. Changing the perineal pad every 2 to 3 hours in an appropriate measure. The peribottle should be used in a backward direction over the perineum. The flow should never be directed upward into the vagina because debris would be forced upward into the uterus through the still-open cervix.

5. Which measure would be least effective in preventing postpartum hemorrhage?

A. Administer Methergine, 0.2 mg every 6 hours for four doses, as ordered.
B. Encourage the woman to void every 2 hours.
C. Massage the fundus every hour for the first 24 hours following birth.
D. Teach the woman the importance of rest and nutrition to enhance healing.

C. Massage the fundus every hour for the first 24 hours following birth.

Administration of Methergine can help prevent postpartum hemorrhage. Voiding frequently can help the uterus contract, thus preventing postpartum hemorrhage. The fundus should be massaged only when boggy or soft. Massaging a firm fundus could cause it to relax. Rest and nutrition are helpful for enhancing healing and preventing hemorrhage.

6. While admitting the pregnant woman, the nurse should be aware that postpartum hospital stays that are becoming shorter are primarily the result of the influence of:

A. Health maintenance organizations (HMOs) and private insurers.
B. Consumer demand.
C. Hospitals.
D. The federal government.

A. Health maintenance organizations (HMOs) and private insurers.

The trend for shortened hospital stays is based largely on efforts to reduce health care costs. Secondarily consumers have demanded less medical intervention and more family-centered experiences. Hospitals are obligated to follow standards of care and federal statutes regarding discharge policies. The Newborns’ and Mothers’ Health Protection Act provided minimum federal standards for health plan coverage for mothers and their newborns. Under this act, couples were allowed to stay in the hospital for longer periods.

7. Discharge instruction, or teaching the woman what she needs to know to care for herself and her newborn, officially begins:

A. At the time of admission to the nurse’s unit.
B. When the infant is presented to the mother at birth.
C. During the first visit with the physician in the unit.
D. When the take-home information packet is given to the couple.

A. At the time of admission to the nurse’s unit.

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

8. The __________ test is used to detect the amount of fetal blood in the maternal circulation.

Kleihauer-Betke

If more than 15 ml of fetal blood is present in maternal circulation, the dose of Rh immune globulin must be increased.

Chapter 16: Physiologic and Behavioral Adaptations of the Newborn
acrocyanosis
Peripheral cyanosis; blue color of hands and feet in most infants at birth that may persist for 7 to 10 days
brown fat
Source of heat unique to neonates that is capable of greater thermogenic activity than ordinary fat; deposits are found around the adrenals, kidneys, and neck; between the scapulae; and behind the sternum for several weeks after birth
caput succedaneum
Swelling of the tissue over the presenting part of the fetal head caused by pressure during labor
cephalhematoma
Extravasation of blood from ruptured vessels between a skull bone and its external covering, the periosteum; swelling is limited by the margins of the cranial bone affected (usually parietals)
cold stress
Excessive loss of heat that results in increased respirations and nonshivering thermogenesis to maintain core body temperature
erythema toxicum
Innocuous pink papular neonatal rash of unknown cause, with superimposed vesicles appearing within 24 to 48 hours after birth and resolving spontaneously within a few days
habituation
Psychologic and physiologic phenomenon whereby the response to a constant or repetitive stimulus is decreased
jaundice
Yellow color of skin due to increased level of bilirubin in body tissues
meconium
Greenish black, viscous first stool formed during fetal life from the amniotic fluid and its constituents, intestinal secretions (including bilirubin), and cells (shed from the mucosa)
milia
Small, white sebaceous glands, appearing as tiny, white, pinpoint papules on the forehead, nose, cheeks, and chin of the neonate
mongolian spots
Bluish gray or dark nonelevated pigmented areas usually found over the lower back and buttocks that are present at birth in some infants, primarily nonwhite, usually fading by school age
sleep-wake states
Variation in states of newborn consciousness from deep sleep to extreme irritability
surfactant
Phosphoprotein necessary for normal respiratory function that prevents alveolar collapse (atelectasis)
thermogenesis
Creation or production of heat, especially in the body
thermoregulation
Control of temperature; a balance between heat loss and heat production
transition period
Period from birth to 4 to 6 hours later in which the infant passes through a period of reactivity, sleep, and a second period of reactivity
vernix caseosa
Protective gray-white fatty substance of cheesy consistency covering the fetal skin
• At birth, a full-term infant’s anatomic and physiologic systems allow extrauterine life.
• During the first 6 to 8 hours after birth, newborns go through a transition period between intrauterine and extrauterine life.
• The most critical adjustment a newborn makes at birth is establishing respirations.
• Signs of respiratory distress include nasal flaring, intercostal or subcostal retractions, and grunting with respirations.
• The cardiovascular system changes significantly after birth.
• The newborn’s average systolic blood pressure is 60 to 80 millimeters of mercury (mm Hg); the average diastolic pressure is 40 to 50 mm Hg.
• In the healthy term newborn, heat loss may exceed the capacity to produce heat, leading to metabolic and respiratory complications.
• In the newborn, heat loss results from convection, radiation, evaporation, and conduction.
• At birth, the lower intestine is filled with meconium, which is formed from amniotic fluid and its constituents, intestinal secretions including bilirubin, and cells shed from the mucosa.
• At birth, a protective covering, called vernix caseosa, is fused with the epidermis.
• During the first year of life, the infant’s skeletal system undergoes rapid development.
• Within 24 hours of birth, the newborn undergoes a complete physical examination.
• Baseline measurements include weight, head circumference, and body length.
• A healthy infant must accomplish behavioral and biologic tasks to develop normally.
• Sleep-wake states and other factors influence the newborn’s behavior.
• From birth, infants have sensory capabilities that indicate a state of readiness for social interaction.
• Habituation is a protective mechanism that allows the infant to become accustomed to environmental stimuli.
Critical Thinking/Clinical Decision Making
Near Term Infant with Physiologic JaundiceVeronica gave birth vaginally with the assistance of vacuum extraction to a 7-lb baby boy 36 hours ago. The baby was estimated to be at 35 to 36 weeks of gestation. As a result of the vacuum extraction the baby’s occiput is bruised and slightly edematous (his condition appeared much worse yesterday). For the first 24 hours, he was very sleepy and difficult to arouse for feedings, but for the last 12 hours, he has breastfed every 2 to 3 hours for approximately 15 minutes. He has voided twice and passed only one small meconium stool since birth. Randy was holding his baby this morning and stated, “Look at his handsome skin tones! Why, he looks like he has been on vacation and started to get his suntan.”

1. Evidence—Is evidence sufficient to draw conclusions about the baby’s skin color?
The nurse can assess the newborn for the presence of jaundice by blanching the skin over the baby’s forehead, chest, abdomen, and legs. At this point, the baby is over 24 hours of age and would likely be experiencing physiologic jaundice.
2. Assumptions—What assumptions can be made about the following?
a. The baby’s skin color
b. Baby’s intake and output since birth
c. The parents’ understanding of physiologic jaundice
Assumptions.
a. At 36 hours of age, the newborn is likely exhibiting physiologic jaundice. He is at risk for development of physiologic jaundice because of the bruising of his head and because he is preterm.
b. The baby has not been feeding well thus far and has had only one stool. Because bilirubin is excreted primarily through the stool, it is important that his bowel movements increase. Because he is preterm, he may be more difficult to awaken for feedings than a full-term infant. The more he feeds, the greater his output will be.
c. Randy noted the appearance of his son’s skin color as evidenced by his comment. The nurse can explain why the baby appears somewhat “yellow” and describe physiologic jaundice in terms that the parents can understand.
3. What implications and priorities for nursing care can be drawn at this time?

The infant’s level of jaundice should be assessed and the health care provider notified. The nurse may be able to determine a transcutaneous measurement of hyperbilirubinemia if equipment is available. The health care provider may order a serum bilirubin measurement to establish a baseline and reassess bilirubin levels periodically to determine whether hyperbilirubinemia is increasing. It is important to closely monitor the infant and to intervene to prevent the development of kernicterus.

Feeding is important because it promotes excretion of excess bilirubin. The parents may need to be encouraged to awaken the baby for feedings, and breastfeeding should be observed to determine the mother’s ability to feed and to assess for milk transfer. Assistance is given as needed. The baby’s output is closely monitored; parents may be instructed to keep a log of feedings, urination, and stooling.

The parents will likely need some explanation about physiologic jaundice. First, the nurse will assess their knowledge and proceed to provide needed information. They are encouraged to ask questions of the nurse and the health care provider.

4. Does the evidence objectively support your conclusion?
If bilirubin levels are measured, there may be evidence to support the conclusion that the baby is experiencing physiologic jaundice. If this is the case, the baby will appear more jaundiced over the next 2 or 3 days.
5. Do alternative perspectives to your conclusion exist?
Jaundice could also be caused by blood incompatibilities or liver anomalies; however, this type of jaundice is considered pathologic and usually appears within the first 24 hours of life.

1. What would be a warning sign of ineffective adaptation to extrauterine life if noted when assessing a 24-hour-old breastfed newborn before discharge?

A. Apical heart rate of 90 beats/min, slightly irregular, when awake and active
B. Acrocyanosis
C. Harlequin color sign
D. Weight loss representing 5% of the newborn’s birth weight

A. Apical heart rate of 90 beats/min, slightly irregular, when awake and active

The heart rate of a newborn should range from 120 to 140 beats/min, especially when active. The rate should be regular with sharp, strong sounds. Acrocyanosis is a normal finding in a newborn at 24 hours of age. A harlequin sign is a normal finding related to the immature neurologic system of a newborn. A 5% weight loss is acceptable in the newborn.

2. When caring for a newborn, the nurse must be alert for signs of cold stress, including:

A. Decreased activity level.
B. Increased respiratory rate.
C. Hyperglycemia.
D. Shivering.

B. Increased respiratory rate.

Infants experiencing cold stress would have an increased activity level. An increased respiratory rate is a sign of cold stress in the newborn. Hypoglycemia would occur with cold stress. Newborns are unable to shiver as a means of increasing heat production; they increase their activity level instead.

3. The nurse helps a breastfeeding mother change the diaper of her 16-hour-old newborn after the first bowel movement. The mother expresses concern because the large amount of thick, sticky stool is very dark green, almost black in color. She asks the nurse if something is wrong. The nurse should respond to this mother’s concern by:

A. Telling the mother not to worry because all breastfed babies have this type of stool.
B. Explaining to the mother that the stool is called meconium and is expected of all newborns for the first few bowel movements.
C. Asking the mother what she ate at her last meal.
D. Suggesting that the mother ask her pediatrician to explain newborn stool patterns to her.

B. Explaining to the mother that the stool is called meconium and is expected of all newborns for the first few bowel movements.

This thick dark stool, known as meconium, is typical of the first stool of all newborns, not just breastfed babies. At this early age, this type of stool (meconium) is typical of both bottle-fed and breastfed newborns. The mother’s nutritional intake is not responsible for the appearance of meconium stool. The nurse is fully capable of and responsible for teaching a new mother about the characteristics of her newborn, including expected stool patterns.

4. When weighing a newborn, the nurse should:

A. Leave its diaper on for comfort.
B. Place a sterile scale paper on the scale for infection control.
C. Keep a hand on the newborn’s abdomen for safety.
D. Weigh the newborn at the same time each day for accuracy.

D. Weigh the newborn at the same time each day for accuracy.

The baby should be weighed without a diaper or clothes. Clean scale paper is acceptable; it does not need to be sterile. The nurse’s hand should be above, not on, the abdomen for safety. Weighing a newborn at the same time each day allows for accurate weights.

5. Vitamin K is given to the newborn to:

A. Reduce bilirubin levels.
B. Increase the production of red blood cells.
C. Enhance ability of blood to clot.
D. Stimulate the formation of surfactant.

C. Enhance ability of blood to clot.

Vitamin K does not reduce bilirubin levels. Vitamin K does not increase the production of red blood cells. Newborns have a deficiency of vitamin K until intestinal bacteria that produce vitamin K are formed. Vitamin K is required for the production of certain clotting factors. Vitamin K does not stimulate the formation of surfactant.

6. The nurse notes that, when the newborn is placed on the scale, he immediately abducts and extends his arms and his fingers fan out with the thumb and forefinger forming a “C.” This response is known as a:

A. Tonic neck reflex.
B. Moro reflex.
C. Cremasteric reflex.
D. Babinski reflex.

B. Moro reflex.

Tonic neck reflex refers to the “fencing posture” a newborn assumes when he is supine and turns his head to the side. These actions show the Moro reflex. The cremasteric reflex refers to retraction of testes when chilled. The Babinski reflex refers to the flaring of the toes when the sole is stroked.

7. A newborn male, estimated to be 39 weeks of gestation, would exhibit:

A. Extended posture when at rest.
B. Testes descended into scrotum.
C. Abundant lanugo over his entire body.
D. Ability to move his elbow past his sternum.

B. Testes descended into scrotum.

The newborn’s good muscle tone will result in a more flexed posture when at rest. A full-term male infant will have both testes in his scrotum and rugae on his scrotum. The newborn will exhibit only a moderate amount of lanugo, usually on his shoulders and back. The newborn would not have the ability to move his elbow past midline.

8. While examining a newborn, the nurse notes uneven skinfolds on the buttocks and a click sound when performing the Ortolani maneuver. The nurse recognizes these findings as a sign that the newborn probably has:

A. Polydactyly.
B. Clubfoot.
C. Hip dysplasia.
D. Webbing

C. Hip dysplasia.

Polydactyly is the presence of extra digits. Clubfoot (talipes equinovarus) is a deformity in which the foot turns inward and is fixed in a plantar-flexion position. The Ortolani maneuver is used to detect the presence of hip dysplasia. Webbing, or syndactyly, is a fusing of the fingers or toes.

