Combo with "Chapter 22 Maternal Child Nursing Perry 4th Edition" and 13 others

After giving birth to a healthy infant boy, a primiparous woman, 16, is admitted to the postpartum unit. An appropriate nursing diagnosis for her at this time is risk for impaired parenting related to deficient knowledge of newborn care. In planning for the woman’s discharge, what should the nurse be certain to include in the plan of care?
a. Tell the woman how to feed and bathe her infant.
b. Give the woman written information on bathing her infant.
c. Advise the woman that all mothers instinctively know how to care for their infants.
d. Provide time for the woman to bathe her infant after she views an infant bath demonstration.
ANS: D
Having the mother demonstrate infant care is a valuable method of assessing the client’s understanding of her newly acquired knowledge, especially in this age group, because she may inadvertently neglect her child. Although verbalizing how to care for the infant is a form of client education, it is not the most developmentally appropriate teaching for a teenage mother. Although providing written information is useful, it is not the most developmentally appropriate teaching for a teenage mother. Advising the woman that all mothers instinctively know how to care for their infants is an inappropriate statement; it is belittling and false
The nurse observes several interactions between a postpartum woman and her new son. What behavior, if exhibited by this woman, would the nurse identify as a possible maladaptive behavior regarding parent-infant attachment?
a. Talks and coos to her son
b. Seldom makes eye contact with her son
c. Cuddles her son close to her
d. Tells visitors how well her son is feeding
ANS: B
The woman should be encouraged to hold her infant in the en face position and make eye contact with the infant. Normal infant-parent interactions include talking and cooing to her son, cuddling her son close to her, and telling visitors how well her son is feeing.
The nurse observes that a 15-year-old mother seems to ignore her newborn. A strategy that the nurse can use to facilitate mother-infant attachment in this mother is to:
a. Tell the mother she must pay attention to her infant.
b. Show the mother how the infant initiates interaction and pays attention to her.
c. Demonstrate for the mother different positions for holding her infant while feeding.
d. Arrange for the mother to watch a video on parent-infant interaction.
ANS: B
Pointing out the responsiveness of the infant is a positive strategy for facilitating parent-infant attachment. Telling the mother that she must pay attention to her infant may be perceived as derogatory and is not appropriate. Educating the young mother in infant care is important, but pointing out the responsiveness of her baby is a better tool for facilitating mother-infant attachment. Videos are an educational tool that can demonstrate parent-infant attachment, but encouraging the mother to recognize the infant’s responsiveness is more appropriate.
The nurse hears a primiparous woman talking to her son and telling him that his chin is just like his dad’s chin. This woman’s statement reflects:
a. Mutuality. c. Claiming.
b. Synchrony. d. Reciprocity.
ANS: C
Claiming refers to the process by which the child is identified in terms of likeness to other family members. Mutuality occurs when the infant’s behaviors and characteristics call forth a corresponding set of maternal behaviors and characteristics. Synchrony refers to the “fit” between the infant’s cues and the parent’s responses. Reciprocity is a type of body movement or behavior that provides the observer with cues.
New parents express concern that, because of the mother’s emergency cesarean birth under general anesthesia, they did not have the opportunity to hold and bond with their daughter immediately after her birth. The nurse’s response should convey to the parents that:
a. Attachment, or bonding, is a process that occurs over time and does not require early contact.
b. The time immediately after birth is a critical period for people.
c. Early contact is essential for optimum parent-infant relationships.
d. They should just be happy that the infant is healthy.
ANS: A
Attachment, or bonding, is a process that occurs over time and does not require early contact. The formerly accepted definition of bonding held that the period immediately after birth was a critical time for bonding to occur. Research since has indicated that parent-infant attachment occurs over time. A delay does not inhibit the process. Parent-infant attachment involves activities such as touching, holding, and gazing; it is not exclusively eye contact. A response that conveys that the parents should just be happy that the infant is healthy is inappropriate because it is derogatory and belittling.
During a phone follow-up conversation with a woman who is 4 days’ postpartum, the woman tells the nurse, “I don’t know what’s wrong. I love my son, but I feel so let down. I seem to cry for no reason!” The nurse would recognize that the woman is experiencing:
a. Taking-in. c. Postpartum (PP) blues.
b. Postpartum depression (PPD). d. Attachment difficulty.
ANS: C
During the PP blues women are emotionally labile, often crying easily and for no apparent reason. This lability seems to peak around the fifth PP day. The taking-in phase is the period after birth when the mother focuses on her own psychologic needs. Typically this period lasts 24 hours. PPD is an intense, pervasive sadness marked by severe, labile mood swings; it is more serious and persistent than the PP blues. Crying is not a maladaptive attachment response; it indicates PP blues
The nurse can help a father in his transition to parenthood by:
a. Pointing out that the infant turned at the sound of his voice.
b. Encouraging him to go home to get some sleep.
c. Telling him to tape the infant’s diaper a different way.
d. Suggesting that he let the infant sleep in the bassinet.
ANS: A
Infants respond to the sound of voices. Because attachment involves a reciprocal interchange, observing the interaction between parent and infant is very important. Separation of the parent and infant does not encourage parent-infant attachment. Educating the parent in infant care techniques is important, but the manner in which a diaper is taped is not relevant and does not enhance parent-infant interactions.
Parent-infant attachment involves touching, holding, and cuddling. It is appropriate for a father to want to hold the infant as the baby sleeps.
The nurse notes that a Vietnamese woman does not cuddle or interact with her newborn other than to feed him, change his diapers or soiled clothes, and put him to bed. In evaluating the woman’s behavior with her infant, the nurse realizes that:
a. What appears to be a lack of interest in the newborn is in fact the Vietnamese way of demonstrating intense love by attempting to ward off evil spirits.
b. The woman is inexperienced in caring for newborns.
c. The woman needs a referral to a social worker for further evaluation of her parenting behaviors once she goes home with the newborn.
d. Extra time needs to be planned for assisting the woman in bonding with her newborn.
ANS: A
The nurse may observe a Vietnamese woman who gives minimal care to her infant and refuses to cuddle or interact with her infant. The apparent lack of interest in the newborn is this cultural group’s attempt to ward off evil spirits and actually reflects an intense love and concern for the infant. It is important to educate the woman in infant care, but it is equally important to acknowledge her cultural beliefs and practices.
Many first-time parents do not plan on their parents’ help immediately after the newborn arrives. What statement by the nurse is the most appropriate when counseling new parents about the involvement of grandparents?
a. “You should tell your parents to leave you alone.”
b. “Grandparents can help you with parenting skills and also help preserve family traditions.”
c. “Grandparent involvement can be very disruptive to the family.”
d. “They are getting old. You should let them be involved while they can.”
ANS: B
“Grandparents can help you with parenting skills and also help preserve family traditions” is the most appropriate response. Intergenerational help may be perceived as interference, but a statement of this sort is not therapeutic to the adaptation of the family. Not only is “Grandparent involvement can be very disruptive to the family” invalid, it also is not an appropriate nursing response. Regardless of age, grandparents can help with parenting skills and preserve family traditions. Talking about the age of the grandparents is not the most appropriate statement, and it does not demonstrate sensitivity on the part of the nurse.
When the infant’s behaviors and characteristics call forth a corresponding set of maternal behaviors and characteristics, this is called:
a. Mutuality. c. Claiming.
b. Bonding. d. Acquaintance.
ANS: A
Mutuality extends the concept of attachment to include this shared set of behaviors. Bonding is the process over time of parents forming an emotional attachment to their infant. Mutuality refers to a shared set of behaviors that is a part of the bonding process.
Claiming is the process by which parents identify their new baby in terms of likeness to other family members and their differences and uniqueness. Mutuality refers to a shared set of behaviors that is part of the bonding process. Like mutuality, acquaintance is part of attachment. It describes how parents get to know their baby during the immediate postpartum period through eye contact, touching, and talking.
In follow-up appointments or visits with parents and their new baby, it may be useful if the nurse can identify parental behaviors that can either facilitate or inhibit attachment. What is a facilitating behavior?
a. The parents have difficulty naming the infant.
b. The parents hover around the infant, directing attention to and pointing at the infant.
c. The parents make no effort to interpret the actions or needs of the infant.
d. The parents do not move from fingertip touch to palmar contact and holding.
ANS: B
Hovering over the infant and obviously paying attention to the baby are facilitating behaviors. Inhibiting behaviors include difficulty naming the infant, making no effort to interpret the actions or needs of the infant, and not moving from fingertip touch to palmar contact and holding.
With regard to parents’ early and extended contact with their infant and the relationships built, nurses should be aware that:
a. Immediate contact is essential for the parent-child relationship.
b. Skin-to-skin contact is preferable to contact with the body totally wrapped in a blanket.
c. Extended contact is especially important for adolescents and low-income women because they are at risk for parenting inadequacies.
d. Mothers need to take precedence over their partners and other family matters.
ANS: C
Nurses should encourage any activity that optimizes family extended contact. Immediate contact facilitates the attachment process but is not essential; otherwise, adopted infants would not establish the affectionate ties they do. The mode of infant-mother contact does not appear to have any important effect. Mothers and their partners are considered equally important.
In the United States the en face position is preferred immediately after birth. Nurses can facilitate this process by all of these actions except:
a. Washing both the infant’s face and the mother’s face.
b. Placing the infant on the mother’s abdomen or breast with their heads on the same plane.
c. Dimming the lights.
d. Delaying the instillation of prophylactic antibiotic ointment in the infant’s eyes.
ANS: A
To facilitate the position in which the parent’s and infant’s faces are approximately 8 inches apart on the same plane, allowing them to make eye contact, the nurse can place the infant at the proper height on the mother’s body, dim the light so that the infant’s eyes open, and delay putting ointment in the infant’s eyes.
Other early sensual contacts between infant and mother involve sound and smell. Nurses should be aware that, despite what folk wisdom might say:
a. High-pitched voices irritate newborns.
b. Infants can learn to distinguish their mother’s voice from others soon after birth.
c. All babies in the hospital smell alike.
d. A mother’s breast milk has no distinctive odor.
ANS: B
Infants know the sound of their mother’s voice early. Infants respond positively to high-pitched voices. Each infant has a unique odor. Infants quickly learn to distinguish the odor of their mother’s breast milk.
After birth a crying infant may be soothed by being held in a position in which the newborn can hear the mother’s heartbeat. This phenomenon is known as:
a. Entrainment. c. Synchrony.
b. Reciprocity. d. Biorhythmicity.
ANS: D
The newborn is in rhythm with the mother. The infant develops a personal biorhythm with the parents’ help over time. Entrainment is the movement of newborns in time to the structure of adult speech. Reciprocity is body movement or behavior that gives cues to the person’s desires. These take several weeks to develop with a new baby. Synchrony is the fit between the infant’s behavioral cues and the parent’s responses.
Of the many factors that influence parental responses, nurses should be aware that all of these statements regarding age are true except:
a. An adolescent mother’s egocentricity and unmet developmental needs interfere with her ability to parent effectively.
b. An adolescent mother is likely to use less verbal instruction, be less responsive, and interact less positively than other mothers.
c. Adolescent mothers have a higher documented incidence of child abuse.
d. Mothers older than 35 often deal with more stress related to work and career issues and decreasing libido.
ANS: C
Adolescent mothers are more inclined to have a number of parenting difficulties that benefit from counseling, but a higher incidence of child abuse is not one of them. Midlife mothers have many competencies but are more likely to have to deal with career and sexual issues than are younger mothers.
When dealing with parents who have some form of sensory impairment, nurses should realize that all of these statements are true except:
a. One of the major difficulties visually impaired parents experience is the skepticism of health care professionals.
b. Visually impaired mothers cannot overcome the infant’s need for eye-to-eye contact.
c. The best approach for the nurse is to assess the parents’ capabilities rather than focusing on their disabilities.
d. Technologic advances, including the Internet, can provide deaf parents with a full range of parenting activities and information.
ANS: B
Other sensory output can be provided by the parent, other people can participate, and other coping devices can be used. The skepticism, open or hidden, of health care professionals places an additional and unneeded hurdle for the parents. After the parents’ capabilities have been assessed (including some the nurse may not have expected), the nurse can help find ways to assist the parents that play to their strengths. The Internet affords an extra teaching tool for the deaf, as do videos with subtitles or nurses signing. A number of electronic devices can turn sound into light flashes to help pick up a child’s cry. Sign language is acquired readily by young children.
With regard to the adaptation of other family members, mainly siblings and grandparents, to the newborn, nurses should be aware that:
a. Sibling rivalry cannot be dismissed as overblown psychobabble; negative feelings and behaviors can take a long time to blow over.
b. Participation in preparation classes helps both siblings and grandparents.
c. In the United States paternal and maternal grandparents consider themselves of equal importance and status.
d. Since 1990 the number of grandparents providing permanent care to their grandchildren has been declining.
ANS: B
Preparing older siblings and grandparents helps with everyone to adapt. Sibling rivalry should be expected initially, but the negative behaviors associated with it have been overemphasized and stop in a comparatively short time. In the United States, in contrast to other cultures, paternal grandparents frequently consider themselves secondary to maternal grandparents. The number of grandparents providing permanent child care has been rising.
Nursing activities that promote parent-infant attachment are many and varied. One activity that should not be overlooked is the management of the environment. While providing routine mother-baby care, the nurse should ensure that:
a. The baby is able to return to the nursery at night so that the new mother can sleep.
b. Routine times for care are established to reassure the parents.
c. The father should be encouraged to go home at night to prepare for mother-baby discharge.
d. An environment that fosters as much privacy as possible should be created.

ANS: D

Care providers need to knock before gaining entry. Nursing care activities should be grouped. Once the baby has demonstrated adjustment to extrauterine life (either in the mother’s room or the transitional nursery), all care should be provided in one location. This important principle of family-centered maternity care fosters attachment by giving parents the opportunity to learn about their infant 24 hours a day. One nurse should provide care to both mother and baby in this couplet care or rooming-in model. It is not necessary for the baby to return to the nursery at night. In fact, the mother will sleep better with the infant close by. Care should be individualized to meet the parents’ needs, not the routines of the staff. Teaching goals should be developed in collaboration with the parents. The father or other significant other should be permitted to sleep in the room with the mother. The maternity unit should develop policies that allow for the presence of significant others as much as the new mother desires.

The early postpartum period is a time of emotional and physical vulnerability. Many mothers can easily become psychologically overwhelmed by the reality of their new parental responsibilities. Fatigue compounds these issues. Although the baby blues are a common occurrence in the postpartum period, about one-half million women in America experience a more severe syndrome known as postpartum depression (PPD). Which statement regarding PPD is essential for the nurse to be aware of when attempting to formulate a nursing diagnosis?
a. PPD symptoms are consistently severe.
b. This syndrome affects only new mothers.
c. PPD can easily go undetected.
d. Only mental health professionals should teach new parents about this condition.
ANS: C
PPD can go undetected because parents do not voluntarily admit to this type of emotional distress out of embarrassment, fear, or guilt. PPD symptoms range from mild to severe, with women having both good and bad days. Both mothers and fathers should be screened. PPD in new fathers ranges from 1% to 26%. The nurse should include information on PPD and how to differentiate this from the baby blues for all clients on discharge. Nurses also can urge new parents to report symptoms and seek follow-up care promptly if they occur
What concerns about parenthood are often expressed by visually impaired mothers? Choose all that apply.
a. Infant safety
b. Transportation
c. The ability to care for the infant
d. Missing out visually
e. Needing extra time for parenting activities to accommodate the visual limitations
ANS: A, B, D, E
Concerns expressed by visually impaired mothers include infant safety, extra time needed for parenting activities, transportation, handling other people’s reactions, providing proper discipline, and missing out visually. Blind people sense reluctance on the part of others to acknowledge that they have a right to be parents. However, blind parents are fully capable of caring for their infants.
amniotomy
artificial rupture of the amniotic sac; done in conjunction with induction of labor, enables internal electronic fetal monitoring
risks of amniotomy
prolapse and compression of the umbilical cord, risk for infection increases the longer the membranes are ruptured, greater risk of abruption of placenta
AROM
artificial rupture of membranes
start an antibiotic
after membranes have been ruptured for more than 12 hours
after an amniotomy
check temperature every 2 hours
induction
start labor if they are past there due date, fetal compromise, chorioamniotitis, HTN, fetal death,
elective induction
a medical reason to be induced before 39 weeks
chorioamniotitis
infection of the chorion-amnion
placenta previa
implantation in lower uterus
vasa previa
umbilical vessels go over the amniotic sac rather than the placenta
contraindications in induction
placenta previa, vasa previa, abnormal presentation, umbilical cord prolapse, previous uterine surgery, nonreassuring FHR patterns
previa
first
listen to FHR
listen to this for a full minute after rupturing membranes in the mom
augmentation
having some contractions but your not progressing fast; help labor going but not in labor
ways of doing induction
cervical ripening, oxytocin administration via IV
oxytocin
diluted in an isotonic solution and given as a secondary infusion
signs of tachysystole
contraction longer than 90-120 seconds, contractions occuring less than 2 minutes apart or relaxtion of less than 30 seconds between contractions, uterine resting tone about 20mmHg, peak pressure higher than 90mmHg during first stage labor, montevideo units greater than 400, FHR late decelerations
tachysystole
FHR patterns that suggest reduced placental exchange secondary to contractions that are too strong, too long, or do not relax at least 30 minutes
intrauterine pressure catheter (IUPC)
used to measure uterine resting tone
montevideo
length of the contraction x height of the contraction in 10 minutes
nursing action for tachysystole
reduce or stop oxytocin, increase rate of primary nonadditive infusion, keep mom in lateral position, give oxygen 8-10L/min, notify physician
operative vaginal birth
forceps, vacuum extractor
forceps
used to guide a way out for the baby
vacuum extractor
used 4x as more often than forceps, also used in c-sections
trauma with operative delivery
mom: vaginal wall laceratiion, hematoma
infant: ecchymosis, lacerations, abrasions, facial nerve injury, intracranial hemorrhage
version
to change the fetus so head is down, typically used for a breached baby; usually wait until 37 weeks; external and internal which is used for twins
episiotomy
incision of the perineum just before birth, reduces pain, perineal tearing, and later pelvic relaxation have not been proven true
cesarean birth
c-section increasing in U.S. and elective c-sections is on the rise, given in obese people, preferred incision is the low transverse because it is less likely to rupture in a subsequent pregnancy
vaginal birth after cesarean (VBAC)
women have feelings of inadequacy if they have a c-section, low transverse uterine incisions reduce the risk of rupture, talk with provider to determine if a trial of labor is appropriate
physilogical effects of the birth process
contractions can be intermittent allowing placental blood flow and exchange of oxygen and nutrients and waste, upper uterus contracts actively during labor as it pushes the fetus down
effacement
getting thinner and shortening of the cervix dialates,
increment
occurs as the contractions begins in the fundus and spreads throughout the uterus
peak
also called acme, period during which the contraction is most intense
decrement
period of decreasing intensity as the uterus relaxes
physiologic effects of the fetus during birth
fetal lung fluid production decreases and its absorption into lung tissue increases during late pregnancy and labor
components of the birthing process
powers, passage, passenger, psyche
powers
strength of the contractions; uterine contractions and maternal pushing efforts
passage
how the baby is faced and coming through the pelvis;
passenger
the relation of the fetus to the maternal pelvis; the way he is facing and want vertex
psyche
are you ready?
posterior
back pain, babies back is to mom’s back
best pelvis for a vaginal delivery
gynecoid pelvis
boney pelvis
how pelvis is shaped and if they can deliver the baby vaginally
premonitory signs of labor
braxton hicks contractions, lightening, increase in clear and nonirritating vaginal secretions, “bloody show”, energy spurt, small weight loss
frank breech
feet up to the ears
true labor
has cervical change
false labor
prodromal labor
lightening
dropping, the baby is dropping
mechanisms of labor
descent, engagement of the presenting part (head goes into pelvis, widest part of the ischial spine), flexion of the fetal head, internal rotation, extension of the fetal head (comes past the symphisis pubis), external rotation, expulsion of the fetal shoulders and body
first stage of labor
latent, active, and transition phases
latent phase
beginning of labor until 3-5cm dilation
active phase
4-6cm dialation
transition phase
7cm to complete
second stage of labor
from complete to delivery, usually lasts up to 2 hours
third stage of labor
from the delivery to the placenta, from 2-20 minutes
fourth stage of labor
1-4 hours after birth, recovery time
labor progress
consistent progress of uterine contractions, effacement, normal FHR
conditions associated with fetal compromise
FHR outside of range, meconium stained amniotic fluid, foul weird color amniotic fluid (infection), excessive frequency or duration of contractions, incomplete uterine relaxation, maternal fever, maternal hyper/hypotension
meconium stained amniotic fluid
baby pooped inside of you and put stress on it
providing comfort measures
dim lights, temperature comfortable for the mom, keep them clean, positioning, give mouth care, make sure to get them up to empty bladder, encouragement, pain control
impending birth
“its coming”, grunting sounds, bearing down, check the perineum
responsibilities during birth
sterile table, perineal cleansing preparation, initial care and assessment of the newborn, administration of medication
responsibilities after birth
care of infant: promote normal respiration’s, support thermoregulation, identify infant
care of mother: observe for hemorrhage, promote further uterine contraction, promote mom-infant attachment
APGAR score
tells us how the baby is doing at 1 minute and 5 minute
childbirth pain is unique
normal and self-timing, can be prepared for, ends with babies birth, pain is psychological and physiologic expereince
adverse physiologic effects
increase inmetabolic rate and oxygen demand, increase in production of catecholamines, cortisol, glucagon, less oxygen/waste exchange for fetus
adverse psychological effects
no interaction with infant, unpleasant memories, inadequate feelings of partner
sources of pain
tissue ischemia, cervical dilation, pressure and pulling on pelvic structures, distention of the vagina and perineum
factors influencing pain: physical
intensity of labor, cervical readiness, fetal position, characteristics of the pelvis, fatigue, intervention by caregiver
factors influencing pain: psychological
culture, anxiety of fear, previous expereinces with pain, preparation for childbirth, support systems
non-pharmacologic pain management
relaxation, cutaneous and mental stimulation, breathing
pharmacologic pain management effects
effects the fetus, may alter a woman’s response, effects course of labor,
advantages of regional pain management
the woman remains awake and can participate in her birth experience, retains her airway reflex
relaxation
doing this for pain can promote blood flow to the fetus and decreases tension
regional pain management limitations
maternal hypotension, FHR changes associated with impaired placental perfusion, delayed respiratory depression, nausea and vomiting, pruritus (itching)
types of regional pain management
epidural block, intrathecal opioid analgesics, subarachnoid block
opioid analgesics
a drug you need to check for respiratory depression in the neonate
things to check for with regional pain management
ringing in the ears, metallic taste in the mouth meaning an epidural may be in the spinal fluid not dural space
general anestetics
given when mom refuses regional anesthesia or can’t get that because it can pass to the fetus
severe headaches after c-section
can be a spinal headache need to draw blood and inject it where the anesthetic was placed; blood patch
involution of the uterus: three processess
contraction of the muscle fibers, catabolic processes, regeneration of uterine epithelium,
exfoliation
the site of placental attachment heals by a process called:
14 days
after this long after delivery you shouldn’t be able to feel the fundus; goes down about 1cm a day
Ephedrine
given to raise mom’s blood pressure
lochia rubra
reddish or red brown color; usually first 3 days
lochia serosa
red pink to brown tinged
lochia alba
white, cream, yellow color
ibuprofen
given and good for uterine contractions, number of mg given is number of hours you wait between, 200mg=2hours
vagina
takes 6-10 weeks to regain its nonpregnant size and contour
perineum trauma and hemorrhoids
cause discomfort and can interfere with activity and bowel elminiation
cardiovascular system
blood from the uterus and placenta returns to the central circulation, ECF moves into the vascular compartment, CO increases and excess fluid is excreted by diuresis and diaphoresis
gastrointestinal system
constipation may occur, decreased food and fluid intake during labor, reduced muscle and bowel tone, fear of pain to poop, first stool 2-3 days after birth
urinary system
increased bladder capacity and decreased sense of fluid pressure mat result in urinary retention, UTI’s, distended bladder displaces the uterus and can interfere with uterine contractions and cause excessive bleeding
signs of distended bladder
location of fundus above baseline level, fundus displacement from midline, excessive lochia, bladder discomfort, bulge bladder above symphysis, frequent voidings of less than 150mL
musculoskeletal system
1-2 days after birth fatigue and aches,
endocrine system
integumentary: as hormone levels decline the skin gradually returns to its nonpregnant state,
breastfeeding
may delay ovulation and your period, ovulation may occur before the first period back, more likely to experience vaginal dryness that results from inadequate estrogen
homan’s sign
checking for a blood clot in the leg
risk factors for postpartum hemorrhage
grand multiparity, overdistention of uterus, c-section, fast short labor, use of vacuum, placenta previa, medications,
risk factors for postpartum infection
operative procedures, multiple cervical examinations, prolonged labor, prolonged ruptured membranes, diabetes, catheterization, manual extraction of placenta
en face
looking and laughing face to face
enfolding
bringing baby in to you
claiming
saying that they look like you in ways like you have your moms nose
puerperal phases
taking in, taking hold, letting go
taking in
mom focuses on her own needs, anxious
taking hold
more independent and manages her own body
letting go
time of relinquishment for mother and often father too
postpartum blues
baby blues, affects 70-80% of new mothers, lasts about 2 weeks, must be distinguished from postpartum depression or postpartum psychoses
A pregnant woman at 37 weeks of gestation has had ruptured membranes for 26 hours. A cesarean section is performed for failure to progress. The fetal heart rate (FHR) before birth is 180 beats/min with limited variability. At birth the newborn has Apgar scores of 6 and 7 at 1 and 5 minutes and is noted to be pale and tachypneic. On the basis of the maternal history, the cause of this newborn’s distress is most likely to be:
a. Hypoglycemia. c. Respiratory distress syndrome.
b. Phrenic nerve injury. d. Sepsis.
ANS: D
The prolonged rupture of membranes and the tachypnea (before and after birth) both suggest sepsis. An FHR of 180 beats/min is also indicative. This infant is at high risk for sepsis.
The most important nursing action in preventing neonatal infection is:
a. Good handwashing. c. Separate gown technique.
b. Isolation of infected infants. d. Standard Precautions.
ANS: A
Virtually all controlled clinical trials have demonstrated that effective handwashing is responsible for the prevention of nosocomial infection in nursery units. Measures to be taken include Standard Precautions, careful and thorough cleaning, frequent replacement of used equipment, and disposal of excrement and linens in an appropriate manner. Overcrowding must be avoided in nurseries. However, the most important nursing action for preventing neonatal infection is effective handwashing.
A pregnant woman presents in labor at term, having had no prenatal care. After birth her infant is noted to be small for gestational age with small eyes and a thin upper lip. The infant also is microcephalic. On the basis of her infant’s physical findings, this woman should be questioned about her use of which substance during pregnancy?
a. Alcohol c. Heroin
b. Cocaine d. Marijuana
ANS: A
The description of the infant suggests fetal alcohol syndrome, which is consistent with maternal alcohol consumption during pregnancy. Fetal brain, kidney, and urogenital system malformations have been associated with maternal cocaine ingestions. Heroin use in pregnancy frequently results in intrauterine growth restriction. The infant may have a shrill cry and sleep cycle disturbances and present with poor feeding, tachypnea, vomiting, diarrhea, hypothermia or hyperthermia, and sweating. Studies have found a higher incidence of meconium staining in infants born of mothers who used marijuana during pregnancy.
A plan of care for an infant experiencing symptoms of drug withdrawal should include:
a. Administering chloral hydrate for sedation.
b. Feeding every 4 to 6 hours to allow extra rest.
c. Swaddling the infant snugly and holding the baby tightly.
d. Playing soft music during feeding.
ANS: C
The infant should be wrapped snugly to reduce self-stimulation behaviors and protect the skin from abrasions. Phenobarbital or diazepam may be administered to decrease central nervous system (CNS) irritability. The infant should be fed in small, frequent amounts and burped well to diminish aspiration and maintain hydration. The infant should not be stimulated (such as with music) because this will increase activity and potentially increase CNS irritability.
Human immunodeficiency virus (HIV) may be perinatally transmitted:
a. Only in the third trimester from the maternal circulation.
b. By a needlestick injury at birth from unsterile instruments.
c. Only through the ingestion of amniotic fluid.
d. Through the ingestion of breast milk from an infected mother.
ANS: D
Postnatal transmission of HIV through breastfeeding may occur. Transmission of HIV from the mother to the infant may occur transplacentally at various gestational ages. Transmission close to or at the time of birth is thought to account for 50% to 80% of cases.
The abuse of which of the following substances during pregnancy is the leading cause of cognitive impairment in the United States?
a. Alcohol c. Marijuana
b. Tobacco d. Heroin
ANS: A
Alcohol abuse during pregnancy is recognized as one of the leading causes of cognitive impairment in the United States.
During a prenatal examination, the woman reports having two cats at home. The nurse informs her that she should not be cleaning the litter box while she is pregnant. When the woman asks why, the nurse’s best response would be:
a. “Your cats could be carrying toxoplasmosis. This is a zoonotic parasite that can infect you and have severe effects on your unborn child.”
b. “You and your baby can be exposed to the human immunodeficiency virus (HIV) in your cats’ feces.”
c. “It’s just gross. You should make your husband clean the litter boxes.”
d. “Cat feces are known to carry Escherichia coli, which can cause a severe infection in both you and your baby.”
ANS: A
Toxoplasmosis is a multisystem disease caused by the protozoal Toxoplasma gondii parasite, commonly found in cats, dogs, pigs, sheep, and cattle. About 30% of women who contract toxoplasmosis during gestation transmit the disease to their offspring. Clinical features ascribed to toxoplasmosis include hydrocephalus or microcephaly, chorioretinitis, seizures, or cerebral calcifications. HIV is not transmitted by cats. Although suggesting that the woman’s husband clean the litter boxes may be a valid statement, it is not appropriate, does not answer the client’s question, and is not the nurse’s best response. E. coli is found in normal human fecal flora. It is not transmitted by cats.
A primigravida has just delivered a healthy infant girl. The nurse is about to administer erythromycin ointment in the infant’s eyes when the mother asks, “What is that medicine for?” The nurse responds:
a. “It is an eye ointment to help your baby see you better.”
b. “It is to protect your baby from contracting herpes from your vaginal tract.”
c. “Erythromycin is given prophylactically to prevent a gonorrheal infection.”
d. “This medicine will protect your baby’s eyes from drying out over the next few days.”