9. A patient feels too warm and asks for a fan in her room for her comfort. The nurse enters the room to assess the mother and her infant and finds the infant unwrapped in his crib with the fan blowing over him on “high.” The nurse instructs the mother that the fan should not be directed toward the newborn and the newborn should be wrapped in a blanket. The mother asks why. The nurse’s best response is:

A. “Your baby may lose heat by convection, which means that he will lose heat from his body to the cooler ambient air. You should keep him wrapped and prevent cool air from blowing on him.”
B. “Your baby may lose heat by conduction, which means that he will lose heat from his body to the cooler ambient air. You should keep him wrapped and prevent cool air from blowing on him.”
C. “Your baby may lose heat by evaporation, which means that he will lose heat from his body to the cooler ambient air. You should keep him wrapped and prevent cool air from blowing on him.”
D. “Your baby will get cold stressed easily and needs to be bundled up at all times.”

A. “Your baby may lose heat by convection, which means that he will lose heat from his body to the cooler ambient air. You should keep him wrapped and prevent cool air from blowing on him.”

Saying the baby will lose heat by convection is an accurate statement. Conduction is the loss of heat from the body surface to cooler surfaces, not air, in direct contact with the newborn. Evaporation is loss of heat that occurs when a liquid is converted into a vapor. In the newborn, heat loss by evaporation occurs as a result of vaporization of moisture from the skin. Cold stress may occur from excessive heat loss, but this does not imply that the infant will become stressed if not bundled at all times. Furthermore, excessive bundling may result in a rise in the infant’s temperature.

10. All of these statements describe the first phase of the transition period except:

A. It lasts no longer than 30 minutes.
B. It is marked by spontaneous tremors, crying, and head movements.
C. It includes the passage of meconium.
D. It may involve the infant suddenly sleeping briefly.

D. It may involve the infant suddenly sleeping

The first phase is the shortest, lasting less than 30 minutes. Spontaneous tremors, crying, head movements, and also spontaneous startle reactions are expected exploratory behaviors in the first phase. In the first phase, in addition to passing meconium, the newborn also produces saliva. The first phase is an active phase in which the baby is alert. Decreased activity and sleep mark the second phase.

11. The shivering mechanism of heat production is rarely functioning in the newborn. Nonshivering __________ is accomplished primarily by metabolism of brown fat, which is unique to the newborn, and by increased metabolic activity in the brain, heart, and liver.

Thermogenesis

Hypothermia from excessive heat loss is a common and dangerous problem in neonates. The newborn infant’s ability to produce heat (thermogenesis) often approaches that of the adult; however, the tendency toward rapid heat loss in a cold environment is increased in the newborn and poses a hazard.

Chapter 17: Assessment and Care of the Newborn and Family
Apgar score
Numeric expression of the condition of a newborn obtained by rapid assessment at 1 and 5 minutes of age; developed by Dr. Virginia Apgar
circumcision
Excision of the prepuce (foreskin) of the penis, exposing the glans
hyperbilirubinemia
Elevation of unconjugated serum bilirubin concentrations
hypothermia
Temperature that falls below the normal range, that is, below 35° C, usually caused by exposure to cold
kernicterus
Pathologic process characterized by deposition of bilirubin in the brain
late preterm infant
Infants born at 34-0/7 to 36-6/7 weeks of gestation
ophthalmia neonatorum
Infection in the neonate’s eyes usually resulting from gonorrheal, chlamydial, or other infection contracted when the fetus passes through the birth canal (vagina)
phototherapy
Use of lights to reduce serum bilirubin levels by oxidation of bilirubin into water-soluble compounds that are processed in the liver and excreted in bile and urine
physiologic jaundice
Yellow tinge to skin and mucous membranes in response to increased serum levels of unconjugated bilirubin; not usually apparent until after 24 hours; also called neonatal jaundice, physiologic hyperbilirubinemia
• Immediately after birth, the nurse focuses on assessing and stabilizing the newborn’s condition, while the physician or midwife focuses on care of the mother.
• The immediate assessment includes Apgar scoring and a general evaluation of physical status.
• The Apgar score is based the nurse’s assessment of the neonate’s heart rate, respiratory rate, muscle tone, reflex irritability, and skin color.
• The initial physical assessment includes a brief review of systems.
• Immediately after birth, nursing care includes maintaining an open airway, preventing heat loss, instilling a prophylactic agent into the eyes, administering vitamin K intramuscularly, providing umbilical cord care, and promoting parent-infant interaction.
• Gestational age and birth weight are related to perinatal morbidity and mortality rates.
• A complete physical examination is performed within 24 hours of birth.
• Common problems in neonates include soft tissue injuries, skeletal injuries, physiologic jaundice, hypoglycemia, and hypocalcemia.
• Common tests for neonates include newborn screening tests and measurements of blood glucose, bilirubin, and drug serum levels.
• Ensuring a protective environment for the neonate includes following identification procedures and taking precautions to prevent infection.
• During phototherapy, the unclothed infant is placed under a bank of lights.
• Suggested benefits of circumcision include a decreased incidence of urinary tract infection and decreased risks of sexually transmitted infection, penile cancer, and human papillomavirus infection.
• The goals of neonatal pain management are to minimize the intensity, duration, and physiologic cost of the pain and to maximize the neonate’s ability to cope with and recover from the pain.
• To set priorities for discharge teaching, the nurse follows parental cues.
• The nurse should teach parents the signs of illness in newborns, especially jaundice in newborns discharged early.
• All parents should be taught infant cardiopulmonary resuscitation.
Critical Thinking/Clinical Decision Making
Sudden Infant Death Syndrome and Infant Sleep PositionMarlys gave birth to a full-term male infant named Daniel. They are being discharged today. The nurse has given her instructions about placing the baby on his back for sleep. Marlys said that she had noticed that the nurses placed Daniel on his side in the nursery and wondered why they did that when she was instructed to place Daniel on his back.

Michelle gave birth to Michael at 32 weeks. During the stay in the nursery the nurses placed Michael on his abdomen to sleep. At discharge, Michelle was instructed to place Michael on his back to sleep. Michelle asked why she had to place Michael on his back to sleep when he was used to sleeping on his abdomen. How should the nurses respond to these questions?

1. Evidence—Is evidence sufficient to draw conclusions about the safety and efficacy of the supine position for sleep in reducing the incidence of sudden infant death syndrome (SIDS)?
Yes. There is ample evidence that the supine position for sleep reduces the incidence of sudden infant death syndrome (SIDS). The nurses should cite the evidence as well as explain that in preterm infants, use of the prone position can assist breathing in the early phases of recovery from respiratory distress. However, as the infant matures, he should be placed on his back to sleep.

2. Assumptions—What assumptions can be made about the following factors related to infant positioning?

a. Role modeling by nurses
b. Sleep position in the nursery versus sleep position at home
c. Sleep position for preterm versus term infants
d. Nurses’ knowledge and use of research evidence

Assumptions.
a. Role modeling by the nurses is a powerful teacher. Stastny and colleagues (2004) found that only 30% of nursery staff placed babies on their backs to sleep and cited fear of aspiration as the reason. Continued staff education is necessary to promote the use of the supine position for sleep.
b. In the newborn nursery, nurses may place an infant on his or her side to promote drainage of secretions, although there is no evidence that this is effective. In the neonatal intensive care unit (NICU), infants in respiratory distress may breathe more easily in the prone position. As the distress lessens and the infant matures, the infant should be placed on his or her back for sleep. Parents should be counseled to place infants on their backs for sleep. During waking hours, while the parent is supervising, the infant can be placed on his or her side or abdomen.
c. Discuss sleep position for preterm versus term infants. Preterm infants may be placed in prone position to facilitate respiration; however, they should be on a cardiorespiratory monitor.
d. Not all nurses read research reports and use research evidence in their practices. Therefore they do not place infants on their backs to sleep and do not instruct parents in sleep positioning. Continuing education programs for nurses working in nurseries should address the latest findings related to the prevention of SIDS by use of positioning infants on their backs to sleep.
3. What implications and priorities for nursing care can be drawn at this time?
The nurse needs to reinforce the importance of placing the infant on his or her back to sleep and discuss with the parents the acceptability of placing the infant on the side or abdomen while the infant is awake. The nurse can also advocate for continuing education programs for the nurses to update their clinical knowledge. Signs could be posted in the nursery to remind nurses of the correct positioning.
4. Does the evidence objectively support your conclusion?
There is ample evidence of the efficacy of sleeping on the back in prevention of SIDS. There is also documentation that many nurses do not follow these recommendations. Stastny and colleagues (2004) found that Latina and Pacific Islander mothers were less likely than Caucasian mothers to be instructed in positioning the infant on his or her back to sleep.
5. Do alternative perspectives to your conclusion exist?
Nursery nurses may have had experience with babies choking on mucus and used the prone or side-lying position to promote drainage of mucus. Based on that experience, they may fear that the back-lying position will promote aspiration. They may rely on experience rather than research evidence in their care of infants. Continuing education programs should address research findings. Nurse managers can implement programs of reward for those nurses who base their practice on evidence.

1. At 1 minute following birth, a newborn exhibited the following: heart rate of 155; loud, vigorous crying with active movement of all extremities; sneezing when nose was stimulated with a catheter; hands and feet bluish and cool to the touch. The Apgar score of this newborn should be recorded as:

A. 5.
B. 7.
C. 9.
D. 10.

C. 9.

The newborn receives 2 points each for a heart rate over 100 beats/min, a vigorous cry, active movement, and sneezing as a response to nasal stimulation. The newborn receives 1 point for color because he exhibits acrocyanosis. The point total is 9.

2. The nurse must administer erythromycin ophthalmic ointment to a newborn after birth. The nurse should:

A. Instill within 15 minutes of birth for maximum effectiveness.
B. Cleanse eyes from inner to outer canthus before administration.
C. Apply directly over the cornea.
D. Flush eyes 10 minutes after instillation to reduce irritation.

B. Cleanse eyes from inner to outer canthus before administration.

Instillation of the ointment can be delayed for up to 1 hour to facilitate eye-to-eye contact between the newborn and parents, an activity that fosters bonding and attachment, especially for fathers. The newborn’s eyes should be cleansed from the inner to the outer canthus before the administration of erythromycin ointment. Erythromycin should be applied into the conjunctival sac to avoid accidental injury to the eye. The eyes should not be flushed after instillation of the erythromycin.

3. Newborns are at high risk for injury if appropriate safety precautions are not implemented. Parents should be taught to:

A. Place newborn on abdomen (prone) after feeding and for sleep.
B. Avoid use of pacifiers.
C. Use a rear-facing car seat until the infant weighs at least 20 lb.
D. Use a crib with side-rail slats that are no more than 3 inches apart.

C. Use a rear-facing car seat until the infant weighs at least 20 lb.

The prone position is no longer recommended because it may interfere with chest expansion and lead to sudden infant death syndrome. Approved pacifiers are safe to use and fulfill a newborn’s need to suck. If the newborn is breastfed, the use of pacifiers should be delayed until breastfeeding is well established to avoid the development of nipple confusion. The APA recommends using a rear-facing car seat until a baby weighs 20 lb. Slats in a crib should be no more than 2 inches apart.

4. Following circumcision of a newborn, the nurse provides instructions to his parents regarding postcircumcision care. The nurse should tell the parents to:

A. Apply topical anesthetics with each diaper change.
B. Expect a yellowish exudate to cover the glans after the first 24 hours.
C. Change the diaper every 2 hours and cleanse the site with soap and water or baby wipes.
D. Apply constant pressure to the site if bleeding occurs and call the physician.

B. Expect a yellowish exudate to cover the glans after the first 24 hours.

Topical anesthetics are applied before the circumcision. Infant-comforting techniques are generally sufficient following the procedure. Parents should be taught that a yellow exudate will develop over the glans and should not be removed. The diaper is changed frequently, but the site is cleansed with warm water only because soap and baby wipes can cause pain/burning and irritation at the site. Intermittent pressure is applied if bleeding occurs.

5. When placing a newborn under a radiant heat warmer to stabilize temperature after birth, the nurse should:

A. Place the thermistor probe on left side of the chest.
B. Cover probe with a nonreflective material.
C. Recheck temperature by periodically taking a rectal temperature.
D. Prewarm the radiant heat warmer and place the undressed newborn under it.

D. Prewarm the radiant heat warmer and place the undressed newborn under it.

The thermistor probe should be placed on the upper abdomen away from the ribs. The probe should be covered with reflective material. Rectal temperatures should be avoided because rectal thermometers can perforate the intestine, and the temperature may remain normal until cold stress is advanced. The radiant warmer should be prewarmed so the infant does not experience more cold stress.

6. With regard to umbilical cord care, nurses should be aware that:

A. The stump can easily become infected.
B. A nurse noting bleeding from the vessels of the cord should immediately call for assistance.
C. The cord clamp is removed at cord separation.
D. The average cord separation time is 5 to 7 days.

A. The stump can easily become infected.

The cord stump is an excellent medium for bacterial growth. The nurse should first check the clamp (or tie) and apply a second one. If the bleeding does not stop, then the nurse calls for assistance. The cord clamp is removed after 24 hours when it is dry. The average cord separation time is 10 to 14 days.

7. During the complete physical examination 24 hours after birth:

A. The parents are excused from the room to reduce their normal anxiety.
B. The nurse can gauge the neonate’s maturity level by assessing its general appearance.
C. Once often neglected, blood pressure is now routinely checked.
D. When the nurse listens to the heart, the S1 and S2 sounds can be heard; the first sound is somewhat higher in pitch and sharper than the second.

B. The nurse can gauge the neonate’s maturity level by assessing its general appearance.

Having the parents present during the examination actively involves them in child care and gives the nurse a chance to observe interactions. The nurse is able to gauge maturity level by assessing appearance. The nurse will be looking at skin color, alertness, cry, head size, and other features. Blood pressure is not usually taken unless cardiac problems are suspected. The second heart sound is higher and sharper than the first.

8. With regard to laboratory tests and diagnostic tests performed in the hospital after birth, nurses should be aware that:

A. All states test for phenylketonuria (PKU), hypothyroidism, cystic fibrosis, and sickle cell diseases.
B. Federal law prohibits newborn genetic testing without parental consent.
C. If genetic screening is done before the infant is 24 hours old, it should be repeated at age 1 to 2 weeks.
D. Hearing screening is now mandated by federal law.