ANS: C

With the prophylactic use of erythromycin, the incidence of gonococcal conjunctivitis has declined to less than 0.5%. Eye prophylaxis is administered at or shortly after birth to prevent ophthalmia neonatorum. Erythromycin has no bearing on enhancing vision, is used to prevent an infection caused by gonorrhea, not herpes, and is not used for eye lubrication.

With regard to skeletal injuries sustained by a neonate during labor or birth, nurses should be aware that:
a. A newborn’s skull is still forming and fractures fairly easily.
b. Unless a blood vessel is involved, linear skull fractures heal without special treatment.
c. Clavicle fractures often need to be set with an inserted pin for stability.
d. Other than the skull, the most common skeletal injuries are to leg bones.
ANS: B
About 70% of neonatal skull fractures are linear. Because the newborn skull is flexible, considerable force is required to fracture it. Clavicle fractures need no special treatment. The clavicle is the bone most often fractured during birth.
With regard to injuries to the infant’s plexus during labor and birth, nurses should be aware that:
a. If the nerves are stretched with no avulsion, they should recover completely in 3 to 6 months.
b. Erb palsy is damage to the lower plexus.
c. Parents of children with brachial palsy are taught to pick up the child from under the axillae.
d. Breastfeeding is not recommended for infants with facial nerve paralysis until the condition resolves.
ANS: A
If the nerves are stretched with no avulsion, they should recover completely in 3 to 6 months. However, if the ganglia are disconnected completely from the spinal cord, the damage is permanent. Erb palsy is damage to the upper plexus and is less serious than brachial palsy. Parents of children with brachial palsy are taught to avoid picking up the child under the axillae or by pulling on the arms. Breastfeeding is not contraindicated, but both the mother and infant will need help from the nurse at the start.
With regard to central nervous system injuries to the infant during labor and birth, nurses should be aware that:
a. Intracranial hemorrhage (ICH) as a result of birth trauma is more likely to occur in the preterm, low-birth-weight infant.
b. Subarachnoid hemorrhage (the most common form of ICH) occurs in term infants as a result of hypoxia.
c. In many infants signs of hemorrhage in a full-term infant are absent and diagnosed only through laboratory tests.
d. Spinal cord injuries almost always result from forceps-assisted deliveries.
ANS: C
Abnormalities in lumbar punctures or red blood cell counts, for instance, or in visuals on computed tomography scan might reveal a hemorrhage. ICH as a result of birth trauma is more likely to occur in the full-term, large infant. Subarachnoid hemorrhage in term infants is a result of trauma; in preterm infants it is a result of hypoxia. Spinal cord injuries are almost always from breech births; they are rare today because cesarean birth often is used for breech presentation
With regard to the classification of neonatal bacterial infection, nurses should be aware that:
a. Congenital infection progresses slower than nosocomial infection.
b. Nosocomial infection can be prevented by effective handwashing; early-onset infections cannot.
c. Infections occur with about the same frequency in boy and girl infants, although female mortality is higher.
d. The clinical sign of a rapid, high fever makes infection easier to diagnose.
ANS: B
Handwashing is an effective preventive measure for late-onset (nosocomial) infections because these infections come from the environment around the infant. Early-onset, or congenital, infections are caused by the normal flora at the maternal vaginal tract and progress more rapidly than nosocomial (late-onset) infections. Infection occurs about twice as often in boys and results in higher mortality. Clinical signs of neonatal infection are nonspecific and similar to noninfectious problems, making diagnosis difficult.
Near the end of the first week of life an infant who has not been treated for any infection develops a copper-colored, maculopapular rash on the palms and around the mouth and anus. The newborn is showing signs of:
a. Gonorrhea. c. Congenital syphilis.
b. Herpes simplex virus infection. d. Human immunodeficiency virus.
ANS: C
The rash is indicative of congenital syphilis. The lesions may extend over the trunk and extremities
What bacterial infection is definitely decreasing because of effective drug treatment?
a. Escherichia coli infection c. Candidiasis
b. Tuberculosis d. Group B streptococcal infection
ANS: D
Penicillin has significantly decreased the incidence of group B streptococcal infection. E. coli may be increasing, perhaps because of the increasing use of ampicillin (resulting in a more virulent E. coli resistant to the drug). Tuberculosis is increasing in the United States and Canada. Candidiasis is a fairly benign fungal infection.
In caring for the mother who has abused (or is abusing) alcohol and for her infant, nurses should be aware that:
a. The pattern of growth restriction of the fetus begun in prenatal life is halted after birth, and normal growth takes over.
b. Two thirds of newborns with fetal alcohol syndrome (FAS) are boys.
c. Alcohol-related neurodevelopmental disorders not sufficient to meet FAS criteria (learning disabilities, speech and language problems) are often not detected until the child goes to school.
d. Both the distinctive facial features of the FAS infant and the diminished mental capacities tend toward normal over time.
ANS: C
Some learning problems do not become evident until the child is at school. The pattern of growth restriction persists after birth. Two thirds of newborns with FAS are girls. Although the distinctive facial features of the FAS infant tend to become less evident, the mental capacities never become normal.
A careful review of the literature on the various recreational and illicit drugs reveals that:
a. More longer-term studies are needed to assess the lasting effects on infants when mothers have taken or are taking illegal drugs.
b. Heroin and methadone cross the placenta; marijuana, cocaine, and phencyclidine (PCP) do not.
c. Mothers should get off heroin (detox) any time they can during pregnancy.
d. Methadone withdrawal for infants is less severe and shorter than heroin withdrawal.
ANS: A
Studies on the effects of marijuana and cocaine use by mothers are somewhat contradictory. More long-range studies are needed. Just about all of these drugs cross the placenta, including marijuana, cocaine, and PCP. Drug withdrawal is accompanied by fetal withdrawal, which can lead to fetal death. Therefore detoxification from heroin is not recommended, particularly later in pregnancy. Methadone withdrawal is more severe and more prolonged than heroin withdrawal.
With regard to the understanding and treatment of infants born to mothers who are substance abusers, nurses should be aware that:
a. Infants born to addicted mothers are also addicted.
b. Mothers who abuse one substance likely will use or abuse another, compounding the infant’s difficulties.
c. The NICU Network Neurobehavioral Scale (NNNS) is designed to assess the damage the mother has done to herself.
d. No laboratory procedures are available that can identify the intrauterine drug exposure of the infant.
ANS: B
Multiple substance use (even just alcohol and tobacco) makes it difficult to assess the problems of the exposed infant, particularly with regard to withdrawal manifestations. Infants of substance-abusing mothers may have some of the physiologic signs but are not addicted in the behavioral sense. “Drug-exposed newborn” is a more accurate description than “addict.” The NNNS is designed to assess the neurologic, behavioral, and stress/abstinence function of the neonate. Newborn urine, hair, or meconium sampling may be used to identify an infant’s intrauterine drug exposure.
Providing care for the neonate born to a mother who abuses substances can present a challenge for the health care team. Nursing care for this infant requires a multisystem approach. The first step in the provision of this care is:
a. Pharmacologic treatment.
b. Reduction of environmental stimuli.
c. Neonatal abstinence syndrome scoring.
d. Adequate nutrition and maintenance of fluid and electrolyte balance.

ANS: C

Neonatal abstinence syndrome (NAS) is the term used to describe the cohort of symptoms associated with drug withdrawal in the neonate. The Neonatal Abstinence Scoring System evaluates CNS, metabolic, vasomotor, respiratory, and gastrointestinal disturbances. This evaluation tool enables the care team to develop an appropriate plan of care. The infant is scored throughout the length of stay, and the treatment plan is adjusted accordingly. Pharmacologic treatment is based on the severity of withdrawal symptoms. Symptoms are determined by using a standard assessment tool. Medications of choice are morphine, phenobarbital, diazepam, or diluted tincture of opium. Swaddling, holding, and reducing environmental stimuli are essential in providing care to the infant who is experiencing withdrawal. These nursing interventions are appropriate for the infant who displays central nervous system (CNS) disturbances. Poor feeding is one of the gastrointestinal symptoms common to this client population. Fluid and electrolyte balance must be maintained, and adequate nutrition provided. These infants often have a poor suck reflex and may need to be fed via gavage.

While completing a newborn assessment, the nurse should be aware that the most common birth injury is:
a. To the soft tissues.
b. Caused by forceps gripping the head on delivery.
c. Fracture of the humerus and femur.
d. Fracture of the clavicle.
ANS: D
The most common birth injury is fracture of the clavicle (collarbone). It usually heals without treatment, although the arm and shoulder may be immobilized for comfort.
The most common cause of pathologic hyperbilirubinemia is:
a. Hepatic disease. c. Postmaturity.
b. Hemolytic disorders in the newborn. d. Congenital heart defect.
ANS: B
Hemolytic disorders in the newborn are the most common cause of pathologic jaundice. Hepatic damage may be a cause of pathologic hyperbilirubinemia, but it is not the most common cause. Prematurity would be a potential cause of pathologic hyperbilirubinemia in neonates, but it is not the most common cause. Congenital heart defect is not a common cause of pathologic hyperbilirubinemia in neonates.
Which infant would be more likely to have Rh incompatibility?
a. Infant of an Rh-negative mother and a father who is Rh positive and homozygous for the Rh factor
b. Infant who is Rh negative and whose mother is Rh negative
c. Infant of an Rh-negative mother and a father who is Rh positive and heterozygous for the Rh factor
d. Infant who is Rh positive and whose mother is Rh positive
ANS: A
If the mother is Rh negative and the father is Rh positive and homozygous for the Rh factor, all the offspring will be Rh positive. Only Rh-positive offspring of an Rh-negative mother are at risk for Rh incompatibility. If the mother is Rh negative and the father is Rh positive and heterozygous for the factor, there is a 50% chance that each infant born of the union will be Rh positive and a 50% chance that each will be born Rh negative.
A major nursing intervention for an infant born with myelomeningocele is to:
a. Protect the sac from injury.
b. Prepare the parents for the child’s paralysis from the waist down.
c. Prepare the parents for closure of the sac at around 2 years of age.
d. Assess for cyanosis.
ANS: A
A major preoperative nursing intervention for a neonate with a myelomeningocele is protection of the protruding sac from injury to prevent its rupture and the resultant risk of central nervous system infection. The long-term prognosis in an affected infant can be determined to a large extent at birth with the degree of neurologic dysfunction related to the level of the lesion, which determines the nerves involved. A myelomeningocele should be surgically closed within 24 hours. Although the nurse would assess for multiple potential problems in this infant, the major nursing intervention would be to protect the sac from injury.
The priority nursing diagnosis for a newborn diagnosed with a diaphragmatic hernia would be:
a. Risk for impaired parent-infant attachment.
b. Imbalanced nutrition: less than body requirements.
c. Risk for infection.
d. Impaired gas exchange.
ANS: D
Herniation of the abdominal viscera into the thoracic cavity may cause severe respiratory distress and represent a neonatal emergency. Oxygen therapy, mechanical ventilation, and the correction of acidosis are necessary in infants with large defects. Although the nursing diagnoses of Risk for impaired parent-infant attachment, Imbalanced nutrition: less than body requirements, and Risk for infection may be factors in providing care to a newborn with a diaphragmatic hernia, the priority nursing diagnosis relates to the oxygenation issues arising from the lung hypoplasia that occurs with diaphragmatic hernia.
An infant diagnosed with erythroblastosis fetalis would characteristically exhibit:
a. Edema. c. Enlargement of the heart.
b. Immature red blood cells. d. Ascites.
ANS: B
Erythroblastosis fetalis occurs when the fetus compensates for the anemia associated with Rh incompatibility by producing large numbers of immature erythrocytes to replace those hemolyzed. Edema would occur with hydrops fetalis, a more severe form of erythroblastosis fetalis. The fetus with hydrops fetalis may exhibit effusions into the peritoneal, pericardial, and pleural spaces. The infant with hydrops fetalis displays signs of ascites.
With regard to hemolytic diseases of the newborn, nurses should be aware that:
a. Rh incompatibility matters only when an Rh-negative offspring is born to an Rh-positive mother.
b. ABO incompatibility is more likely than Rh incompatibility to precipitate significant anemia.
c. Exchange transfusions frequently are required in the treatment of hemolytic disorders.
d. The indirect Coombs’ test is performed on the mother before birth; the direct Coombs’ test is performed on the cord blood after birth.
ANS: D
An indirect Coombs’ test may be performed on the mother a few times during pregnancy. Only the Rh-positive offspring of an Rh-negative mother is at risk. ABO incompatibility is more common than Rh incompatibility but causes less severe problems; significant anemia, for instance, is rare with ABO. Exchange transfers are needed infrequently because of the decrease in the incidence of severe hemolytic disease in newborns from Rh incompatibility.
With regard to congenital anomalies of the cardiovascular and respiratory systems, nurses should be aware that:
a. Cardiac disease may be manifested by respiratory signs and symptoms.
b. Screening for congenital anomalies of the respiratory system need only be done for infants having respiratory distress.
c. Choanal atresia can be corrected by a suction catheter.
d. Congenital diaphragmatic hernias are diagnosed and treated after birth.
ANS: A
The cardiac and respiratory systems function together. Screening for congenital respiratory system anomalies is necessary even for infants who appear normal at birth.
Choanal atresia requires emergency surgery. Congenital diaphragmatic hernias are discovered prenatally on ultrasound.
When attempting to diagnose and treat developmental dysplasia of the hip (DDH), the nurse should:
a. Be able to perform the Ortolani and Barlow tests.
b. Teach double or triple diapering for added support.
c. Explain to the parents the need for serial casting.
d. Carefully monitor infants for DDH at follow-up visits.
ANS: D
Because DDH often is not detected at birth, infants should be monitored carefully at follow-up visits. The Ortolani and Barlow tests must be performed by experienced clinicians to prevent fracture or other damage to the hip. Double or triple diapering is not recommended because it promotes hip extension, thus worsening the problem. Serial casting is done for clubfeet, not DDH.
Cleft lip or palate is a common congenital midline fissure, or opening, in the lip or palate resulting from failure of the primary palate to fuse. Multiple genetic and to a lesser extent environmental factors may lead to the development of a cleft lip or palate. Such factors include (choose all that apply):
a. Alcohol consumption.
b. Female gender.
c. Use of some antiepileptics.
d. Maternal cigarette smoking.
e. Antibiotic use in pregnancy.
ANS: A, C, D
Factors that are associated with the potential development of cleft lip or palate are maternal infections, radiation exposure, corticosteroids, anticonvulsants, male gender, Native American or Asian descent, and smoking during pregnancy. Cleft lip is more common in male infants. Antibiotic use in pregnancy is not associated with the development of cleft lip or palate
Many common drugs of abuse cause significant physiologic and behavioral problems in infants who are breastfed by mothers currently using (choose all that apply):
a. Amphetamine.
b. Heroin.
c. Nicotine.
d. PCP.
e. Morphine.
ANS: A, B, C, D
Amphetamine, heroin, nicotine, and PCP are contraindicated during breastfeeding because of the reported effects on the infant. Morphine is a medication that often is used to treat neonatal abstinence syndrome.
A 25-year-old gravida 2, para 2-0-0-2 gave birth 4 hours ago to a 9-pound, 7-ounce boy after augmentation of labor with Pitocin. She puts on her call light and asks for her nurse right away, stating, “I’m bleeding a lot.” The most likely cause of postpartum hemorrhage in this woman is:
a. Retained placental fragments. c. Uterine atony.
b. Unrepaired vaginal lacerations. d. Puerperal infection.
ANS: C
This woman gave birth to a macrosomic boy after Pitocin augmentation. The most likely cause of bleeding 4 hours after delivery, combined with these risk factors, is uterine atony. Although retained placental fragments may cause postpartum hemorrhage, this typically would be detected in the first hour after delivery of the placenta and is not the most likely cause of hemorrhage in this woman. Although unrepaired vaginal lacerations may cause bleeding, they typically would occur in the period immediately after birth. Puerperal infection can cause subinvolution and subsequent bleeding, but it typically would be detected 24 hours after delivery.
On 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 first action is to:
a. Begin an intravenous (IV) infusion of Ringer’s lactate solution.
b. Assess the woman’s vital signs.
c. Call the woman’s primary health care provider.
d. Massage the woman’s fundus.
ANS: D
The nurse should assess the uterus for atony. Uterine tone must be established to prevent excessive blood loss. The nurse may begin an IV infusion to restore circulatory volume, but this would not be the first action. Blood pressure is not a reliable indicator of impending shock from impending hemorrhage; assessing vital signs should not be the nurse’s first action. The physician would be notified after the nurse completes the assessment of the woman.
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?
a. The woman is a gravida 2, para 2.
b. The woman had a vacuum-assisted birth.
c. The woman received epidural anesthesia.
d. The woman has an episiotomy.
ANS: D
These orders are typical interventions for a woman who has had an episiotomy, lacerations, and hemorrhoids. A multiparous classification is not an indication for these orders. A vacuum-assisted birth may be used in conjunction with an episiotomy, which would indicate these interventions. Use of epidural anesthesia has no correlation with these orders
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?
a. Rubella vaccine should be given.
b. A blood transfusion is necessary.
c. Rh immune globulin is necessary within 72 hours of birth.
d. A Kleihauer-Betke test should be performed.
ANS: A
This client’s rubella titer indicates that she is not immune and that she needs to receive a vaccine. These data do not indicate that the client needs a blood transfusion. Rh immune globulin is indicated only if the client has a negative Rh status and the infant has a positive Rh status. A Kleihauer-Betke test should be performed if a large fetomaternal transfusion is suspected, especially if the mother is Rh negative. The data do not provide any indication for performing this test.
A woman gave birth 48 hours ago to a healthy infant girl. She has decided to bottle-feed. During your assessment you notice that both of her breasts are swollen, warm, and tender on palpation. The woman should be advised that this condition can best be treated by:
a. Running warm water on her breasts during a shower.
b. Applying ice to the breasts for comfort.
c. Expressing small amounts of milk from the breasts to relieve pressure.
d. Wearing a loose-fitting bra to prevent nipple irritation.
ANS: B
Applying ice to the breasts for comfort is appropriate for treating engorgement in a mother who is bottle-feeding. This woman is experiencing engorgement, which can be treated by using ice packs (since she is not breastfeeding) and cabbage leaves. A bottle-feeding mother should avoid any breast stimulation, including pumping or expressing milk. A bottle-feeding mother should wear a well-fitted support bra or breast binder continuously for at least the first 72 hours after giving birth. A loose-fitting bra will not aid lactation suppression. Furthermore, the shifting of the bra against the breasts may stimulate the nipples and thereby stimulate lactation.
A 25-year-old multiparous woman gave birth to an infant boy 1 day ago. Today her husband brings a large container of brown seaweed soup to the hospital. When the nurse enters the room, the husband asks for help with warming the soup so that his wife can eat it. The nurse’s most appropriate response is to ask the woman:
a. “Didn’t you like your lunch?”
b. “Does your doctor know that you are planning to eat that?”
c. “What is that anyway?”
d. “I’ll warm the soup in the microwave for you.”
ANS: D
“I’ll warm the soup in the microwave for you” shows cultural sensitivity to the dietary preferences of the woman and is the most appropriate response.
Cultural dietary preferences must be respected. Women may request that family members bring favorite or culturally appropriate foods to the hospital. “What is that anyway?” does not show cultural sensitivity.
A primiparous woman is to be discharged from the hospital tomorrow with her infant girl. Which behavior indicates a need for further intervention by the nurse before the woman can be discharged?
a. The woman leaves the infant on her bed while she takes a shower.
b. The woman continues to hold and cuddle her infant after she has fed her.
c. The woman reads a magazine while her infant sleeps.
d. The woman changes her infant’s diaper and then shows the nurse the contents of the diaper.