C. If genetic screening is done before the infant is 24 hours old, it should be repeated at age 1 to 2 weeks.

All states test for PKU and hypothyroidism, but other genetic defects are not universally covered. Federal law mandates newborn genetic screening, but not screening for hearing problems (although more than half the states do mandate hearing screening). If done very early, genetic screening should be repeated. Federal law mandates newborn genetic screening, but not screening for hearing problems (although more than half the states do mandate hearing screening).

9. The nurse is performing a blood glucose test every 4 hours on an infant born to a diabetic mother. This is to assess the infant’s risk of hypoglycemia. The nurse becomes concerned if the infant’s blood glucose concentration falls below _________ mg/dl.

36 mg/dL

If the newborn has a blood glucose level below 36 mg/dl, intervention such as breatfeeding or bottle-feeding should be instituted. If levels remain low after this intervention, an intravenous infusion with dextrose may be warranted.

Chapter 18: Newborn Nutrition and Feeding
colostrum
Early milk, produced from approximately 16 weeks of pregnancy into the first postpartum days; rich in antibodies, higher in protein, and lower in fat than mature milk, with laxative effect to clear meconium and promote excretion of bilirubin
demand feeding
Feeding in response to feeding cues exhibited by the infant that indicate the presence of hunger
engorgement
Painful swelling of breast tissue as a result of rapid increase in milk production and venous congestion causing interstitial tissue edema; impaired milk flow results in accumulation of milk in breasts; most often occurs between the third and fifth postpartum days
feeding-readiness cues
Infant behaviors (mouthing motions, sucking fist, awakening, and crying) indicating that the infant is interested in feeding
growth spurts
Times of increased neonatal growth that usually occur at approximately 6 to 10 days, 6 weeks, 3 months, and 6 months; increased caloric needs of the infant prompt more frequent feedings
inverted nipples
Nipples invert rather than evert when stimulated; may interfere with effective latch
lactation consultant
Health care professional who has specialized training and experience working with breastfeeding mothers and infants
lactogenesis
Process of breast milk production
latch
Placement of the infant’s mouth over the nipple, areola, and breast, making a seal between the mouth and breast to create adequate suction for milk removal
mastitis
Inflammation of the breast, often associated with infection, characterized by influenza-like symptoms and redness and tenderness in the affected breast
milk ejection reflex (MER)
Release of milk caused by the contraction of the myoepithelial cells surrounding the milk glands in response to oxytocin; also called the let-down reflex
plugged milk duct
Blockage of milk duct causing ineffective emptying of breast
rooting reflex
Normal response of the newborn to move toward whatever touches the area around the mouth and to attempt to suck; usually disappears by 3 to 4 months of age
supply-meets-demand system
Physiologic basis for milk production; milk volume is produced in response to amount removed from the breast
• The American Academy of Pediatrics (AAP) recommends breast milk only for the first 6 months of life and breast milk as the only source of milk for the second 6 months.
• Breast milk provides immunologic protection against infections and diseases.
• The benefits of breast milk continue after weaning and extend beyond childhood.
• During the prenatal period, expectant parents should be taught the benefits of breastfeeding for infants, mothers, families, and society.
• Breastfeeding beliefs and practices vary across cultures.
• Milk production is a supply-meets-demand system; as the baby removes milk from the breast, more milk is produced.
• Prolactin and oxytocin are called the mothering hormones because they affect the mother’s emotions as well as her physical state.
• The composition of breast milk changes with each stage of lactation, during each feeding, and as the infant grows.
• Feeding-readiness cues include hand-to-mouth or hand-to-hand movements, sucking motions, the rooting reflex, and mouthing.
• The four basic positions for breastfeeding are the football or clutch-hold, cradle, modified cradle or across-the-lap, and side-lying positions.
• As the baby begins sucking on the nipple, the milk ejection, or let-down, reflex is stimulated.
• Newborns need to breastfeed 8 to 12 times a day.
• Initially, preterm milk contains higher concentrations of energy, fat, protein, sodium, chloride, potassium, iron, and magnesium than term milk.
• Depending on gestational age and physical condition, many preterm infants can breastfeed for some of their daily feedings.
• Mothers commonly use breast milk expression to obtain breast milk that someone else can feed to the baby.
• Engorgement typically occurs 3 to 5 days after birth and lasts about 24 hours.
• The nurse should teach inexperienced parents who are using formula feedings about the types of formulas, formula preparation, and correct feeding technique.
• The four main categories of infant formulas are cow’s milk-based formulas, soy-based formulas, casein- or whey-hydrolysate formulas, and amino-acid formulas.
• The infant’s individual growth pattern helps determine the right time to start solid foods.
Critical Thinking/Clinical Decision Making
Breastfeeding: Engorgement and Nipple SorenessMary was discharged from the birthing center at 48 hours postpartum with her newborn son, Matthew. He is now 4 days of age, and she has brought him to the clinic for a follow-up visit. Mary states that her milk came in yesterday, and her breasts have been hard and painful ever since. Latching the baby on has been difficult. She reports that breastfeeding is very painful and that her nipples are cracked and so sore that she “can hardly stand to feed the baby.” Matthew has had only one wet diaper and no bowel movements in the last 24 hours. He is crying most of the time and never seems to settle down to sleep for very long. Mary states, “I am ready to give up on this breastfeeding thing and just switch to formula.”

1. Evidence—Does the nurse have sufficient evidence at this time to draw conclusions about the feeding difficulties experienced by this mother and infant?
Mary is experiencing a crisis that involves physical discomfort from engorged breasts and sore nipples, physical exhaustion from the demands of a fussy infant who is not sleeping well, frustration in being unable to successfully latch her baby on and provide milk to satisfy him, such that she is questioning her commitment to breastfeeding and considering formula for her infant.
2. Assumptions—What assumptions can be made about the following issues?
a. Mary’s milk supply
b. Mary’s sore nipples
c. Matthew’s urinary output and bowel elimination pattern
d. Mary’s commitment to breastfeeding
Assumptions.
a. This mother has experienced the onset of mature milk production at the expected time, approximately 3 days after birth. Her breasts are engorged, the tissues surrounding the milk glands and milk ducts are edematous, and the milk is not flowing well from the breasts because of the compression of the milk ducts. She is producing mature milk, but has a problem with milk transfer to the baby.
b. The sore nipples are likely to be the result of a problem with latching the baby onto the breast. This most likely began during the first 2 days after birth and has grown more severe with the increased pressure in the breasts because of fullness, which tends to flatten the nipple and make it more difficult for the baby to latch on. She is experiencing pain with latch-on, which can inhibit her milk ejection or let-down reflex.
c. The urinary output and number of stools are signs that the baby has not received sufficient feeding. After the milk has come in, from about the fourth day of life, the baby should have at least six to eight wet diapers and at least three or four bowel movements every 24 hours. His fussiness and lack of sleep are evidence that he is not being satisfied when he nurses; he is hungry and needs more milk to feel satiated.
d. Mary’s frustration, fatigue, and mental exhaustion are causing her to question her desire to breastfeed. She is tired and her breasts are painful. The discomfort intensifies when the baby tries to breastfeed on the very sore nipples. She may be wondering whether breastfeeding is worth all this.
3. What implications and priorities for nursing care can be identified at this time?

The major priority at this time is to feed the baby. He is at risk of becoming dehydrated because of inadequate intake. If the engorgement can be treated quickly, he may be able to breastfeed. Otherwise, he needs to be fed some infant formula via syringe or slow flow bottle until she can express milk or get him to nurse. Mary needs help with her engorgement; ice packs can be applied to the breasts for 20 minutes to help reduce the tissue swelling. She can also take an antiinflammatory medication such as ibuprofen. After the ice is applied, Mary can use a hospital-grade electric breast pump to try to express milk to begin softening the breasts. Even with the pumping of just a half ounce or so, the nipples may soften enough for the baby to latch on and continue softening the breasts. Ideally, the infant will latch on and the milk will flow sufficiently to provide him with enough milk to feel satisfied and to allow Mary’s breasts to feel more comfortable. If the ice and pumping do not result in milk flow, cabbage leaves may be used on the breasts for 20 minutes, followed by pumping. The cracked, sore nipples need to be treated. Hydrogel pads can be applied after feeding or pumping. If the nipples are too uncomfortable for the baby to nurse, Mary may pump her breasts with an electric breast pump for 24 hours to allow the nipples some time to begin healing; the expressed breast milk can be syringe fed or fed with a slow flow nipple or bottle. As the nipples improve, the baby can be gradually reintroduced to the breast, with a nurse or lactation consultant assisting Mary with proper latch-on technique.

Mary needs emotional support at this time. The nurse can provide her an opportunity to express her frustrations and concerns. It is important that Mary is aware that what she is experiencing is not uncommon; the breasts of many women become engorged. It is a temporary condition, usually lasting no more than 24 to 48 hours. She may be feeling as if she is failing as a mother. Empathetic concern from the nurse can help to boost Mary’s self-esteem and increase her confidence as a mother.

4. Does the evidence objectively support your conclusion?
Yes, according to the American Academy of Pediatrics (AAP) (2005) guidelines for breastfeeding, the infant is not receiving adequate feedings. Mary is experiencing primary engorgement, a common problem that is temporary and should resolve with appropriate interventions.
5. Do alternative perspectives to your conclusion exist?
Mary could have a history of breast surgery, in which case the milk ducts may have been severed, and there is no outlet for the milk to be emptied from the breasts. The baby may be the source of the latch problem because of some physical characteristic such as a tight frenulum (“tongue-tied”). The baby needs to be assessed to determine whether there are factors that may inhibit successful latch-on. In addition, Mary may be lacking in her commitment to breastfeed and may be looking for an excuse to stop. In her mind, the difficulties she is experiencing may provide her with enough reason to switch to formula.

1. The birth weight of a breastfed newborn was 8 pounds, 4 ounces. On the third day the newborn’s weight was 7 pounds, 12 ounces. On the basis of this finding, the nurse should:

A. Encourage the mother to continue breastfeeding because it is effective in meeting the newborn’s nutrient and fluid needs.
B. Suggest that the mother switch to bottle-feeding because the breastfeeding is ineffective in meeting the newborn’s needs for fluid and nutrients.
C. Notify the physician because the newborn is being poorly nourished.
D. Refer the mother to a lactation consultant to improve her breastfeeding technique.

A. Encourage the mother to continue breastfeeding because it is effective in meeting the newborn’s nutrient and fluid needs.

Weight loss of 8 ounces falls within the 5% to 10% expected weight loss from birth weight during the first few days of life, which for this newborn would be 6.6 to 13.2 ounces. Breastfeeding is effective at this time. Breastfeeding is effective, and bottle-feeding does not need to be initiated at this time. The infant is not undernourished, and the physician does not need to be notified. The weight loss is within normal limits; breastfeeding is effective.

2. Which action of a breastfeeding mother indicates the need for further instruction?

A. Holds breast with four fingers along bottom and thumb at top
B. Leans forward to bring breast toward the baby
C. Stimulates the rooting reflex and then inserts nipple and areola into newborn’s open mouth
D. Puts her finger into newborn’s mouth before removing breast

B. Leans forward to bring breast toward the baby

Holding the breast with four fingers along the bottom and the thumb at top is a correct technique. To maintain a comfortable, relaxed position, the mother should bring the baby to the breast, not the breast to the baby. The mother would need further demonstration and teaching to correct the ineffective action. Stimulating the rooting reflex is correct technique. Placing the finger in the mouth to remove the baby from the breast is correct technique.

3. The nurse taught new parents the guidelines to follow regarding the bottle feeding of their newborn. They will be using formula from a can of concentrate. The parents would demonstrate an understanding of the nurse’s instructions if they:

A. Wash the top of the can and the can opener with soap and water before opening the can.
B. Adjust the amount of water added according to weight gain pattern of the newborn.
C. Add some honey to sweeten the formula and make it more appealing to a fussy newborn.
D. Warm formula in a microwave oven for a couple of minutes prior to feeding.

A. Wash the top of the can and the can opener with soap and water before opening the can.

Washing the top of the can and the can opener with soap and water before opening the can of formula is a good habit for parents to get into to prevent contamination of the formula. Directions on the can for dilution should be followed exactly and not adjusted according to weight gain to prevent nutritional and fluid imbalances. Honey is not necessary and could contain botulism spores. The formula should be warmed in a container of hot water because a microwave can easily overheat it or heat it unevenly.

4. Benefits to the mother associated with breastfeeding include all except it:

A. Decreases risk of breast cancer.
B. Is an effective method of birth control.
C. Increases bone density.
D. May enhance postpartum weight loss.

B. Is an effective method of birth control.

Women who breastfeed have a decreased risk of breast cancer. Breastfeeding delays the return of fertility, but it is NOT an effective birth control method. Women who breastfeed display an increase in bone density. Women who breastfeed report a quicker weight loss postpartum.

5. With regard to the special qualities of human breast milk, nurses should be aware that:

A. Frequent feedings during predictable growth spurts stimulate increased milk production.
B. The milk of preterm mothers is the same as the milk of mothers who gave birth at term.
C. The milk at the beginning of the feeding is the same as the milk at the end of the feeding.
D. Colostrum is an early, less concentrated, less rich version of mature milk.

A. Frequent feedings during predictable growth spurts stimulate increased milk production.

Growth spurts (at 10 days, 3 weeks, 6 weeks, 3 months) usually last 24 to 48 hours, after which infants resume normal feeding and milk production returns to previous production level. The milk of mothers of preterm infants is different from that of mothers of full-term infants, which is necessary to meet the needs of these newborns. The composition of milk changes during feeding. The fat content of the milk increases as the infant feeds. Colostrum precedes mature milk and is more concentrated and richer in proteins and minerals (but not fat).

6. Nurses should be able to tell breastfeeding mothers that all of the following are signs that the infant has latched on correctly to her breast except:

A. She feels a firm tugging sensation on her nipples but not pinching or pain.
B. The baby sucks with cheeks rounded, not dimpled.
C. The baby’s jaw glides smoothly with sucking.
D. She hears a clicking or smacking sound when the infant feeds.

D. She hears a clicking or smacking sound when the infant feeds.

The tugging sensation without pinching is a good sign. The clicking or smacking sound may indicate that the baby is having difficulty keeping the tongue out over the lower gum ridge. The mother should hope to hear the sound of swallowing. Rounded cheeks are a good sign. The clicking or smacking sound may indicate that the baby is having difficulty keeping the tongue out over the lower gum ridge. The mother should hope to hear the sound of swallowing. A smoothly gliding jaw is a good sign. The clicking or smacking sound may indicate that the baby is having difficulty keeping the tongue out over the lower gum ridge. The mother should hope to hear the sound of swallowing. The clicking or smacking sound may indicate that the baby is having difficulty keeping the tongue out over the lower gum ridge. The mother should hope to hear the sound of swallowing.

7. With regard to basic care of the breastfeeding mother, nurses should be able to advise her that she:

A. Will need an extra 1000 calories a day to maintain energy and produce milk.
B. Can go back to prepregnancy consumption patterns of any drinks as long as she gets enough calcium.
C. Should avoid trying to lose large amounts of weight.
D. Must avoid exercising because it is too fatiguing.

C. Should avoid trying to lose large amounts of weight.

A breastfeeding mother need add only 200 to 500 extra calories to her diet to provide extra nutrients for the infant. This is true only if she doesn’t drink alcohol, limits coffee to no more than two cups (caffeine is also found in chocolate, tea, and some sodas), and reads the herbal tea ingredients carefully. Large weight loss would release fat-stored contaminants into her breast milk. It would also likely involve eating too little and/or exercising too much. She needs her rest, but moderate exercise is healthy.

8. Examples of appropriate techniques to wake a sleepy infant for breastfeeding include (choose all that apply):

A. Unwrapping the infant.
B. Changing the diaper.
C. Talking to the infant.
D. Slapping the infant’s hands and feet.
E. Applying a cold towel to the infant’s abdomen.

A. Unwrapping the infant.
B. Changing the diaper.
C. Talking to the infant.Unwrapping the infant is an appropriate technique to use when trying to wake a sleepy infant. Changing the diaper is an appropriate technique to use when trying to wake a sleepy infant. Talking to the infant is an appropriate technique to use when trying to wake a sleepy infant. Slapping an infant’s hands and feet is not appropriate. The parent can gently rub the infant’s hands or feet to wake the infant. Applying a cold towel to the infant’s abdomen may lead to cold stress in the infant. The parent may want to apply a cool cloth to the infant’s face to wake the infant.

– epidurals:

fluid bolus before 1000ccs, monitor BP (vasodilation), decreased O2 to baby. positioning: fetal position.

Epidural anesthesia or analgesia (block)

Relief from the pain of uterine contractions and birth (vaginal and cesarean) can be relieved by injecting a suitable local anesthetic agent (e.g., bupivacaine, ropivacaine), an opioid analgesic (e.g., fentanyl, sufentanil), or both into the epidural (peridural) space. Injection is made between the fourth and fifth lumbar vertebrae for a lumbar epidural block (see Figs. 10-8, B, and 10-10, A). Depending on the type, amount, and number of medications used, an anesthetic or analgesic effect will occur with varying degrees of motor impairment. The combination of an opioid with the local anesthetic agent reduces the dose of anesthetic required, thereby preserving a greater degree of motor function.

Epidural anesthesia and analgesia is the most effective pharmacologic pain-relief method for labor that is currently available. As a result, it is the most commonly used method for relieving pain during labor in the United States and its use has been increasing. Nearly two thirds of American women giving birth choose epidural analgesia (AAP & ACOG, 2007; Bucklin et al., 2005; Hawkins et al., 2007). For relieving the discomfort of labor and vaginal birth, a block from T10 to S5 is required. For cesarean birth, a block from at least T8 to S1 is essential. The diffusion of epidural anesthesia depends on the location of the catheter tip, the dose and volume of the anesthetic agent used, and the woman’s position (e.g., horizontal or head-up position). The woman must cooperate and maintain her position without moving during insertion of the epidural catheter so as to prevent misplacement, neurologic injury, or hematoma formation (Cunningham et al., 2005).

NURSING ALERT

Epidural anesthesia effectively relieves the pain caused by uterine contractions. For most women, however, it does not completely remove the pressure sensations that occur as the fetus descends in the pelvis.

For the induction of an epidural block, the woman is positioned as for a spinal block. She may sit with her back curved or she may assume a modified Sims position with her shoulders parallel, legs slightly flexed, and back arched (see Fig. 10-11). A large-bore needle is inserted into the epidural space. A catheter is then threaded through the needle until its tip rests in the epidural space. Then the needle is removed and the catheter is taped in place. After the epidural catheter is inserted, a small amount of medication, called a test dose, is injected to be sure that the catheter has not been accidentally placed in the subarachnoid (spinal) space or in a blood vessel (Hawkins et al., 2007).

After the epidural has been initiated the woman is positioned preferably on her side so that the uterus does not compress the ascending vena cava and descending aorta, which can impair venous return, reduce cardiac output and blood pressure, and decrease placental perfusion. Her position should be alternated from side to side every hour. Upright positions and ambulation may be possible, depending on the degree of motor impairment. Oxygen should be available if hypotension occurs despite maintenance of hydration with IV fluid and displacement of the uterus to the side. Ephedrine or phenylephrine (vasopressors used to increase maternal blood pressure) and increased IV fluid infusion may be needed (see Emergency box). The FHR, contraction pattern, and progress in labor must be monitored carefully because the woman may not be aware of changes in the strength of the uterine contractions or the descent of the presenting part.

Several methods can be used for an epidural block. An intermittent block is achieved by using repeated injections of anesthetic solution; it is the least common method. The most common method is the continuous block, achieved by using a pump to infuse the anesthetic solution through an indwelling plastic catheter. Patient-controlled epidural analgesia (PCEA) is the newest method; it uses an indwelling catheter and a programmed pump that allows the woman to control the dosing. This method has been found to provide optimal analgesia with better maternal satisfaction during labor while decreasing the amount of local anesthetic used (Saito et al., 2005).

The advantages of an epidural block are numerous: The woman remains alert and is more comfortable and able to participate, good relaxation is achieved, airway reflexes remain intact, only partial motor paralysis develops, gastric emptying is not delayed, and blood loss is not excessive. Fetal complications are rare but may occur in the event of rapid absorption of the medication or marked maternal hypotension. The dose, volume, type, and number of medications used can be modified to allow the woman to push and to assume upright positions and even to walk, to produce perineal anesthesia, and to permit forceps-assisted, vacuum-assisted, or cesarean birth if required (Cunningham et al., 2005).

The disadvantages of epidural block also are numerous. The woman’s ability to move freely and to maintain control of her labor is limited, related to the use of numerous medical interventions (e.g., an IV infusion and electronic monitoring) and the occurrence of orthostatic hypotension and dizziness, sedation, and weakness of the legs. CNS effects (Box 10-4) can occur if a solution containing a local anesthetic agent is accidentally injected into a blood vessel or if excessive amounts of local anesthetic are given. High spinal or “total spinal” anesthesia, resulting in respiratory arrest, can occur if the relatively high dose of local anesthetic used with an epidural block is accidentally injected into the subarachnoid space. Women who receive an epidural have a higher rate of fever (i.e., intrapartum temperature of 38° C or higher), especially when labor lasts longer that 12 hours; the temperature elevation most likely is related to thermoregulatory changes, although infection cannot be ruled out. The elevation in temperature can result in fetal tachycardia and neonatal workup for sepsis, whether or not signs of infection are present (see Box 10-4).

Severe hypotension (more than a 20% decrease in baseline blood pressure) as a result of sympathetic blockade can be an outcome of an epidural block (Anim-Somuah, Smyth, & Howell, 2005) (see Emergency box). It can result in a significant decrease in uteroplacental perfusion and oxygen delivery to the fetus. Urinary retention and stress incontinence can occur in the immediate postpartum period. Pruritus (itching) is a side effect that often occurs with the use of an opioid, especially fentanyl. A relationship between epidural analgesia and longer second-stage labor, use of oxytocin, and forceps-assisted or vacuum-assisted birth has been documented. Research findings have been unable to demonstrate a significant increase in cesarean birth associated with epidural analgesia (Anim-Somuah et al.). For some women, the epidural block is not effective, and a second form of analgesia is required to establish effective pain relief. When women progress rapidly in labor, pain relief may not be obtained before birth occurs.

BOX 10-4 Side Effects of Epidural and Spinal Anesthesia

• Hypotension
• Local anesthetic toxicity
• Light-headedness
• Dizziness
• Tinnitus (ringing in the ears)
• Metallic taste
• Numbness of the tongue and mouth
• Bizarre behavior
• Slurred speech
• Convulsions
• Loss of consciousness
• High or total spinal anesthesia
• Fever
• Urinary retention
• Pruritus (itching)
• Limited movement
• Longer second stage labor
• Increased use of oxytocin
• Increased likelihood of forceps- or vacuum-assisted birth

Combined spinal-epidural analgesia
In the combined spinal-epidural (CSE) analgesia technique, sometimes called a “walking epidural,” an epidural needle is inserted into the epidural space. Before the epidural catheter is placed, a smaller-gauge spinal needle is inserted through the bore of the epidural needle into the subarachnoid space. A small amount of opioid or combination of opioid and local anesthetic is then injected intrathecally to provide analgesia rapidly. Afterward the epidural catheter is inserted as usual. The CSE technique is an increasingly popular approach that can be used to block pain transmission without compromising motor ability. The concentration of opioid receptors is high along the pain pathway in the spinal cord, in the brainstem, and in the thalamus. Because these receptors are highly sensitive to opioids, a small quantity of an opioid-agonist analgesic produces marked pain relief lasting for several hours. If additional pain relief is needed, medication can be injected through the epidural catheter (see Fig. 10-10, A). The most common side effects of CSE are pruritus and nausea (Hawkins et al., 2007). CSE analgesia may also be associated with fetal bradycardia, necessitating close assessment of fetal heart rate (Cunningham et al., 2005).

Although women can walk, they often choose not to do so because of sedation and fatigue, abnormal sensations perceived in their legs, weakness of the legs, and a feeling of insecurity. Health care providers are often reluctant to encourage or assist women to ambulate for fear of injury. However, women can be assisted to change positions and use upright positions during labor and birth. Upright positioning is associated with less pain, more efficient labor progress, and a lower incidence of forceps- or vacuum-assisted birth (Albers, 2007; Berghella et al., 2008). Laboring upright also conveys a sense of normalcy, autonomy, and personal control (Albers).

Epidural and intrathecal (spinal) opioids
Opioids also can be used alone, eliminating the effect of a local anesthetic altogether. The use of epidural or intrathecal opioids without the addition of a local anesthetic agent during labor has several advantages. Opioids administered in this manner do not cause maternal hypotension or affect vital signs. The woman feels contractions but not pain. Her ability to bear down during the second stage of labor is preserved because the pushing reflex is not lost, and her motor power remains intact.

Fentanyl, sufentanil, or preservative-free morphine may be used. Fentanyl and sufentanil produce short-acting analgesia (i.e., 1.5 to 3.5 hours), and morphine may provide pain relief for 4 to 7 hours. Morphine may be combined with fentanyl or sufentanil. Using short-acting opioids with multiparous women and morphine with nulliparous women or women with a history of long labor would be appropriate. For most women, intrathecal opioids do not provide adequate analgesia for second-stage labor pain, episiotomy, or birth (Cunningham et al., 2005). Pudendal nerve blocks or local perineal infiltration anesthesia may be necessary.

A more common indication for the administration of epidural or intrathecal analgesics is the relief of postoperative pain. For example, women who give birth by cesarean can receive fentanyl or morphine through a catheter. The catheter may then be removed, and the women are usually free of pain for 24 hours. The catheter is occasionally left in place in the epidural space in case another dose is needed.

Women receiving epidurally administered morphine after a cesarean birth may ambulate sooner than women who do not. The early ambulation and freedom from pain also facilitate bladder emptying, enhance peristalsis, and prevent clot formation in the lower extremities (e.g., thrombophlebitis). Women may require additional medication for pain during the first 24 hours after surgery. If so, they will usually be given oral analgesics (e.g., oxycodone/acetaminophen [Percocet]), rather than IV or IM narcotics.

Side effects of opioids administered by the epidural and intrathecal routes include nausea, vomiting, pruritus, urinary retention, and delayed respiratory depression. These side effects are more common when morphine is administered. Antiemetics, antipruritics, and opioid antagonists are used to relieve these symptoms. For example, naloxone (Narcan), nalbuphine (Nubain), or metoclopramide (Reglan) may be administered. Hospital protocols or detailed physician orders should provide specific instructions for the treatment of these side effects. Use of epidural opioids is not without risk. Respiratory depression is a serious concern; for this reason the woman’s respiratory rate should be assessed and documented every hour for 24 hours, or as designated by hospital protocol. Naloxone should be readily available for use if the respiratory rate decreases to less than 10 breaths per minute or if the oxygen saturation rate decreases to less than 89%. Administration of oxygen by facemask also may be initiated, and the anesthesia care provider should be notified.

Contraindications to epidural blocks
Some contraindications to epidural analgesia include the following (Cunningham et al., 2005; Hawkins et al., 2007):
• Active or anticipated serious maternal hemorrhage (Acute hypovolemia leads to increased sympathetic tone to maintain the blood pressure. Any anesthetic technique that blocks the sympathetic fibers can produce significant hypotension that can endanger the mother and baby.)
• Coagulopathy (If a woman is receiving anticoagulant therapy or has a bleeding disorder, injury to a blood vessel may cause the formation of a hematoma that may compress the cauda equina or the spinal cord and lead to serious CNS complications.)
• Infection at the injection site (Infection can be spread through the peridural or subarachnoid spaces if the needle traverses an infected area.)
• Increased intracranial pressure caused by a mass lesion.
• Maternal refusal.
• Some types of maternal cardiac conditions.