ANS: A

Leaving an infant on a bed unattended is never acceptable for various safety reasons. Holding and cuddling the infant after feeding and reading a magazine while the infant sleeps are appropriate parent-infant interactions. Changing the diaper and then showing the nurse the contents of the diaper is appropriate because the mother is seeking approval from the nurse and notifying the nurse of the infant’s elimination patterns.

What would prevent early discharge of a postpartum woman?
a. Hemoglobin <10 g
b. Birth at 38 weeks of gestation
c. Voids about 200 to 300 ml per void
d. Episiotomy that shows slight redness and edema and is dry and approximated
ANS: A
The mother’s hemoglobin should be above 10 g for early discharge. The birth of an infant at term is not a criterion that would prevent early discharge. A normal voiding volume is 200 to 300 ml per void and does not indicate that the woman should not be discharged early. A normal episiotomy would show slight redness and edema and would be dry and approximated and would not prevent a woman from being discharged early.
Which finding could prevent early discharge of a newborn who is now 12 hours old?
a. Birth weight of 3000 g
b. One meconium stool since birth
c. Voided, clear, pale urine three times since birth
d. Infant breastfed once with some difficulty latching on and sucking and once with some success for about 5 minutes on each breast.
ANS: D
Infant breastfed once with some difficulty latching on and sucking and once with some success for about 5 minutes on each breast indicates that the infant is having some difficulty with breastfeeding. The infant needs to complete at least two successful feedings (normal sucking and swallowing) before an early discharge. Birth weight of 3000 g; one meconium stool since birth; and voided, clear, pale urine three times since birth are normal infant findings and would not prevent early discharge.
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.
ANS: A
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.
The trend in the United States is for women to remain hospitalized no longer than 1 or 2 days after giving birth for all of the following reasons except:
a. A wellness orientation rather than a sick-care model.
b. A desire to reduce health care costs.
c. Consumer demand for fewer medical interventions and more family-focused experiences.
d. Less need for nursing time as a result of more medical and technologic advances and devices available at home that can provide information.
ANS: D
Nursing time and care are in demand as much as ever; the nurse just has to do things more quickly. A wellness orientation seems to focus on getting clients out the door sooner. Less hospitalization means lower costs in most cases. People believe the family gives more nurturing care than the institution
In the recovery room, if a woman is asked either to raise her legs (knees extended) off the bed or to flex her knees, place her feet flat on the bed, and raise her buttocks well off the bed, most likely she is being tested to see whether she:
a. Has recovered from epidural or spinal anesthesia.
b. Has hidden bleeding underneath her.
c. Has regained some flexibility.
d. Is a candidate to go home after 6 hours.
ANS: A
If the numb or prickly sensations are gone from her legs after these movements, she likely has recovered from the epidural or spinal anesthesia.
Under the Newborns’ and Mothers’ Health Protection Act, all health plans are required to allow new mothers and newborns to remain in the hospital for a minimum of _____ hours after a normal vaginal birth and for _____ hours after a cesarean birth.
a. 24, 73 c. 48, 96
b. 24, 96 d. 48, 120
ANS: C
The specified stays are 48 hours (2 days) for a vaginal birth and 96 hours (4 days) for a cesarean birth. The attending provider and the mother together can decide on an earlier discharge.
In a variation of rooming-in, called couplet care, the mother and infant share a room, and the mother shares the care of the infant with:
a. The father of the infant.
b. Her mother (the infant’s grandmother).
c. Her eldest daughter (the infant’s sister).
d. The nurse.
ANS: D
In couplet care the mother shares a room with the newborn and shares infant care with a nurse educated in maternity and infant care.
Nursing care in the fourth trimester includes an important intervention sometimes referred to as taking the time to mother the mother. Specifically this expression refers to:
a. Formally initializing individualized care by confirming the woman’s and infant’s identification (ID) numbers on their respective wrist bands. (“This is your baby.”)
b. Teaching the mother to check the identity of any person who comes to remove the baby from the room. (“It’s a dangerous world out there.”)
c. Including other family members in the teaching of self-care and child care. (“We’re all in this together.”)
d. Nurturing the woman by providing encouragement and support as she takes on the many tasks of motherhood.

ANS: D

Many professionals believe that the nurse’s nurturing and support function is more important than providing physical care and teaching. Matching ID wrist bands is more of a formality, but it is also a get-acquainted procedure. “Mothering the mother” is more a process of encouraging and supporting the woman in her new role. Having the mother check IDs is a security measure for protecting the baby from abduction. Teaching the whole family is just good nursing practice.
ANS: D

Many professionals believe that the nurse’s nurturing and support function is more important than providing physical care and teaching. Matching ID wrist bands is more of a formality, but it is also a get-acquainted procedure. “Mothering the mother” is more a process of encouraging and supporting the woman in her new role. Having the mother check IDs is a security measure for protecting the baby from abduction. Teaching the whole family is just good nursing practice.

A hospital has a number of different perineal pads available for use. A nurse is observed soaking several of them and writing down what she sees. This activity indicates that the nurse is trying to:
a. Improve the accuracy of blood loss estimation, which usually is a subjective assessment.
b. Determine which pad is best.
c. Demonstrate that other nurses usually underestimate blood loss.
d. Reveal to the nurse supervisor that one of them needs some time off.
ANS: A
Saturation of perineal pads is a critical indicator of excessive blood loss, and anything done to aid in assessment is valuable. The nurse is noting the saturation volumes and soaking appearances. It’s possible the nurse if trying to determine which pad is best, but it is more likely that the nurse is noting saturation volumes and soaking appearances to improve the accuracy of blood loss estimation. Nurses usually overestimate blood loss, if anything. It is more likely that the nurse is noting saturation volumes and soaking appearances to improve the accuracy of blood loss estimation.
Excessive blood loss after childbirth can have several causes; the most common is:
a. Vaginal or vulvar hematomas.
b. Unrepaired lacerations of the vagina or cervix.
c. Failure of the uterine muscle to contract firmly.
d. Retained placental fragments.
ANS: C
Uterine atony can best be thwarted by maintaining good uterine tone and preventing bladder distention. Although vaginal or vulvar hematomas, unpaired lacerations of the vagina or cervix, and retained placental fragments are possible causes of excessive blood loss, uterine muscle failure (uterine atony) is the most common cause.
Because a full bladder prevents the uterus from contracting normally, nurses intervene to help the woman empty her bladder spontaneously as soon as possible. If all else fails, the last thing the nurse might try is:
a. Pouring water from a squeeze bottle over the woman’s perineum.
b. Placing oil of peppermint in a bedpan under the woman.
c. Asking the physician to prescribe analgesics.
d. Inserting a sterile catheter.
ANS: D
Invasive procedures usually are the last to be tried, especially with so many other simple and easy methods available (e.g., water, peppermint vapors, pain pills). Pouring water over the perineum may stimulate voiding. It is easy, noninvasive, and should be tried early. The oil of peppermint releases vapors that may relax the necessary muscles. It is easy, noninvasive, and should be tried early. If the woman is anticipating pain from voiding, pain medications may be helpful. Other nonmedical means could be tried first, but medications still come before insertion of a catheter.
If a woman is at risk for thrombus and is not ready to ambulate, nurses might intervene by doing all of these interventions except:
a. Putting her in antiembolic stockings (TED hose) and/or sequential compression device (SCD) boots.
b. Having her flex, extend, and rotate her feet, ankles, and legs.
c. Having her sit in a chair.
d. Notifying the physician immediately if a positive Homans’ sign occurs.
ANS: C
Sitting immobile in a chair will not help. Bed exercise and prophylactic footwear might.TED hose and SCD boots are recommended. Bed exercises, such as flexing, extending, and rotating her feet, ankles, and legs, are useful. A positive Homans’ sign (calf muscle pain or warmth, redness, or tenderness) requires the physician’s immediate attention.
With regard to rubella and Rh issues, nurses should be aware that:
a. Breastfeeding mothers cannot be vaccinated with the live attenuated rubella virus.
b. Women should be warned that the rubella vaccination is teratogenic and that they must avoid pregnancy for 1 month after vaccination.
c. Rh immune globulin is safely administered intravenously because it cannot harm a nursing infant.
d. Rh immune globulin boosts the immune system and thereby enhances the effectiveness of vaccinations.
ANS: B
Women should understand they must practice contraception for 1 month after being vaccinated. Because the live attenuated rubella virus is not communicable in breast milk, breastfeeding mothers can be vaccinated. Rh immune globulin is administered intramuscularly; it should never be given to an infant. Rh immune globulin suppresses the immune system and therefore might thwart the rubella vaccination
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.
ANS: A
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
A recently delivered mother and her baby are at the clinic for a 6-week postpartum checkup. The nurse should be concerned that psychosocial outcomes are not being met if the woman:
a. Discusses her labor and birth experience excessively.
b. Believes that her baby is more attractive and clever than any others.
c. Has not given the baby a name.
d. Has a partner or family members who react very positively about the baby.