Epidural block effects on the neonate
Analgesia or anesthesia during labor and birth has little or no lasting effect on the physiologic status of the neonate. Currently, no evidence has been found that the administration of analgesia or anesthesia during labor and birth has a significant effect on the child’s later mental and neurologic development (AAP & ACOG, 2007).

– pain: individualized response. culturally expressive. visceral and somatic pain.

DISCOMFORT DURING LABOR AND BIRTH

Neurologic Origins
The pain and discomfort of labor have two origins, visceral and somatic. During the first stage of labor, uterine contractions cause cervical dilation and effacement. Uterine ischemia (decreased blood flow and therefore local oxygen deficit) results from compression of the arteries supplying the myometrium during uterine contractions. Pain impulses during the first stage of labor are transmitted via the T-1 to T-12 spinal nerve segment and accessory lower thoracic and upper lumbar sympathetic nerves. These nerves originate in the uterine body and cervix (Blackburn, 2007).

The pain from cervical changes, distention of the lower uterine segment, stretching of cervical tissue as it dilates, and pressure on adjacent structures and nerves during the first stage of labor is visceral pain. It is located over the lower portion of the abdomen. Referred pain occurs when the pain that originates in the uterus radiates to the abdominal wall, lumbosacral area of the back, iliac crests, gluteal area, thighs, and lower back (Blackburn, 2007; Zwelling et al., 2006).

During the second stage of labor the woman has somatic pain, which is often described as intense, sharp, burning, and well localized. Pain results from stretching and distention of perineal tissues and the pelvic floor to allow passage of the fetus, from distention and traction on the peritoneum and uterocervical supports during contractions, and from lacerations of soft tissue (e.g., cervix, vagina, perineum). Other physical factors related to pain during second stage labor include fetal position, rapidity of fetal descent, maternal position, interval and duration of contractions, and fatigue (Zwelling et al., 2006). Pain impulses during the second stage of labor are transmitted via the pudendal nerve through S2 to S4 spinal nerve segments and the parasympathetic system (Blackburn, 2007).

Pain experienced during the third stage of labor and the afterpains of the early postpartum period are uterine, similar to the pain experienced early in the first stage of labor. Areas of discomfort during labor are shown in Fig. 10-1.

Perception of Pain
Although the pain threshold is remarkably similar in all persons regardless of gender, social, ethnic, or cultural differences, these differences play a definite role in the person’s perception of and behavioral responses to pain. The effects of factors such as culture, counterstimuli, and distraction in coping with pain are not fully understood. The meaning of pain and the verbal and nonverbal expressions given to pain are apparently learned from interactions within the primary social group. Cultural influences impose certain behavioral expectations regarding acceptable and unacceptable behavior when experiencing pain.

Expression of Pain
Pain results in physiologic effects and sensory and emotional (affective) responses. During childbirth, pain gives rise to identifiable physiologic effects. Sympathetic nervous system activity is stimulated in response to intensifying pain, resulting in increased catecholamine levels. Blood pressure and heart rate increase. Maternal respiratory patterns change in response to an increase in oxygen consumption. Hyperventilation, sometimes accompanied by respiratory alkalosis, can occur as pain intensifies. Pallor and diaphoresis may be seen. Gastric acidity increases, and nausea and vomiting are common in the active phase of labor. Placental perfusion may decrease, and uterine activity may diminish, potentially prolonging labor and affecting fetal well-being.

Certain emotional (affective) expressions of pain are often seen. Such changes include increasing anxiety with lessened perceptual field, writhing, crying, groaning, gesturing (hand clenching and wringing), and excessive muscular excitability throughout the body.

Factors Influencing Pain Response
Pain during childbirth is unique to each woman. How she perceives or interprets that pain is influenced by a variety of physical, emotional, psychosocial, cultural, and environmental factors (Zwelling et al., 2006).

Physiologic factors
A variety of physiologic factors can affect the intensity of pain that women experience during childbirth. Women with a history of dysmenorrhea may experience increased pain during childbirth as a result of higher prostaglandin levels. Back pain associated with menstruation also may increase the likelihood of contraction-related low back pain. Other physical factors include fatigue, the interval and duration of contractions, fetal position, rapidity of fetal descent, and maternal position (Zwelling et al., 2006).

Endorphins are endogenous opioids secreted by the pituitary gland that act on the central and peripheral nervous systems to reduce pain. Beta-endorphin is the most potent of the endorphins. Endorphin levels increase during pregnancy and birth in humans. Endorphins are associated with feelings of euphoria and analgesia. Increased endorphin levels may increase the pain threshold and enable women in labor to tolerate acute pain (Blackburn, 2007).

Culture
The obstetric population reflects the increasingly multicultural nature of U.S. society. As nurses care for women and families from a variety of cultural backgrounds, they must have knowledge and understanding of how culture mediates pain. Although all women expect to experience at least some pain and discomfort during childbirth, their culture and religious belief system determines how they will perceive, interpret, and respond to and manage the pain. For example, women with strong religious beliefs often accept pain as a necessary and inevitable part of bringing a new life into the world (Callister, Khalaf, Semenic, Kartchner, & Vehvilainen-Julkunen, 2003). An understanding of the beliefs, values, and practices of various cultures will narrow the cultural gap and help the nurse to assess the woman’s pain experience more accurately. The nurse can then provide appropriate culturally sensitive care by using pain-relief measures that preserve the woman’s sense of control and self-confidence (see Cultural Considerations box). Recognize that although a woman’s behavior in response to pain may vary according to her cultural background, it may not accurately reflect the intensity of the pain she is experiencing. Assess the woman for the physiologic effects of pain and listen to the words she uses to describe the sensory and affective qualities of her pain.

Cultural Considerations
Some Cultural Beliefs about Pain
The following examples demonstrate how women of different cultural backgrounds may react to pain. Because they are generalizations the nurse must assess each woman experiencing pain related to childbirth.
• Chinese women may not exhibit reactions to pain, although exhibiting pain during childbirth is acceptable. They consider accepting something when it is first offered as impolite; therefore pain interventions must be offered more than once. Acupuncture may be used for pain relief.
• Arab or Middle Eastern women may be vocal in response to labor pain. They may prefer medication for pain relief.
• Japanese women may be stoic in response to labor pain, but they may request medication when pain becomes severe.
• Southeast Asian women may endure severe pain before requesting relief.
• Hispanic women may be stoic until late in labor, when they may become vocal and request pain relief.
• Native American women may use medications or remedies made from indigenous plants. They are often stoic in response to labor pain.
• African-American women may express pain openly. Use of medication for pain relief varies.

Anxiety
Anxiety is commonly associated with increased pain during labor. Mild anxiety is considered normal for a woman during labor and birth. However, excessive anxiety and fear cause additional catecholamine secretion, which increases the stimuli to the brain from the pelvis because of decreased blood flow and increased muscle tension; this action, in turn, magnifies pain perception (Zwelling et al., 2006). Thus, as fear and anxiety heighten, muscle tension increases, the effectiveness of uterine contractions decreases, the experience of discomfort increases, and a cycle of increased fear and anxiety begins. Ultimately this cycle will slow the progress of labor. The woman’s confidence in her ability to cope with pain will be diminished, potentially resulting in reduced effectiveness of pain-relief measures being used.

Previous experience
Previous experience with pain and childbirth may affect a woman’s description of her pain and her ability to cope with the pain. Childbirth, for a healthy young woman, may be her first experience with significant pain, and as a result, she may not have developed effective pain-coping strategies. She may describe the intensity of even early labor pain as a “10” on a 10-point scale. The nature of previous childbirth experiences also may affect a woman’s responses to pain. For women who have had a difficult and painful previous birth experience, anxiety and fear from this past experience may lead to increased pain perception.

COMMUNITY ACTIVITY

Visit a birthing center and a high risk hospital labor and birth unit in your community. Compare the types of pain management used in each facility for laboring mothers, including both nonpharmacologic and pharmacologic methods. Describe how information about pain management is taught. Is the information culturally appropriate? If not, state how teaching might be improved.

Sensory pain for nulliparous women is often greater than that for multiparous women during early labor (dilation less than 5 cm) because their reproductive tract structures are less supple. During the transition phase of the first stage of labor and during the second stage of labor, multiparous women may experience greater sensory pain than nulliparous women because their more supple tissue increases the speed of fetal descent and thereby intensifies pain. The firmer tissue of nulliparous women results in a slower, more gradual descent. Affective pain is usually increased for nulliparous women throughout the first stage of labor but decreases for both nulliparous and multiparous women during the second stage of labor (Lowe, 2002).

Parity may affect perception of labor pain because nulliparous women often have longer labors and therefore greater fatigue. Because fatigue magnifies pain, the combination of increased pain, fatigue, and reduced ability to cope may lead to more use of pharmacologic support.

Gate-control theory of pain
Even particularly intense pain stimuli can, at times, be ignored. This phenomenon is possible because certain nerve cell groupings within the spinal cord, brainstem, and cerebral cortex have the ability to modulate the pain impulse through a blocking mechanism. This gate-control theory of pain helps explain the way hypnosis and the pain-relief techniques taught in childbirth preparation classes work to relieve the pain of labor. According to this theory, pain sensations travel along sensory nerve pathways to the brain, but only a limited number of sensations, or messages, can travel through these nerve pathways at one time. Using distraction techniques such as massage or stroking, music, focal points, and imagery reduces or completely blocks the capacity of nerve pathways to transmit pain. These distractions are thought to work by closing down a hypothetic gate in the spinal cord, thus preventing pain signals from reaching the brain. The perception of pain is thereby diminished.

In addition, when the laboring woman engages in neuromuscular and motor activity, activity within the spinal cord itself further modifies the transmission of pain. Cognitive work involving concentration on breathing and relaxation requires selective and directed cortical activity that activates and closes the gating mechanism as well. As labor intensifies, more complex cognitive techniques are required to maintain effectiveness. The gate-control theory underscores the need for a supportive birth setting that allows the laboring woman to relax and use various higher mental activities.

– positioning of fundus post partum: 2 fingerwidths above umbilicus, goes down every 24hrs

Uterus

Involution process
The return of the uterus to a nonpregnant state after birth is known as involution. This process begins immediately after expulsion of the placenta with contraction of the uterine smooth muscle.

At the end of the third stage of labor the uterus is in the midline, approximately 2 cm below the level of the umbilicus, with the fundus resting on the sacral promontory. At this time the uterus weighs approximately 1000 g.

Within 12 hours the fundus rises to the level of the umbilicus, or slightly above or below (Fig. 13-1). Thereafter the fundus descends approximately 1 cm every day. By 1 week after birth the fundus is located 4 to 5 fingerbreadths below the umbilicus. The uterus should not be palpable abdominally after 2 weeks and should have returned to its nonpregnant location by 6 weeks after birth (Blackburn, 2007).

The uterus, which at full term weighs approximately 11 times its prepregnancy weight, involutes to approximately 500 g by 1 week after birth and to 350 g by 2 weeks after birth. At 6 weeks, it weighs 60 to 80 g (see Fig. 13-1).

Increased estrogen and progesterone levels are responsible for stimulating the massive growth of the uterus during pregnancy. Prenatal uterine growth results from both hyperplasia, an increase in the number of muscle cells, and from hypertrophy, an enlargement of the existing cells. Postpartally, the decrease in these hormones causes autolysis, the self-destruction of excess hypertrophied tissue. The additional cells laid down during pregnancy remain, however, and account for the slight increase in uterine size after each pregnancy.

Subinvolution is the failure of the uterus to return to a nonpregnant state. The most common causes of subinvolution are retained placental fragments and infection (see Chapter 23).

– multipara mom is going to have greater pain than primipara

Afterpains

In first-time mothers, uterine tone is good, the fundus generally remains firm, and the mother usually perceives only mild uterine cramping. Periodic relaxation and vigorous contraction are more common in subsequent pregnancies and may cause uncomfortable cramping called afterpains (afterbirth pains) that persist throughout the early puerperium. Afterpains are more noticeable after births in which the uterus was overdistended (e.g., large baby, multifetal gestation, polyhydramnios). Breastfeeding and exogenous oxytocic medication usually intensify these afterpains because both stimulate uterine contractions.

– know all the lochias (rubra, serosa, alba) and duration

Lochia

Post-childbirth uterine discharge, commonly called lochia, is initially bright red (lochia rubra) and may contain small clots. For the first 2 hours after birth the amount of uterine discharge should be approximately that of a heavy menstrual period. After that time the lochial flow should steadily decrease.

Lochia rubra consists mainly of blood and decidual and trophoblastic debris. The flow pales, becoming pink or brown (lochia serosa) after 3 to 4 days. Lochia serosa consists of old blood, serum, leukocytes, and tissue debris. The median duration for lochia serosa discharge is 22 to 27 days (Katz, 2007). In most women, approximately 10 days after childbirth the drainage becomes yellow to white (lochia alba). Lochia alba consists primarily of leukocytes and decidual cells but also contains epithelial cells, mucus, serum, and bacteria. Lochia alba may last until 6 weeks after birth (Blackburn, 2007).

If the woman receives an oxytocic medication, the flow of lochia is often scant until the effects of the medication wear off. The amount of lochia is typically smaller after cesarean births. Flow of lochia usually increases with ambulation and breastfeeding. Lochia tends to pool in the vagina when the woman is lying in bed; on standing the woman may experience a gush of blood. This gush should not be confused with hemorrhage.

Persistence of lochia rubra early in the postpartum period suggests continued bleeding as a result of retained fragments of the placenta or membranes. Recurrence of bleeding approximately 7 to 14 days after birth is from the healing placental site. Approximately 10% to 15% of women will still be experiencing normal lochia serosa discharge at the 6-week postpartum examination (Katz, 2007). In the majority of women, however, a continued flow of lochia serosa or lochia alba by 3 to 4 weeks after birth may indicate endometritis, particularly if fever, pain, or abdominal tenderness is associated with the discharge. Lochia should smell similar to normal menstrual flow; an offensive odor usually indicates infection.

Not all postpartal vaginal bleeding is lochia; vaginal bleeding after birth may be a result of unrepaired vaginal or cervical lacerations. Table 13-1 distinguishes between lochial and nonlochial bleeding

TABLE 13-1 Lochial and Nonlochial Bleeding

LOCHIAL BLEEDING
– Lochia usually trickles from the vaginal opening. The steady flow increases as the uterus contracts.
– A gush of lochia may result as the uterus is massaged. If the lochia is dark in color, it has been pooled in the relaxed vagina, and the amount soon lessens to a trickle of bright red lochia (in the early puerperium).

NONLOCHIAL BLEEDING
– If the bloody discharge spurts from the vagina, damage to a blood vessel may have occurred during birth. If so, some of the bleeding is not just normal lochial flow.
– If the amount of bleeding continues to be excessive and bright red, a vaginal or cervical tear may be the source.

– diaphoresis during labor normal: releasing accumulated blood volume. normal to lose up to 2kg during labor.

Postpartal Diuresis

Within 12 hours of birth, women begin to lose excess tissue fluid accumulated during pregnancy. Profuse diaphoresis often occurs, especially at night, for the first 2 or 3 days after childbirth. Postpartal diuresis, caused by decreased estrogen levels, removal of increased venous pressure in the lower extremities, and loss of the remaining pregnancy-induced increase in blood volume, also aids the body in ridding itself of excess fluid. Fluid loss through perspiration and increased urinary output accounts for a weight loss of approximately 2.25 kg during the puerperium.

Profuse diaphoresis that occurs in the immediate postpartum period is the most noticeable change in the integumentary system.

– clotting factors increase during pregnancy. increased risk for DVT.
Coagulation factors
Clotting factors and fibrinogen are normally increased during pregnancy and remain elevated in the immediate puerperium. When combined with vessel damage and immobility, this hypercoagulable state causes an increased risk of thromboembolism, especially after a cesarean birth. Fibrinolytic activity also increases during the first 1 to 4 days after childbirth (Katz, 2007).Circulation and coagulation times
The circulation time decreases slightly by week 32. It returns to near normal by near term. The blood tends to coagulate (clot) during pregnancy because of increases in various clotting factors (factors VII, VIII, IX, X, and fibrinogen). This change, combined with the fact that fibrinolytic activity (the splitting up or the dissolving of a clot) is depressed during pregnancy and the postpartum period, provides a protective function to decrease the chance of bleeding, but it also makes the woman more vulnerable to thrombosis, especially after cesarean birth.

– when in doubt, massage the fundus
– care of episiotomy: ice packs, sitz baths
Episiotomy
An episiotomy is an incision made in the perineum to enlarge the vaginal outlet (Fig. 12-23). It is performed more commonly in the United States and Canada than in Europe. The side-lying position for birth, used routinely in Europe, reduces tension on the perineum, making possible a gradual stretching of the perineum with fewer indications for episiotomies. Different types of episiotomies are performed, depending on the site and direction of the incision (see Fig. 12-23). The type of episiotomy that provides the best outcome is unknown (Berghella et al., 2008). Midline (median) episiotomy is most commonly used in the United States. It is effective, easily repaired, and generally the least painful. However, midline episiotomies also are associated with an increased incidence of third- and fourth-degree lacerations. Sphincter tone is usually restored after primary healing and a good repair. Mediolateral episiotomy is used in operative births when the need for posterior extension is likely. Although a fourth-degree laceration can be prevented using this technique, a third-degree laceration may occur. The blood loss is also greater and the repair more difficult and painful than with midline episiotomies. It is also more painful in the postpartum period, and the pain lasts longer.Routine performance of episiotomies has declined in the United States since the 1990s. The practice in many settings now is to support the perineum manually during birth and allow the perineum to tear rather than perform an episiotomy. Tears are often smaller than an episiotomy, are repaired easily or not at all, and heal quickly. Routine use of episiotomy is associated with increased posterior perineal trauma, suturing and healing complications, and later pain with intercourse. Therefore episiotomy should be avoided if at all possible (Berghella et al., 2008).

When the third stage of labor has been completed the primary health care provider examines the woman for any perineal, vaginal, or cervical lacerations requiring repair. If an episiotomy was performed, it will be sutured. Immediate repair promotes healing, limits residual damage, and decreases the possibility of infection.

– bladder distention can affect fundus: boggy, bleed more. empty bladder
– s/s lactose intolerance: GI distress

One problem that can interfere with milk consumption is lactose intolerance, the inability to digest milk sugar (lactose) caused by the absence of the lactase enzyme in the small intestine. Lactose intolerance is relatively common in adults, particularly African-Americans, Asians, Native Americans, and Inuits. Milk consumption may cause abdominal cramping, bloating, and diarrhea in such people, although many lactose-intolerant individuals can tolerate small amounts of milk without symptoms. Yogurt, sweet acidophilus milk, buttermilk, cheese, chocolate milk, and cocoa may be tolerated even when fresh fluid milk is not. Commercial lactase supplements (e.g., Lactaid) are widely available to consume with milk. Many supermarkets stock lactase-treated milk. The lactase in these products hydrolyzes, or digests, the lactose in milk, thus enabling lactose-intolerant people to drink milk.

Women with lactose intolerance and those who do not include milk in their diet for any reason are at risk for vitamin D deficiency.

– high C2+ foods: small fish (sardines, anchovies), green leafy vegetables avoid high mercury fish,
Calcium
The DRI shows no increase of calcium during pregnancy and lactation, in comparison with the recommendation for the nonpregnant woman (see Table 8-1). The DRI appears to provide sufficient calcium for fetal bone and tooth development to proceed while maintaining maternal bone mass.Milk and yogurt are especially rich sources of calcium, providing approximately 300 mg per cup (240 ml). Nevertheless, many women do not consume these foods or do not consume adequate amounts to provide the recommended intakes of calcium. One problem that can interfere with milk consumption is lactose intolerance, the inability to digest milk sugar (lactose) caused by the absence of the lactase enzyme in the small intestine. Lactose intolerance is relatively common in adults, particularly African-Americans, Asians, Native Americans, and Inuits. Milk consumption may cause abdominal cramping, bloating, and diarrhea in such people, although many lactose-intolerant individuals can tolerate small amounts of milk without symptoms. Yogurt, sweet acidophilus milk, buttermilk, cheese, chocolate milk, and cocoa may be tolerated even when fresh fluid milk is not. Commercial lactase supplements (e.g., Lactaid) are widely available to consume with milk. Many supermarkets stock lactase-treated milk. The lactase in these products hydrolyzes, or digests, the lactose in milk, thus enabling lactose-intolerant people to drink milk.

BOX 8-4 Calcium Sources for Women Who Do Not Drink Milk

Each of the following food items provides approximately the same amount of calcium as 1 cup of milk.

FISH
• 3-oz can of sardines
• 4.5-oz can of salmon (if bones are eaten)

BEANS AND LEGUMES
• 3 cups cooked dried beans
• 2.5 cups refried beans
• 2 cups baked beans with molasses
• 1 cup tofu (calcium is added in processing)

GREENS
• 1 cup collards
• 1.5 cups kale or turnip greens

BAKED PRODUCTS
• 3 pieces cornbread
• 3 English muffins
• 4 slices French toast
• 2 waffles (7 inches in diameter)

FRUITS
• 11 dried figs
• 1.125 cups orange juice with calcium added

SAUCES
• 3 oz pesto sauce
• 5 oz cheese sauce

In some cultures, adults rarely drink milk. For example, Puerto Ricans and other Hispanic people may use milk only as an additive in coffee. Pregnant women from these cultures may need to consume nondairy sources of calcium. Vegetarian diets may also be deficient in calcium (Box 8-4). If calcium intake appears low and the woman does not change her dietary habits despite counseling, a daily supplement containing 600 mg of elemental calcium may be needed. Calcium supplements may also be recommended when a pregnant woman experiences leg cramps caused by an imbalance in the calcium/phosphorus ratio. Bone meal supplements are not recommended in pregnancy.

– breast engorgement: read in book. lymphatic
Engorgement
Engorgement is a common response of the breasts to the sudden change in hormones and the onset of significantly increased milk volume. It usually occurs 3 to 5 days after birth when the milk “comes in” and lasts approximately 24 hours. Blood supply to the breasts increases and causes swelling of tissues surrounding the milk ducts. The milk ducts may be pinched shut so that milk cannot flow from the breasts. The breasts are firm, tender, and hot and may appear shiny and taut. The areolae are firm, and the nipples may flatten, creating difficulty for the infant in latching on to the breast. Because back pressure on full milk glands inhibits milk production, if milk is not removed from the breasts, the milk supply may diminish.When engorgement occurs, it is a temporary condition that is usually resolved within 24 hours. The mother is instructed to feed every 2 hours, softening at least one breast, and pumping the other breast as needed to soften it. Pumping during engorgement will not cause a problematic increase in milk supply.

Because of the swelling of breast tissue surrounding the milk ducts, ice packs are recommended in a 15 to 20 minutes on, 45 minutes off rotation between feedings. The ice packs should cover both breasts. Large bags of frozen peas or niblet corn make easy packs and can be refrozen between uses.

Fresh, raw cabbage leaves placed over the breasts between feedings may help reduce the swelling. The cabbage leaves are washed, chilled in the refrigerator or freezer, and then placed over the breasts for 15 to 20 minutes (Fig. 18-14). This treatment can be repeated for two or three sessions. Frequent application of cabbage leaves can decrease milk supply. Cabbage leaves are often very effective for formula-feeding mothers who want their milk to “dry up”; they are advised to wear the cabbage leaves constantly while engorged, replacing the leaves with fresh ones as they become wilted. Cabbage leaves should not be used if the mother is allergic to cabbage or sulfa drugs or develops a skin rash.

Antiinflammatory medications, such as ibuprofen, may help reduce the pain and swelling associated with engorgement. Ibuprofen also helps reduce fever and aching in the breasts that are often associated with engorgement.

Because heat increases blood flow, application of heat to an already congested breast is usually counterproductive. Occasionally, however, standing in a warm shower will start the milk leaking, or the mother may be able to manually express enough milk to soften the areola sufficiently to allow the baby to latch on and feed.

Estrogen and progesterone levels drop markedly after expulsion of the placenta and reach their lowest levels 1 week after childbirth. Decreased estrogen levels are associated with breast engorgement and with the diuresis of excess extracellular fluid accumulated during pregnancy. In nonlactating women, estrogen levels begin to rise by 2 weeks after birth and by postpartum day 17 are significantly higher than in women who breastfeed (Katz, 2007).

• If breasts are engorged, have woman apply ice packs to breasts (15 minutes on, 45 minutes off), and apply cabbage leaves in same manner to relieve discomfort (use only two to three times). Use warm compresses or take a warm shower before breastfeeding to stimulate milk flow and relieve stasis. Hand express milk or pump milk to relieve discomfort if infant is unable to latch on and feed.
• If pain is from breast and woman is not breastfeeding, encourage the use of a well-fitted, supportive bra or breast binder and application of ice packs and cabbage leaves to suppress milk production and decrease discomfort.

– if mom doesn’t want to breastfeed: avoid breast stimulation, tight bra, ice packs. leave them alone
– breastfeeding benefits: helps with antibody, readily available, free
– normal amount of wet diapers for babies to see if breastfeeding is effective: 6-8/day
– breastfeed every 2 hours to avoid engorgment
Breastfeeding Mothers
During the first 24 hours after birth, little, if any, change occurs in the breast tissue. Colostrum, a clear yellow fluid, may be expressed from the breasts. The breasts gradually become fuller and heavier as the colostrum transitions to milk by approximately 72 to 96 hours after birth; this breast change is often referred to as the “milk coming in.” The breasts may feel warm, firm, and somewhat tender. Bluish-white milk with a skim-milk appearance (true milk) can be expressed from the nipples. As milk glands and milk ducts fill with milk, breast tissue may feel somewhat nodular or lumpy. Unlike the lumps associated with fibrocystic breast disease or cancer, which may be consistently palpated in the same location, the nodularity associated with milk production tends to shift in position. Some women experience engorgement, but with frequent breastfeeding and proper care, this condition is temporary and typically lasts only 24 to 48 hours (see Chapter 18).Non-Breastfeeding Mothers
The breasts generally feel nodular in contrast to the granular feel of breasts in nonpregnant women. The nodularity is bilateral and diffuse. Prolactin levels drop rapidly. Colostrum is present for the first few days after childbirth. Palpation of the breasts on the second or third day, as milk production begins, may reveal tissue tenderness in some women. On the third or fourth postpartum day, engorgement may occur. The breasts are distended (swollen), firm, tender, and warm to the touch (because of vasocongestion). Breast distention is caused primarily by the temporary congestion of veins and lymphatics rather than by an accumulation of milk. Milk is present but should not be expressed. Axillary breast tissue (the tail of Spence) and any accessory breast or nipple tissue along the milk line may be involved. Engorgement resolves spontaneously, and discomfort decreases usually within 24 to 36 hours. A breast binder or well-fitted, supportive bra, ice packs, fresh cabbage leaves, and mild analgesics may be used to relieve discomfort. Nipple stimulation is avoided. If suckling is never begun (or is discontinued), lactation ceases within a few days to a week.

– breastfeeding storage: look in powerpoint we haven’t covered in class

Storage of breast milk

The preferred containers for long-term storage of breast milk are hard sided, such as hard plastic or glass, with an airtight seal. For short-term storage (<72 hours), plastic bags designed for human milk storage can be safely used.

For full-term, healthy infants, freshly expressed breast milk can be safely stored at room temperature for up to 8 hours, and it can be refrigerated safely for up to 5 days. Milk can be frozen for up to 6 months in the freezer section of a refrigerator with a separate door and for up to 12 months in a deep freeze. Storage guidelines for hospitalized infants are somewhat stricter. When breast milk is stored, the container should be dated, and the oldest milk should be used first (Jones & Tully, 2006).

Frozen milk is thawed by placing the container in the refrigerator for gradual thawing or in warm water for faster thawing. It cannot be refrozen and should be used within 24 hours. After thawing the container needs to be shaken so as to mix the layers that have separated (Academy of Breastfeeding Medicine [ABM], 2004; Jones & Tully, 2006) (see Patient Instructions for Self-Management Box).