ANS: C

If the mother is having difficulty naming her new infant, it may be a signal that she is not adapting well to parenthood. Other red flags include refusal to hold or feed the baby, lack of interaction with the infant, and becoming upset when the baby vomits or needs a diaper change. A new mother who is having difficulty would be unwilling to discuss her labor and birth experience. An appropriate nursing diagnosis might be impaired parenting related to a long, difficult labor or unmet expectations of birth. A mother who is willing to discuss her birth experience is making a healthy personal adjustment. The mother who is not coping well would find her baby unattractive and messy. She may also be overly disappointed in the baby’s sex. The client might voice concern that the baby reminds her of a family member whom she does not like. Having a partner and/or other family members react positively is an indication that this new mother has a good support system in place. This support system will help reduce anxiety related to her new role as a mother.

gametogenesis
produces ova and sperm that have half the full number of chromosomes
half the chromosomes from:
mom and half from dad
ova
not produced
23
# of unpaired chromosomes
after conception 46
# paired chromosomes
no new ova are formed after:
30 weeks
22
# of autosomes and one X chromosome (female)
a man
continuously produce sperm throughout life
x
girl
y
boy
fallopian tubes
where do eggs get fertilized
conception
requires correct timing between ovulation and ejaculation
1-2 days
sperm last only
fertilize egg
sperm can only have 24 hours to
ovulation
temp may change before
mittelschmerz
pain during ovulation
sperm
can’t survive in warm envirnoments
pre-embryonic period
initiation of cell division,
inner cell becomes
the fetus
outer cell becomes
the placenta
full term pregnancy
38-42 weeks
preterm pregnancy
under 38 weeks
embryonic period
3rd week to the 8th week after conception
by the end of the 8th week
all major organ systems are in place
teratogens
may cause major structural and functional damage to the developing organs during the embryonic period
fetal period
beginning at 9 weeks after conception; embryo is now the fetus; CNS can be vulnerable
CRL
crown rump length; measure of the top of the head to your tailbone
6 weeks
fingers toes start to develop
miscarriage
spontaneous abortion
placenta
an embryonic or fetal organ with metabolic, respiratory and endocrine functions
amniotic fluid
cushions the fetus, allows development, maintains stable temp, babies urine
amnion
inner membrane,
chorion
outer membrane, really thin like “saran wrap”
not enough amniotic fluid:
can compromise the physical growth of the fetus, baby might have a kidney problem or is stressed
umbilical cord
one vein and two arteries
2 arteries in the cord (opposite of us)
carry away metabolic waste and deoxygenated blood to the placenta
1 veins in the cord (opposite of us)
carries oxygenated and nutrient rich blood to the fetus
chorionic villus
part of the placenta, has a lot of capillaries, can be tested and drawn up through the mom’s belly or vaginally for genetic testing and can do it earlier in pregnancy at 8 weeks
amniocentesis
also referred to as amniotic fluid test or AFT is a medical procedure used in prenatal diagnosis for development of lungs, genetic problems; there are risks
advanced maternal age
35 years old
velamentous insertion of umbilical cord
where the cord vessels branch far out on membranes; if membrane is ruptured can cause fetus to bleed out
wharton’s jelly
reduces compression and torsion of the umbilical vessels; cushioning around the umbilical arteries and vein; if not enough can cause fetal demise by compressing the vein
over 50%
cord compression’s on the fetus
patent ductus
where fetus circulation doesn’t go to human circulation after birth for more than a few weeks
multifetal pregnancy
twins; most common type
monozygotic twins
identical twins, same sex, from one split zygote, two separate sacs
dizygotic twins
2 zygote, older moms and african americans are common and women who take infertility drugs
1 sac with two babies
not common
reproductive system
there is a predictable growth in preganacy, measure from the symphysis pubis up to the top of the uterus (fundus) in cm
umbilicus (important)
the uterus can be palpated at 20 weeks of gestation
at 36 weeks
the measurement of the pubic symphysis to fundus reaches the xiphoid process
helps estimate of delivery
the measurement of the pubic symphysis to fundus
mucous
fills the cervical canal and protects the fetus from infection; normal to lose some of this during pregnancy
breasts
change in size and appearance, estrogen stimulates growth of mammary tissues, progesterone stimulates growth of lobes, lobules, and alveoli
colostrum is
present at 12-16 weeks pregnancy (liquid out breasts)
expanded blood volume
increases cardiac output but NOT blood pressure
supine hypotensive syndrome
occurs because the gravid uterus partially occludes the vena cava and aorta when mother is on their back because the uterus pushes down
plasma volume expansion
results in physiologic anemia
Hg and Hc
normal to have 11 and 33 in the first and third trimester
diastolic and systolic BP
early part of pregnancy up to 24 weeks can drop about 10mmHg
checking BP
check in the same arm and same spot every time, on lower arm it will be higher on the dependent side
BP when a person lays on their side
systolic drops 5-10mmHg
normal to have a WBC of
30,000 during delivery and after
hormone of pregnancy
progesterone (Pg)
progesterone
helps relax smooth muscle when the uterus stretches, also the gut so you get constipated, get acid reflex from swallowing
gravida
number of pregnancies
para
number of pregnancies that have ended at 20 weeks or more weeks, number of deliveries greater than 20 weeks
T: term
how many deliveries between 38-42 weeks, if you have twins its still 1 delivery
A: abortion
pregnancy ends before 20 weeks, any known pregnancy including miscarriages
SAB
spontaneous
TAB
therapeutic
L
living children you have
P
preterm deliveries, 20-38 weeks
primigravida
a woman who is pregnant for the first time
multipara
a woman who has delivered two or more pregnancies at 20 or more more weeks of gestation
respiratory system
slight hyperventilation and decreased airway resistance allow oxygen needs to be met, oxygen increases by about 20% in pregnancy
uterus, fetus, and placenta
half the oxygen is used by the: and the remainder is consumed by breast tissue and increased cardiac; renal and respiratory maternal demands
physical changes in preganancy
ribs flare, substernal angle widens, chest circumference increases, areas of hyperpigmentation
melasma
“mask of pregnancy”, over the forehead, cheeks, and nose, also happens in women taking oral contraceptives
stria gravidarum
stretchmarks
linea nigra
dark line up the stomach all the way to the xiphoid process
increase GFR in pregnancy may result in
spilling of glucose in the urine, normal to have small amounts
pressure on the
ureters and bladder do to growing fetus
increased risk for
UTI
group strep B
check when pregnant, they can be asymptomatic but can be fatal to infants during delivery
36 weeks
do a culture anal and vaginal swab
treat UTI
macrodantin antibiotic
increased human chorionic gonadotropin and estrogen
may cause nausea in early pregnancy
progesterone
maintains the uterine lining, prevents contractions, helps prepare breasts for lactation
when estrogen rises in early pregnancy
normal to have bleeding gums
treat nausea in early pregnancy
saltines, ginger, peppermint, eat small meals and not to mix liquid and dry solid food
changes in uterus
urine consistency, ballottement, braxon hicks contractions, palpation of the fetal outline
ballottement
vaginally touches babies head and bounces up
braxton hicks
irregular, painless contractions occurring throughout pregnancy, false labor, last 1-2 minutes, uterus practicing labor contractions
hegar’s sign
at 6-8 weeks, lower uterine segment softens
indications of preganancy
amenorrhea, nausea/vomiting, fatigues, no period, urinary frequency, breast/skin changes, fetal movement, vaginal and cervical color changes
amenorrhea
absence of period
chadwick’s sign
dark blue/purple color of the labia, vagina, and cervix
probable pregnancy
abdominal enlargement, cervical softening, uterine changes, + pregnancy tests
positive signs of pregnancy
auscultation of fetal heart sounds, fetal movement felt by examiner, ultrasound of fetus
antepartum
during pregnancy
preconception visit
all women should have, take folic acid
physical examination during pregnancy
get height and weight, check urine, plan of care
negative blood type in pregnancy
need to know if they have a bleeding episode if yes give Rhogam
Rhogam
neutralize any positive cells because it attacks the fetus; give at 28 weeks gestation and bleeding episodes; ONLY negative blood types
check cord blood
after delivery collect this and if baby is positive then give Rhogam again after delivery within 72 hours of delivery
discomforts during pregnancy
nausea and vomiting, heartburn, backache, round ligament pain, urinary frequency, varicosities (legs, in vagina), hemorrhoids, constipation, leg cramps
danger signs in pregnancy
vaginal bleeding w or w/o pain, rupture of membranes, swelling of fingers puffy face/eyes, continuous pounding headache, visual disturbances, persistent or severe abdominal pain, chills and fever, painful urination, changes in strength of fetal movements,
signs of preterm labor
uterine contractions, cramps, constant or irregular low backache, pelvic pressure
if water breaks before preterm
risk of infection
psychological responses: first trimester
uncertainty, ambivalence, self as primary focus
psychological responses: second trimester
physical evidence of pregnancy, fetus is primary focus, body image issues
psychological responses: third trimester
vulnerability, increasing dependence, preparation for birth
cerclage
a suture around the cervix to help the cervix from opening up to avoid preterm delivery, removed when actual delivery is ready
couvade
symptoms of pregnancy and birth experienced by fathers
cultural differences that can cause conflict
health beliefs, health maintence during pregnancy, belief in fate, preventing illness, restoring health, modesty, female genital cutting, communication
settings for delivery
home, birth center, hospital
health care providers
midwife or physician
support person
friend, family, doula
doula
a trained labor support person who is employed by the mother to provide labor support
types of classes available
preconception, early pregnancy, exercise, childbirth preparation, c-section preparation, breastfeeding, parenting, for fathers, postpartum
The nurse has received a report about a woman in labor. The woman’s last vaginal examination was recorded as 4, 80%, and -2. The nurse’s interpretation of this assessment is that:
A) The cervix is dilated 4 cm, it is effaced 80%, and the presenting part is 2 cm below the ischial spines
B) The cervix is effaced 4 cm, it is dilated 80%, and the presenting part is 2 cm below the ischial spines.
C) The cervix is effaced 4 cm, it is dilated 80%, and the presenting part is 2 cm above the ischial spines
D) The cervix is 4 cm dilated, it is effaced 80%, and the presenting part is 2 cm above the ischial spines
D) The cervix is 4 cm dilated, it is effaced 80%, and the presenting part is 2 cm above the ischial spines
What is the correct order of the cardinal movements? A.Extension B.Internal Rotation C.Expulsion D.Engagement, Flexion Descent E.External Rotation
A) D, B, A, E, C
B) D, A, B, E, C
C) B, D, A, C, E
D) D, B, A, C. E
A) D, B, A, E, C
p. 388-389
When assessing a woman in labor, the nurse is aware that the relationship of the fetal body parts to one another is called fetal:
A) Lie.
B) Position.
C) Presentation.
D) Attitude.
D) Attitude.
• Lie = relationship between the longitudinal axis of fetus and mother
• Position = relationship of the presenting part to the 4 quadrants of the mother’s pelvis, ie 3 letter abr:
1.) R or L
2.) O, S, M or Sc (Occiput, Sacrum, Mentum, SCapula)
3.) A, P, or T (Anterior, Posterior, Transverse)
• Presentation = presenting part that overlies pelvic inlet
To adequately care for a laboring woman, the nurse knows that which stage of labor varies the most in length?
A) First
B) Fourth
C) Third
D) Second
A) First
p. 387-388
Which position would the nurse suggest for second-stage labor if the pelvic outlet needs to be increased?
A) Sitting
B) Squatting
C) Side-lying
D) Semirecumbent
B) Squatting
p. 385
When assessing the fetus using Leopold maneuvers, the nurse feels a round, hard, movable fetal part just above the symphysis and a long, smooth surface in the mother’s left side close to midline. In the fundus, there is a prominence- when pushed the whole body seems to follow. What is the likely position of the fetus?
A) RSA
B) ROA
C) LSP
D) LOA
D) LOA
p. 422
With regard to fetal positioning during labor, nurses should be aware that:
A) Birth is imminent when the presenting part is at +4 to +5 cm, below the spine.
B) Engagement is the term used to describe the beginning of labor.
C) The largest transverse diameter of the presenting part is the suboccipitobregmatic diameter.
D) Position is a measure of the degree of descent of the presenting part of the fetus through the birth canal.
A) Birth is imminent when the presenting part is at +4 to +5 cm, below the spine.
p. 378
• Primary Powers (involuntary uterine contractions) = term used to describe the beginning of labor.
• The largest transverse diameter of the presenting part is the biparietal or occipitomental diameter.
• Station = measure of the degree of descent of the presenting part of the fetus through the birth canal.
Which presentation is described accurately in terms of both presenting part and frequency of occurrence?
A) Cephalic: occiput; at least 95%
B) Cephalic: cranial; 80% to 85%
C) Shoulder: scapula; 10% to 15%
D) Breech: sacrum; 10% to 15%
A) Cephalic: occiput; at least 95%
p. 377
A client is admitted to the labor and delivery unit with contractions that are 3-5 minutes apart, lasting 60-70 seconds. She reports that she is leaking fluid. A vaginal exam reveals that her cervix is 80 percent effaced and 4 cm dilated and a -1 station. The nurse knows that the client is in which phase and stage of labor?
A) Latent phase, First Stage
B) Active Phase of First Stage
C) Latent phase of Second Stage
D) Transition
B) Active Phase of First Stage
Second stage = full dilation until birth
To assess uterine contractions the nurse would
A) Asses duration from the beginning of the contraction to the peak of the same contraction, frequency by measuring the time between the beginning of one contraction to the beginning of the next contraction.
B) Assess frequency as the time between the end of one contraction and the beginning of the next contraction, duration as the length of time from the beginning to the end of contractions, and palpate the uterus for strength
C) Assess duration from beginning to end of each contraction. Assess the strength of the contraction by the external fetal monitor reading. Measure frequency by measuring the beginning of one contraction to another.
D) Assess duration from beginning to end of each contraction., frequency by measuring the time between the beginnings of contractions, and palpate the fundus of the uterus for strength.
D) Assess duration from beginning to end of each contraction., frequency by measuring the time between the beginnings of contractions, and palpate the fundus of the uterus for strength.
p. 453
Which basic type of pelvis includes the correct description and percentage of occurrence in women?
A) Platypelloid: flattened, wide, shallow; 3%
B) Anthropoid: resembling the ape; narrower; 10%
C) Android: resembling the male; wider oval; 15%
D) Gynecoid: classic female; heart shaped; 75%
A) Platypelloid: flattened, wide, shallow; 3%
p. 383
What position would be least effective when gravity is desired to assist in fetal descent?
A) Lithotomy
B) Walking
C) Kneeling
D) Sitting
A) Lithotomy
The factors that affect the process of labor and birth, known commonly as the five Ps, include all EXCEPT:
A) Passageway.
B) Powers.
C) Passenger.
D) Pressure.
D) Pressure.
:: The 5 P’s are:
1. Powers (contractions)
2. Passengers (fetus & placenta)
3. Passageway (birth canal)
4. Position (of the mother)
5. Psychological Response
While evaluating an external monitor tracing of a woman in active labor, the nurse notes that the fetal heart rate (FHR) for five sequential contractions begins to decelerate late in the contraction, with the nadir of the decelerations occurring after the peak of the contraction. The nurse’s first priority is to:
A) Notify the care provider.
B) Assist with amnioinfusion
C) Change the woman’s position
D) Insert a scalp electrode.
C) Change the woman’s position
p. 431-432; see box 17-4
During labor a fetus with an average heart rate of 175 beats/min over a 15-minute period would be considered to have:
A) A normal baseline heart rate.
B) Bradycardia.
C) Hypoxia.
D) Tachycardia.
D) Tachycardia.
p. 429
As a perinatal nurse you realize that a fetal heart rate that is tachycardic, is bradycardic, or has late decelerations with loss of variability is nonreassuring and is associated with
A) Cord compression
B) Hypotension
C) Hypoxemia/acidemia
D) Maternal drug use.
C) Hypoxemia/acidemia
The nurse providing care for the laboring woman should understand that amnioinfusion is used to treat:
A) Fetal tachycardia.
B) Fetal bradycardia.
C) Variable decelerations
D) Late decelerations.
C) Variable decelerations
p. 432 & 436; see box 17-5
The most common cause of decreased variability in the fetal heart rate (FHR) that lasts 30 minutes or less is:
A) Fetal hypoxemia
B) Fetal sleep cycles
C) Altered cerebral blood flow.
D) Umbilical cord compression.
B) Fetal sleep cycles
p. 428
While evaluating an external monitor tracing of a woman in active labor whose labor is being induced, the nurse notes that the fetal heart rate (FHR) begins to decelerate in a slow curve at the onset of several contractions and returns to baseline before each contraction ends. The nurse should:
A) Insert an internal monitor