PATIENT INSTRUCTIONS FOR SELF-MANAGEMENT
Breast Milk Storage Guidelines for Home Use
• Before expressing or pumping breast milk, wash your hands.
• Containers for storing milk should be washed in hot, soapy water and rinsed thoroughly; they can also be washed in a dishwasher. If the water supply may not be clean, boil the containers after washing. Plastic bags designed specifically for breast milk storage can be used for short term storage (<72 hr).
• Write the date of expression on the container before storing the milk. A waterproof label is best.
• Store milk in serving sizes of 2 to 4 ounces to prevent waste.
• Storing breast milk in the refrigerator or freezer with other food items is acceptable.
• When storing milk in a refrigerator or freezer, place the containers in the middle or back of the freezer, not on the door.
• When filling a storage container that will be frozen, fill only full, allowing space at the top of the container for expansion.
• To thaw frozen breast milk, place the container in the refrigerator for gradual thawing, or place the container under warm, running water for quicker thawing. Never boil or microwave.
• Milk thawed in the refrigerator can be stored for 24 hours.
• Thawed breast milk should never be refrozen.
• Shake the milk container before feeding baby, and test the temperature of the milk on the inner aspect of your wrist.
• Any unused milk left in the bottle after feeding is discarded.

STORAGE GUIDELINES FOR HUMAN MILK
Method | Healthy Infant | Hospitalized Infant
Room temperature (77° F or 25° C): <6 hours: <4 hours
Refrigerator (39° F or 4° C): <8 days: <8 days
Freezer compartment of a one door refrigerator: 2 weeks: Not recommended
Freezer compartment of a two door refrigerator (23° F or −5° C) (not in door): <6 months: <3 months
Deep freezer(−4° F or −20° C): <12 months: <6 months

NURSING ALERT
Breast milk is never thawed or heated in a microwave oven. Microwaving does not heat evenly and can cause encapsulated boiling bubbles to form in the center of the liquid, which may not be detected when drops of milk are checked for temperature. Babies have sustained severe burns to the mouth, throat, and upper GI tract as a result of microwaved milk. In addition, microwaving (72°-98° C) significantly destroys the antiinfective factors and vitamin C content. The safety of low-temperature microwaving is questionable (Lawrence & Lawrence, 2005).

– normal weight loss for newborn?: 3% is normal.

Acceptable weight loss: 10% or less infirst 3-5 days

Weight loss over 10% to 15% (growth failure, dehydration); assess breastfeeding sucess.

The newborn is usually weighed shortly after birth. This assessment may be performed in the labor and birthing area, the mother’s room, or on admission to the nursery. Care must be taken to ensure that the scales are balanced. The totally unclothed neonate is placed in the center of the scale, which is usually covered with a disposable pad or cloth to prevent heat loss via conduction to prevent cross-infection. The nurse should place one hand over (but not touching) the neonate to prevent the infant from falling off the scales (p. 460). Weighing the infant at the same time every day is common during the hospital stay. Birth weight of a term infant typically ranges from 2500 to 4000 g.

The presence of decreased caloric intake (less milk), weight loss of more than 5% to 7% in the first 5 days of life, increasing serum bilirubin (unconjugated) levels, decreased stooling, and increased jaundice is also sometimes called starvation jaundice or nonbreastfeeding jaundice. To prevent this pattern the following measures are suggested: initiation of breastfeeding within the first few hours of life, continuous rooming-in with the mother, breastfeeding 10 to 12 times per day, no supplements, and recognition of and response to hunger cues.

– how to avoid cold stress: warmer, blankets, hats, avoid drafts

The care given immediately after the birth focuses on assessing and stabilizing the newborn. The nurse’s main responsibility at this time is the infant because the primary health care provider is involved with the delivery of the placenta and the care of the mother. The nurse must watch the infant for any signs of distress and initiate appropriate interventions should any appear.

Perform a brief assessment of the newborn immediately, even while the mother is holding the infant. This assessment includes assigning Apgar scores at 1 and 5 minutes after birth (see Table 17-1). Maintaining a patent airway, supporting respiratory effort, and preventing cold stress by drying the newborn and covering the newborn with a warmed blanket or placing him or her under a radiant warmer are the major priorities in terms of the newborn’s immediate care. You can postpone further examination, identification procedures, and care until later in the third stage of labor or early in the fourth stage.

– mongolian spots.
Mongolian spots
Mongolian spots, bluish-black areas of pigmentation, may appear over any part of the exterior surface of the body, including the extremities. They are more commonly noted on the back and buttocks (Fig. 16-5). These pigmented areas are most frequently noted in newborns whose ethnic origins are in the Mediterranean area, Latin America, Asia, or Africa. They are more common in dark-skinned individuals but may occur in 5% to 13% of Caucasians as well (Blackburn, 2007). They fade gradually over months or years.
– acrocyanosis: normal., blue hands and feet at birth
The hands and feet appear slightly cyanotic (acrocyanosis) [at birth], which is caused by vasomotor instability and capillary stasis. Acrocyanosis is normal and appears intermittently over the first 7 to 10 days, especially with exposure to cold. Acrocyanosis is a normal finding in the neonate, but central cyanosis indicates poor oxygenation.
– at birth: suction mouth first, then nose.
Suction the mouth and nasopharynx with a bulb syringe as needed; clean the nares of crusted secretions to clear the airway and prevent aspiration and airway obstruction.
– vernix caseosa

The epidermis begins as a single layer of cells derived from the ectoderm at 4 weeks. By the seventh week, two layers of cells have formed. The cells of the superficial layer are sloughed and become mixed with the sebaceous gland secretions to form the white, cheesy vernix caseosa, the material that protects the skin of the fetus. The vernix is thick at 24 weeks but becomes scant by term.

Vernix caseosa is a product of the sebaceous glands. Removal of the vernix is followed by desquamation of the epidermis in most infants. Vernix has been shown to be an epidermal barrier with positive benefits for neonatal skin such as decreasing the skin pH, decreased skin erythema, and improved skin hydration.

Vernix caseosa may be present between the labia and should not be forcibly removed during bathing.

Allowing vernix caseosa to remain on the infant’s skin has not been associated with a decrease in axillary temperature in the first hour after birth.

Vernix caseosa has benefits for the preterm infant’s skin. Vernix acts as an epidermal barrier, decreases bacterial contamination of the skin through its antimicrobial peptides and proteins, and decreases transepidermal water loss.

– how to calculate BMIs. what are the ranges
Weight gain
The optimal weight gain during pregnancy is not known precisely. However, the amount of weight gained by the mother during pregnancy has an important bearing on the course and outcome of pregnancy. Adequate weight gain does not necessarily indicate that the diet is nutritionally adequate, but it is associated with a reduced risk of giving birth to a small-for-gestational-age (SGA) or preterm infant.The desirable weight gain during pregnancy varies among women. The primary factor to consider in making a weight gain recommendation is the appropriateness of the prepregnancy weight for the woman’s height. Maternal and fetal risks in pregnancy are increased when the mother is either significantly underweight or overweight before pregnancy and when weight gain during pregnancy is either too low or too high. Severely underweight women are more likely to have preterm labor and to give birth to LBW infants. Women with inadequate weight gain have an increased risk of giving birth to an infant with intrauterine growth restriction (IUGR). Greater-than-expected weight gain during pregnancy may occur for many reasons, including multiple gestation, edema, preeclampsia, and overeating. Obesity (either preexisting or developed during pregnancy) increases the likelihood of macrosomia and fetopelvic disproportion; operative birth; emergency cesarean birth; postpartum hemorrhage; wound, genital tract, or urinary tract infection; birth trauma; and late fetal death. Obese women are more likely than normal-weight women to have gestational hypertension and gestational diabetes; their risk of giving birth to a child with a major congenital defect is double that of normal-weight women.

A commonly used method of evaluating the appropriateness of weight for height is the body mass index (BMI), which is calculated by the following formula: BMI = weight/height^2 where the weight is in kilograms and height is in meters. Therefore for a woman who weighed 51 kg before pregnancy and is 1.57 m tall: BMI = 51/(1.57)^2, or 20.7.

Prepregnant BMI can be classified into the following categories: less than 18.5, underweight or low; 18.5 to 24.9, normal; 25 to 29.9, overweight or high; and greater than 30, obese (www.nhlbisupport.com/bmi/).

For women with single fetuses, current recommendations are that women with a normal BMI should gain 11.3-15.9 kg during pregnancy, underweight women should gain 12.7-18.1 kg, overweight women should gain 6.8-11.3 kg, and obese women should gain 5.0-9.1 kg (Institute of Medicine, 2009). Adolescents are encouraged to strive for weight gains at the upper end of the recommended range for their BMI because the fetus and the still-growing mother apparently compete for nutrients. The risk of mechanical complications at birth is reduced if the weight gain of short adult women (shorter than 157 cm) is near the lower end of their recommended range.

Pattern of weight gain
Weight gain should take place throughout pregnancy. The risk of giving birth to an SGA infant is greater when the weight gain early in pregnancy has been poor. The likelihood of preterm birth increases when the gains during the last half of pregnancy have been inadequate. These risks exist even when the total gain for the pregnancy is in the recommended range.

The optimal rate of weight gain depends on the stage of pregnancy. During the first and second trimesters, growth takes place primarily in maternal tissue; during the third trimester, growth occurs primarily in fetal tissues. During the first trimester the average total weight gain is only 1 to 2.5 kg. Thereafter the recommended weight gain increases to approximately 0.4 kg per week for a woman of normal weight. The recommended weekly weight gain for overweight women during the second and third trimesters is 0.3 kg and for underweight women is 0.5 kg.

In twin gestations the recommended weight gain for women in the normal BMI category is 16.8 to 24.5 kg, for women who are overweight, 14.1 to 22.7 kg, and for obese women 11.3 to 19.1 kg (Institute of Medicine, 2009). The ideal weight gain for higher multiples is likely to be greater, but no specific recommendations have been issued (Malone & D’Alton, 2009).

The recommended caloric intake corresponds to this pattern of gain. For the first trimester, no increment is necessary; during the second and third trimesters an additional 340 kcal per day and 462 kcal per day, respectively, over the prepregnant intake is recommended. The amount of food that provides the needed increase is not great. The 340 additional kcal needed during the second trimester can be provided by one additional serving from any one of the following groups: milk, yogurt, or cheese (all skim milk products); fruits; vegetables; and bread, cereal, rice, or pasta.

The reasons for an inadequate weight gain (less than 1 kg per month for normal-weight women or less than 0.5 kg/month for obese women during the last two trimesters) or excessive weight gain (more than 3 kg per month) should be evaluated thoroughly. Possible reasons for deviations from the expected rate of weight gain, besides inadequate or excessive dietary intake, include measurement or recording errors, differences in weight of clothing, time of day, and accumulation of fluids. An exceptionally high gain is likely to be caused by an accumulation of fluids, and a gain of more than 3 kg in a month, especially after the twentieth week of gestation, often indicates the development of gestational hypertension.

Hazards of restricting adequate weight gain
Figure-conscious women can have difficulty making the transition from guarding against weight gain before pregnancy to valuing weight gain during pregnancy. In counseling these women the nurse can emphasize the positive effects of good nutrition, as well as the adverse effects of maternal malnutrition (demonstrated by poor weight gain) on infant growth and development. This counseling includes information on the components of weight gain during pregnancy (Table 8-2) and the amount of this weight that will be lost at birth. Because lactation can help to reduce maternal energy stores gradually, this discussion provides an opportunity to promote breastfeeding.

In the United States, 20% of women who give birth are obese (Paul, 2008). However, pregnancy is not a time for weight-reduction. Even overweight or obese pregnant women need to gain at least enough weight to equal the weight of the products of conception (fetus, placenta, and amniotic fluid). If overweight women limit their caloric intake to prevent weight gain, they may also excessively limit their intake of important nutrients. Moreover, dietary restriction results in catabolism of fat stores, which, in turn, augments the production of ketones. The long-term effects of mild ketonemia during pregnancy are not known, but ketonuria has been found to be correlated with the occurrence of preterm labor. The idea that the quality of the weight gain is important should be stressed to obese women (and to all pregnant women), with emphasis placed on the consumption of nutrient-dense foods and the avoidance of empty-calorie foods.

Adolescent pregnancy needs
Many adolescent girls have diets that provide less than the recommended intakes of key nutrients, including energy, calcium, and iron. Pregnant adolescents and their infants are at increased risk of complications during pregnancy and parturition. Growth of the pelvis is delayed in comparison with growth in stature, which helps to explain why cephalopelvic disproportion and other mechanical problems associated with labor are common among young adolescents. Competition for nutrients between the growing adolescent and the fetus may also contribute to some of the poor outcomes apparent in teen pregnancies. Pregnant adolescents are encouraged to choose a weight gain goal at the upper end of the range for their BMI.

Dietary management during diabetic pregnancy must be based on blood (not urine) glucose levels. The diet is individualized to allow for increased fetal and metabolic requirements, with consideration of such factors as prepregnancy weight and dietary habits, overall health, ethnic background, lifestyle, stage of pregnancy, knowledge of nutrition, and insulin therapy. The dietary goals are to provide weight gain consistent with a normal pregnancy, to prevent ketoacidosis, and to minimize wide fluctuation of blood glucose levels.

For nonobese women, dietary counseling based on preconceptional body mass index (BMI) is 30 kcal/kg/day (Cunningham et al., 2005). In contrast, for obese women with a BMI greater than 30, experts recommend that the caloric intake total 25 kcal/kg/day (Moore & Catalano, 2009). The average diet includes 2200 calories (first trimester) to 2500 calories (second and third trimesters). Total calories may be distributed among three meals and one evening snack or, more commonly, three meals and two or three snacks. Meals should be eaten on time and never skipped. Going more than 4 hours without food intake increases the risk for episodes of hypoglycemia. Snacks must be carefully planned in accordance with insulin therapy to prevent fluctuations in blood glucose levels. A large bedtime snack of at least 25 g of carbohydrate with some protein or fat is recommended to help prevent hypoglycemia and starvation ketosis during the night (Moore & Catalano).

– how to calculate APGAR score
Initial Assessment and Apgar Scoring
The initial assessment of the neonate is performed immediately after birth using the Apgar score (Table 17-1) and a brief physical examination (Box 17-1). A gestational age assessment is completed within the first hours of birth in a stable newborn. A more comprehensive physical assessment is completed within 24 hours of birth (see Table 16-4).TABLE 17-1 Apgar Score
Heart rate:
0: Absent
1: Slow (<100) 2: >100

Respiratory rate
0: Absent
1: Slow, weak cry
2: Good cry

Muscle tone
0: Flaccid
1: Some flexion of extremities
2: Well flexed

Reflex irritability
0: No response
1: Grimace
2: Cry

Color
0: Blue, pale
1: Body pink, extremities blue
2: Completely pink

Apgar score
The Apgar score permits a rapid assessment of the newborn’s transition to extrauterine existence based on five signs that indicate the physiologic state of the neonate: (1) heart rate, based on auscultation with a stethoscope or palpation of the umbilical cord; (2) respiratory rate, based on observed movement of respiratory efforts; (3) muscle tone, based on degree of flexion and movement of the extremities; (4) reflex irritability, based on response to bulb syringe or catheter inserted in the nasopharynx; and (5) generalized skin color, described as pallid, cyanotic, or pink (see Table 17-1). Evaluations are made at 1 and 5 minutes after birth and can be completed by the nurse or birth attendant. Scores of 0 to 3 indicate severe distress, scores of 4 to 6 indicate moderate difficulty, and scores of 7 to 10 indicate that the infant is having minimal or no difficulty adjusting to extrauterine life. Apgar scores do not predict future neurologic outcome but are useful for describing the newborn’s transition to extrauterine environment (Box 17-2). If resuscitation is required, it should be initiated before the 1-minute Apgar score (American Academy of Pediatrics [AAP] and American College of Obstetricians and Gynecologists [ACOG], 2007).

BOX 17-2 Significance of the Apgar Score

The Apgar score was developed to provide a systematic method of assessing an infant’s condition at birth. Researchers have tried to correlate Apgar scores with various outcomes such as development, intelligence, and neurologic development. In some instances, researchers have attempted to attribute causality to the Apgar score, that is, to suggest that the low Apgar score caused or predicted later problems. This use of the Apgar score is inappropriate. Instead the score should be used to ensure that infants are systematically observed at birth to ascertain the need for immediate care. Either a physician or a nurse may assign the score; however, to avoid the real or perceived appearance of bias, the person assisting with the birth should not assign the score. Lack of consistency in the assigned scores limits studies of the Apgar’s long-term predictive value. Prospective parents and the public need education on the significance of the Apgar score, as well as its limits. Because infants often do not receive the maximal score of 10, parents need to know that scores of 7 to 10 are within normal limits. Attorneys involved in litigation related to injury of an infant at birth or negative outcomes, either short term or long term, also need education about the Apgar score, its significance, and its limits. This useful tool needs to be used appropriately; health care providers, parents, and the public may need education to ensure appropriate use of the score.

– what is a cephalhematoma: more at risk for jaundice than caput

Cephalhematoma

Cephalhematoma is a collection of blood between a skull bone and its periosteum; therefore a cephalhematoma does not cross a cranial suture line. Caput succedaneum and cephalhematoma often occur simultaneously.

Bleeding may occur with spontaneous birth from pressure against the maternal bony pelvis. Low forceps birth and difficult forceps rotation and extraction may also cause bleeding. This soft, fluctuating, irreducible fullness does not pulsate or bulge when the infant cries. It appears several hours or the day after birth and may not become apparent until a caput succedaneum is absorbed. A cephalhematoma is usually largest on the second or third day, by which time the bleeding stops. The fullness of a cephalhematoma spontaneously resolves in 3 to 6 weeks. It is not aspirated because infection may develop if the skin is punctured. As the hematoma resolves, hemolysis of RBCs occurs, and jaundice may result. Hyperbilirubinemia and jaundice may occur after the newborn is discharged home.

– caput succedaneum

Caput succedaneum

Caput succedaneum is a generalized, easily identifiable edematous area of the scalp, most commonly found on the occiput. The sustained pressure of the presenting vertex against the cervix results in compression of local vessels, thereby slowing venous return. The slower venous return causes an increase in tissue fluids within the skin of the scalp, and an edematous swelling develops. This edematous swelling, present at birth, extends across suture lines of the skull and disappears spontaneously within 3 to 4 days. Infants who are born with the assistance of vacuum extraction usually have a caput in the area where the cup was applied.

– pica

Pica and food cravings

Pica, the practice of consuming nonfood substances (e.g., clay, dirt, laundry starch) or excessive amounts of foodstuffs low in nutritional value (e.g., cornstarch, ice, baking powder, baking soda), is often influenced by the woman’s cultural background (Fig. 8-2). In the United States, pica appears to be most common among African-American women, women from rural areas, and women with a family history of pica. Regular and heavy consumption of low-nutrient products may cause more nutritious foods to be displaced from the diet, and the items consumed may interfere with the absorption of nutrients, especially minerals. As an example, cornstarch ingestion is popular among African-American women. It is a source of “empty” calories; one half cup (64 g) provides 240 kcal (57 kJ) but almost no vitamins, minerals, or protein. Grotegut, Dandolu, Katari, Whiteman, Geifman-Holtzman, and Teitelman (2006) reported a case of a 31-week gestation multigravida ingesting a box of baking soda (454 g of sodium bicarbonate) each day, which resulted in severe hypokalemic metabolic alkalosis and rhabdomyolysis. More than one substance may be ingested (Ngozi, 2008). Women with pica have lower hemoglobin levels than those without pica.

Moreover, a risk exists that nonfood items are contaminated with heavy metals or other toxic substances. Among Mexican-American women, consumption of “tierra” includes both soil and pulverized Mexican pottery (Klitzman, Sharma, Nicaj, Vitkevich, & Leighton, 2002; Shannon, 2003). Lead contamination of soils and soil-based products has caused high levels of lead in both pregnant women and their newborns. Regular household use of Mexican pottery in cooking or serving food or ingestion of ground pottery must be included in interviews or questionnaires regarding nutritional intake of pregnant women. The possibility of pica must be considered when pregnant women are found to be anemic, and the nurse should provide counseling about the health risks associated with pica (Corbett, Ryan, & Weinrich, 2003).

One hypothesis proposes that pica and food cravings (e.g., the urge to consume ice cream, pickles, or pizza) during pregnancy are caused by an innate drive to consume nutrients missing from the diet. However, research has not supported this hypothesis.

– know when to take iron: at bedtime with orange juice to increase absorption. avoid taking it with dairy. sip through straw if liquid suspension to avoid staining teeth.
Iron
Iron is needed both to allow transfer of adequate iron to the fetus and to permit expansion of the maternal red blood cell (RBC) mass. The RDA of iron during pregnancy is 27 mg per day (National Institutes of Health, 2007). Pregnant women should receive a supplement of 30 mg of ferrous iron daily, starting by 12 weeks of gestation. (Iron supplements may be poorly tolerated during the nausea that is prevalent in the first trimester.) Iron supplementation of women with iron deficiency can improve maternal hematologic indices and appears to reduce LBW births. If maternal iron-deficiency anemia is present (preferably diagnosed by measurement of serum ferritin, a storage form of iron), increased doses (60-120 mg daily) are recommended. Certain foods taken with an iron supplement can promote or inhibit absorption of iron from the supplement. See the Patient Instructions for Self-Management box regarding iron supplementation. Even when a woman is taking an iron supplement, she should include good food sources of iron in her daily diet (see Table 8-1).PATIENT INSTRUCTIONS FOR SELF-MANAGEMENT

Iron Supplementation
• Iron absorption is promoted by a diet rich in vitamin C (e.g., citrus fruits, melons) or “heme iron” (found in red meats, fish, and poultry).
• Iron supplements are best absorbed on an empty stomach; to this end, they can be taken between meals with beverages other than milk, tea, or coffee.
• Bran, milk, egg yolks, coffee, tea, or oxalate-containing vegetables such as spinach and Swiss chard will inhibit iron absorption if consumed at the same time as iron.
• Some women have gastrointestinal discomfort when they take the supplement on an empty stomach; therefore a good time for them to take the supplement is just before bedtime.
• Constipation is common with iron supplementation.
• Iron supplements should be kept away from any children in the household because ingestion of these supplements could result in acute iron poisoning and even death.
• Iron may cause black, tarry stools.

Zinc is a constituent of numerous enzymes involved in major metabolic pathways. Zinc deficiency is associated with malformations of the central nervous system in infants. When large amounts of iron and folic acid are consumed the absorption of zinc is inhibited, and serum zinc levels are reduced as a result. Because iron and folic acid supplements are commonly prescribed during pregnancy, pregnant women should be encouraged to consume good sources of zinc daily (see Table 8-1). Women with anemia who receive high-dose iron supplements also need supplements of zinc and copper.

Vitamin C, or ascorbic acid, plays an important role in tissue formation and enhances the absorption of iron. The vitamin C needs of most women are readily met by a diet that includes at least one daily serving of citrus fruit or juice or another good source of the vitamin (see Table 8-1), but women who smoke need more. For women at nutritional risk, a supplement of 50 mg/day is recommended. However, if the mother takes excessive doses of this vitamin during pregnancy, a vitamin C deficiency may develop in the infant after birth.

– care of circumcision
Procedural pain management
Circumcision is painful. The pain is characterized by both physiologic and behavioral changes in the infant (see discussion that follows). Four types of anesthesia and analgesia are used in newborns who undergo circumcisions: ring block, dorsal penile nerve block (DPNB), topical anesthetic such as eutectic mixture of local anesthetic (EMLA) (prilocaine-lidocaine) or LMX4 (4% lidocaine), and concentrated oral sucrose. Nonpharmacologic methods such as nonnutritive sucking, containment, and swaddling may be used to enhance pain management. The Cochrane group exploring pain relief for neonatal circumcision (Brady-Fryer, Wiebe, & Lander, 2004) found that DPNB was the most effective intervention for decreasing the pain of circumcision. Studies exploring the use of several strategies concurrently, such as that conducted by Razmus, Dalton, and Wilson (2004), which included groups receiving both concentrated oral sucrose and ring block compared with ring block alone, have the most potential to clarify optimal strategies.A ring block is the injection of buffered lidocaine administered subcutaneously on each side of the penile shaft. A DPNB includes subcutaneous injections of buffered lidocaine at the 2 o’clock and 10 o’clock positions at the base of the penis. The circumcision should not be performed for at least 5 minutes after these injections.

A topical cream containing prilocaine-lidocaine such as EMLA can be applied to the base of the penis at least 1 hour before the circumcision. The area where the prepuce attaches to the glans is well coated with 1 g of the cream and then covered with a transparent occlusive dressing or finger cot. Just before the procedure the cream is removed. Blanching or redness of the skin may occur.

After the circumcision the infant is comforted until he is quieted. If the parents were not present during the procedure, the infant is returned to them. The infant can be fussy for several hours and can have disturbed sleep-wake states and disorganized feeding behaviors. Oral acetaminophen may be administered after the procedure every 4 hours (as ordered by the practitioner) for a maximum of five doses in 24 hours or a maximum of 75 mg/kg/day.

Care of the newly circumcised infant
Post-circumcision protocols vary. In many settings, the circumcision site is assessed for bleeding every 30 minutes for the first hour and then hourly for the next 4 to 6 hours. The nurse monitors the infant’s urinary output, noting the time and amount of the first voiding after the circumcision. If bleeding is noted from the circumcision, the nurse applies gentle pressure to the site of bleeding with a folded sterile gauze square. A hemostatic agent such as Gelfoam® powder or sponge may be applied to the circumcision site to help control the bleeding. If bleeding is not easily controlled, a blood vessel may need to be ligated. In this event, one nurse notifies the physician and prepares the necessary equipment (i.e., circumcision tray and suture material), while another nurse maintains intermittent pressure until the physician arrives. If the parents take the baby home before the end of the observation period, they must be taught proper home care (Teaching Guidelines box).

TEACHING GUIDELINES

Care of the Circumcised Newborn at Home
• Wash hands before touching the newly circumcised penis.

CHECK FOR BLEEDING
• Check circumcision for bleeding with each diaper change.
• If bleeding occurs, apply gentle pressure with a folded sterile gauze square. If bleeding does not stop with pressure, notify primary health care provider.

OBSERVE FOR URINATION
• Check to see that the infant urinates after being circumcised.
• Infant should have a wet diaper 2 to 6 times per 24 hours the first 1 to 2 days after birth, then 6 to 10 times per 24 hours after 3 to 4 days.

KEEP AREA CLEAN
• Change the diaper and inspect the circumcision at least every 4 hours.
• Wash the penis gently with warm water to remove urine and feces. Apply petrolatum to the glans with each diaper change (omit petrolatum if a PlastiBell was used).
• Use soap only after the circumcision is healed (5 to 6 days).
• Apply the diaper to prevent pressure on the circumcised area.

CHECK FOR INFECTION
• Glans penis is dark red after circumcision then becomes covered with yellow exudate in 24 hours, which is normal and will persist for 2 to 3 days. Do not attempt to remove it.
• Redness, swelling, discharge, or odor indicates infection. Notify the primary health care provider if you think the circumcision area is infected.

PROVIDE COMFORT
• Circumcision is painful. Handle the area gently.
• Provide extra holding, feeding, and opportunities for nonnutritive sucking for a day or two.

Nursing actions are planned and implemented to prevent infection. Prepackaged commercial wipes for cleaning the diaper area should not be used because they contain alcohol, which delays healing and causes discomfort. Instead, the nurse washes the penis gently with water to remove urine and feces and, if necessary, applies fresh petrolatum around the glans after each diaper change. The glans penis, normally dark red during healing, becomes covered with a yellow exudate in 24 hours, which is part of normal healing, not an infective process. No attempt should be made to remove the exudate, which persists for 2 to 3 days. Parents should be taught to apply the diaper so that it does not press on the circumcised area. They should be encouraged to change the diaper at least every 4 hours to prevent it from sticking to the penis.

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