B) Document the finding in the client’s record.
C) Discontinue the oxytocin infusion
D) Change the woman’s position
B) Document the finding in the client’s record.
p. 430
What three measures should the nurse implement to provide intrauterine resuscitation? Select the response that best indicates the priority of actions that should be taken.
A) Reposition the mother, increase intravenous (IV) fluid, and provide oxygen via face mask.
B) Perform a vaginal examination, reposition the mother, and provide oxygen via face mask.
C) Administer oxygen to the mother, increase IV fluid, and notify the care provider.
D) Call the provider, reposition the mother, and perform a vaginal examination
A) Reposition the mother, increase intravenous (IV) fluid, and provide oxygen via face mask.
When using intermittent auscultation (IA) to assess uterine activity, nurses should be aware that:
A) The resting tone between contractions is described as either placid or turbulent
B) The examiner’s hand should be placed over the fundus before, during, and after contractions.
C) The frequency and duration of contractions is measured in seconds for consistency
D) Contraction intensity is given a judgment number of 1 to 7 by the nurse and client together.
B) The examiner’s hand should be placed over the fundus before, during, and after contractions.
p. 424
Perinatal nurses are legally responsible for:
A) Applying the external fetal monitor and notifying the care provider.
B) Correctly interpreting fetal heart rate (FHR) patterns, initiating appropriate nursing interventions, and documenting the outcomes.
C) Greeting the client on arrival, assessing her, and starting an intravenous line.
D) Making sure that the woman is comfortable.
B) Correctly interpreting fetal heart rate (FHR) patterns, initiating appropriate nursing interventions, and documenting the outcomes.
p. 434
The nurse providing care for the laboring woman should understand that late fetal heart rate (FHR) decelerations are caused by:
A) Altered cerebral blood flow
B) Spontaneous rupture of membranes
C) Uteroplacental insufficiency
D) Umbilical cord compression
C) Uteroplacental insufficiency
p. 432; see box 17-4
The nurse providing care for the laboring woman should understand that variable fetal heart rate (FHR) decelerations are caused by:
A) Umbilical cord compression.
B) Altered fetal cerebral blood flow
C) Fetal hypoxemia.
D) Uteroplacental insufficiency
A) Umbilical cord compression.
p. 432
Which of the following is NOT a reassuring component of the fetal heart rate
A) FHR of 114
B) Accelerations of the FHR
C) Moderate Variability
D) Absent FHR Variability
D) Absent FHR Variability
p. 428
You are evaluating the fetal monitor tracing of your client, who is in active labor. Suddenly you see the fetal heart rate (FHR) drop from its baseline of 125 down to 80. You reposition the mother, provide oxygen, increase intravenous (IV) fluid, and perform a vaginal examination. The cervix has not changed. Five minutes have passed, and the fetal heart rate remains in the 80s. What additional nursing measures should you take?
A) Call for help and Notify the care provider immediately
B) Start pitocin
C) Have her empty her bladder
D) Insert a Foley catheter
A) Call for help and Notify the care provider immediately
What is an advantage of external electronic fetal monitoring?
A) Once correctly applied by the nurse, the transducer need not be repositioned even when the woman changes positions.
B) The tocotransducer can measure and record the frequency, regularity, intensity, and approximate duration of uterine contractions (UCs).
C) The external EFM does not require rupture of membranes or introduction of scalp electrode or IUPC which may introduce risk of infection or fetal scarring.
D) The external EFM can accurately record FHR all the time.
C) The external EFM does not require rupture of membranes or introduction of scalp electrode or IUPC which may introduce risk of infection or fetal scarring.
p. 426
A number of methods to assist in the assessment of fetal well-being have been developed for use in conjunction with electronic fetal monitoring. These various technologies assist in supporting interventions for a nonreassuring fetal heart rate pattern when necessary. The labor and delivery nurse should be aware that one of these modalities, fetal oxygen saturation monitoring, includes the use of:
A) Fetal blood sampling
B) Umbilical cord acid-base determination
C) Fetal pulse oximetry.
D) A fetal acoustic stimulator.
C) Fetal pulse oximetry.
p. 436 (book says this has been withdrawn from the market)
The nurse caring for the woman in labor should understand that maternal hypotension can result in:
A) Uteroplacental insufficiency.
B) Spontaneous rupture of membranes
C) Fetal dysrhythmias.
D) Early decelerations.
A) Uteroplacental insufficiency.
The nurse providing care for the laboring woman should understand that accelerations with fetal movement:
A) Are caused by umbilical cord compression
B) Are caused by uteroplacental insufficiency
C) Warrant close observation
D) Are reassuring.
D) Are reassuring.
p. 427
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)
A laboring woman received meperidine (Demerol) intravenously 90 minutes before she gave birth. Which medication should be available to reduce the postnatal effects of Demerol on the neonate?
A) Fentanyl (Sublimaze)
B) Promethazine (Phenergan)
C) Naloxone (Narcan)
D) Nalbuphine (Nubain)
C) Naloxone (Narcan)
A woman in labor has just received an epidural block. The most important nursing intervention is to:
A) Limit parenteral fluids.
B) Monitor the fetus for possible tachycardia
C) Monitor the maternal blood pressure for possible hypotension.
D) Monitor the maternal pulse for possible bradycardia
C) Monitor the maternal blood pressure for possible hypotension.
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
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 intravenous fluid for a preprocedural bolus. She reviews her laboratory values and notes that the woman’s hemoglobin is 12 g/dl, hematocrit is 38%, platelets are 67,000, and white blood cells (WBCs) are 12,000/mm3. Which factor would contraindicate an epidural for the woman?
A) She is too far dilated
B) She is anemic.
C) She has thrombocytopenia
D) She is septic
C) She has thrombocytopenia
The role of the nurse with regard to informed consent is to:
A) Inform the client about the procedure and have her sign the consent form.
B) Act as a client advocate and help clarify the procedure and the options.
C) Call the physician to see the client
D) Witness the signing of the consent form.
B) Act as a client advocate and help clarify the procedure and the options.
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.
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) The incidence of after-birth headache is higher with spinal blocks than epidurals.
C) Epidural blocks allow the woman to move freely
D) Spinal and epidural blocks are never used together.
B) The incidence of after-birth headache is higher with spinal blocks than epidurals.
Maternal hypotension is a potential side effect of regional anesthesia and analgesia. What nursing interventions could you use to raise the client’s blood pressure? 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) Continuous Fetal Monitor
E) Administer ephedrine per MD order
B) Place the woman in a lateral position.
C) Increase intravenous (IV) fluids.
E) Administer ephedrine per MD order
Nursing care measures are commonly offered to women in labor. Which nursing measure reflects application of the gate-control theory?
A) Massaging the woman’s back
B) Changing the woman’s position
C) Giving the prescribed medication
D) Encouraging the woman to rest between contractions
A) Massaging the woman’s back
A woman in the active phase of the first stage of labor is using a shallow pattern of breathing, which is about twice the normal adult breathing rate. She starts to complain about feeling lightheaded and dizzy and states that her fingers are tingling. The nurse should:
A) Notify the woman’s physician.
B) Tell the woman to “calm down” and slow the pace of her breathing.
C) Administer oxygen via a mask or nasal cannula.
D) Help her breathe into a paper bag
D) Help her breathe into a paper bag
With regard to a pregnant woman’s anxiety and pain experience, nurses should be aware that:
A) Even mild anxiety must be treated.
B) Severe anxiety increases tension, which increases pain, which in turn increases fear and anxiety, and so on.
C) Anxiety may increase the perception of pain, but it does not affect the mechanism of labor.
D) Women who have had a painful labor will have learned from the experience and have less anxiety the second time because of increased familiarity.
B) Severe anxiety increases tension, which increases pain, which in turn increases fear and anxiety, and so on.
Maternity nurses often have to answer questions about the many, sometimes unusual ways people have tried to make the birthing experience more comfortable. For instance, nurses should be aware that:
A) Music supplied by the support person has to be discouraged because it could disturb others or upset the hospital routine.
B) Women in labor can benefit from sitting in a bathtub, but they must limit immersion to no longer than 15 minutes at a time.
C) Effleurage is permissible, but counterpressure is almost always counterproductive.
D) Electrodes attached to either side of the spine to provide mild-intensity electrical impulses facilitate the release of endorphins.
D) Electrodes attached to either side of the spine to provide mild-intensity electrical impulses facilitate the release of endorphins.
Your patient is a nulliparous woman, requesting pain relief. You examine her and she is 8 cm. What is the best option for pain relief at this point?
A) Demerol
B) Spinal
C) Epidural
D) Stadol
C) Epidural
A primiparous woman is in the triage room being evaluated for labor. She has been having contractions for 2 days, has slept little and is feeling exhausted. On cervical exam she is 1.5 cm dilated, 50% effaced, -1 station – which is not changed from a day ago. Contractions are irregular, 30-40 secs long. Which of the following is the best option for her?
A) Offer morphine IM, and a sedative to help her sleep.
B) Admit her and give her an epidural.
C) Tell her to go home, relax
D) Give her a couple of seconal to help her sleep.
A) Offer morphine IM, and a sedative to help her sleep.
Which of the following is NOT a reason to come to labor and birth.
A) The patient is 39 weeks with second baby. She has been having contractions for 2 hours. Contractions are getting longer and stronger and closer together.
B) The patients says she has noticed greenish fluid leaking from her vagina. She is 41.5 weeks pregnant and not having contractions.
C) The patient is 40 weeks and has contractions that are 8-10 minutes apart, 30 seconds long and been that way for 8 hours.
D) The patient has not felt the baby move for 8 hours, despite drinking cold fluids, and nudging the baby with her hand.
C) The patient is 40 weeks and has contractions that are 8-10 minutes apart, 30 seconds long and been that way for 8 hours.
What is an expected characteristic of amniotic fluid?
A) Deep yellow color
B) Pale, straw color with small white particles
C) Acidic result on a Nitrazine test
D) Absence of ferning
B) Pale, straw color with small white particles
The uterine contractions of a woman early in the active phase of labor are assessed by an internal uterine pressure catheter (IUPC). The nurse notes that the intrauterine pressure at the peak of the contraction ranges from 65 to 70 mm Hg and the resting tone range is 6 to 10 mm Hg. The uterine contractions occur every 3 to 4 minutes and last an average of 55 to 60 seconds. On the basis of this information, the nurse should:
A) Notify the woman’s primary health care provider immediately
B) Prepare to administer an oxytocic to stimulate uterine activity
C) Document the findings because they reflect the expected contraction pattern for the active phase of labor.
D) Prepare the woman for the onset of the second stage of labor.
C) Document the findings because they reflect the expected contraction pattern for the active phase of labor.
A multiparous woman has been in labor for 8 hours. Her membranes have just ruptured. The nurse’s initial response would be to:
A) Prepare the woman for imminent birth
B) Notify the woman’s primary health care provider.
C) Document the characteristics of the fluid.
D) Assess the fetal heart rate and pattern.
D) Assess the fetal heart rate and pattern.
Through vaginal examination the nurse determines that a woman is 4 cm dilated, and the external fetal monitor shows uterine contractions every 3.5 to 4 minutes. The nurse would report this as:
A) First stage, latent phase
B) First stage, active phase
C) First stage, transition phase
D) Second stage, latent phase
B) First stage, active phase
The nurse expects to administer an oxytocic (e.g., Pitocin, Methergine) to a woman after expulsion of her placenta to:
A) Relieve pain.
B) Stimulate uterine contraction
C) Prevent infection
D) Facilitate rest and relaxation.
B) Stimulate uterine contraction
Vaginal examinations should be performed by the nurse under all of these circumstances EXCEPT:
A) An admission to the hospital at the start of labor.
B) When accelerations of the fetal heart rate (FHR) are noted.
C) On maternal perception of perineal pressure or the urge to bear down.
D) When membranes rupture.
B) When accelerations of the fetal heart rate (FHR) are noted.
With regard to a woman’s intake and output during labor, nurses should be aware that:
A) The tradition of restricting the laboring woman to clear liquids and ice chips is being challenged because regional anesthesia is used more often than general anesthesia and studies are not showing harm from drinking fluids in labor.
B) Intravenous (IV) fluids usually are necessary to ensure that the laboring woman stays hydrated.
C) Routine use of an enema empties the rectum and is very helpful for producing a clean, clear delivery.
D) When a nulliparous woman experiences the urge to defecate, it often means birth will follow quickly
A) The tradition of restricting the laboring woman to clear liquids and ice chips is being challenged because regional anesthesia is used more often than general anesthesia and studies are not showing harm from drinking fluids in labor.
For women who have a history of sexual abuse, a number of traumatic memories may be triggered during labor. The woman may fight the labor process and react with pain or anger. Alternately she may become a passive player and emotionally absent herself from the process. The nurse is in a unique position of being able to assist the client to associate the sensations of labor with the process of childbirth and not the past abuse. The nurse can implement a number of care measures to help her client view the childbirth experience in a positive manner. Which intervention would be key for the nurse to use while providing care?
A) Telling the client to relax and that it won’t hurt much
B) Limiting the number of procedures that invade her body
C) Reassuring the client that as the nurse you know what is best
D) Allowing unlimited care providers to be with the client
B) Limiting the number of procedures that invade her body
Concerning the third stage of labor, nurses should be aware that:
A) The placenta eventually detaches itself from a flaccid uterus
B) An active approach to managing this stage of labor reduces the risk of excessive bleeding
C) It is important that the dark, roughened maternal surface of the placenta appear before the shiny fetal surface.
D) The major risk for women during the third stage is a rapid heart rate.
B) An active approach to managing this stage of labor reduces the risk of excessive bleeding
When planning care for a laboring woman whose membranes have ruptured, the nurse recognizes that the woman’s risk for _____ has increased.
A) Intrauterine infection
B) Hemorrhage
C) Precipitous labor
D) Supine hypotension
A) Intrauterine infection
When managing the care of a woman in the second stage of labor, the nurse uses various measures to enhance the progress of fetal descent. These measures include:
A) Encouraging the woman to try various upright positions, including squatting and standing. Giving positive feedback about her efforts.
B) Telling the woman to start pushing as soon as her cervix is fully dilated.
C) Stopping the epidural anesthetic so the woman can feel the urge to push and thereby push more effectively
D) Coaching the woman to use sustained, 10- to 15-second, closed-glottis bearing-down efforts with each contraction.
A) Encouraging the woman to try various upright positions, including squatting and standing. Giving positive feedback about her efforts.
When assessing a multiparous woman who has just given birth to an 8-pound boy, the nurse notes that the woman’s fundus is firm and has become globular in shape. A gush of dark red blood comes from her vagina. The nurse concludes that:
A) The placenta has separated.
B) A cervical tear occurred during the birth
C) The woman is beginning to hemorrhage.
D) Clots have formed in the upper uterine segment.
A) The placenta has separated.
Nurses can help their clients by keeping them informed about the distinctive stages of labor. What description of the phases of the first stage of labor is accurate?
A) Latent: Mild, regular contractions; no dilation; bloody show; duration of 2 to 4 hours
B) Active: Moderate, regular contractions; 4- to 7-cm dilation; duration of 3 to 6 hours
C) Lull: No contractions; dilation stable; duration of 20 to 60 minutes
D) Transition: Very strong but irregular contractions; 8- to 10-cm dilation; duration of 3-4 hours
B) Active: Moderate, regular contractions; 4- to 7-cm dilation; duration of 3 to 6 hours
Match the degree of tear or episiotomy to its description
A. Laceration that goes through the anal sphincter and the rectal wall
B. a tear through part or all of the perineal muscles
C. small nick in the perineum, not involving muscle
D. Laceration through part or all of anal sphincter muscle1st degree
2nd degree
3rd degree
4th degree

1st degree = C. small nick in the perineum, not involving muscle
2nd degree = B. a tear through part or all of the perineal muscles
3rd degree = D. Laceration through part or all of anal sphincter muscle
4th degree = A. Laceration that goes through the anal sphincter and the rectal wall
Which of the following is true about placenta previa.
A) The bleeding from placenta previa usually occurs late in pregnancy at term.
B) In evaluating the bleeding, a vaginal exam would be done to determine the cause of the bleeding.
C) Symptoms of placenta previa are painful frequent contractions and bright red vaginal bleeding
D) Once placenta previa is diagnosed by a 20 week ultrasound, it is very likely the placenta previa will resolve in the third trimester.
D) Once placenta previa is diagnosed by a 20 week ultrasound, it is very likely the placenta previa will resolve in the third trimester.
What assessment is least likely to be associated with a breech presentation?
A) Fetal heart tones heard at or above the maternal umbilicus
B) Meconium-stained amniotic fluid
C) Postterm gestation
D) Preterm labor and birth
C) Postterm gestation
During labor, the patient at 4 cm suddenly becomes dyspneic, cyanotic, and hypotensive. The nurse must prepare immediately for: (Select all that apply.)
A) Immediate vaginal delivery
B) Cesarean delivery
C) CPR
D) McRobert’s maneuver
B) Cesarean delivery
C) CPR
A pregnant woman’s amniotic membranes rupture. Prolapsed cord is suspected. What intervention would be the top priority?
A) Starting oxygen by face mask
B) Preparing the woman for a cesarean birth
C) Covering the cord in sterile gauze soaked in saline
D) Placing the woman in the knee-chest position
D) Placing the woman in the knee-chest position
Which of the following is correct about care for a pregnant woman who has experienced blunt trauma in a car accident? (See Labor Complications Part 4 power point)
A) Rhogam is not necessary for rH negative pregnant women after a blunt force trauma.
B) If the woman does not have more than 6 ctx an hour she may go home after 4 hours.
C) The two most common risks are preterm labor and fetal death.
D) In the ER she is evaluated and treated to hemodynamically stabilize her, then she is evaluated with an electronic fetal monitor for a minimum of 4 hours.
D) In the ER she is evaluated and treated to hemodynamically stabilize her, then she is evaluated with an electronic fetal monitor for a minimum of 4 hours.
In evaluating the effectiveness of magnesium sulfate for the treatment of preterm labor, what finding would alert the nurse to possible side effects?
A) Serum magnesium level of 10 mg/dl
B) Respiratory rate of 16 breaths/min
C) Deep tendon reflexes 2+ and no clonus
D) Urine output of 160 ml in 4 hours
A) Serum magnesium level of 10 mg/dl
For a woman at 42 weeks of gestation, which finding would require more assessment by the nurse?
A) One fetal movement noted in 1 hour of assessment by the mother
B) Fetal heart rate of 116 beats/min
C) Cervix dilated 2 cm and 50% effaced
D) Score of 8 on the biophysical profile
A) One fetal movement noted in 1 hour of assessment by the mother
Which of the following is true with respect to chorioamninitis? (See power point Labor Complications part 4)
A) If a woman has chorioamnionitis she will be treated with penicilin and cefotetan.
B) Most often chorioamnionitis is caused by pathogens such as GBBS, pneumococci, and CMV.
C) Once a woman who has had chorioamnionitis has delivered the antibiotics will be stopped.
D) An epidural can cause maternal fever and fetal tachycardia.
D) An epidural can cause maternal fever and fetal tachycardia.
The nurse recognizes that uterine hyperstimulation with oxytocin requires emergency interventions. What clinical cues would alert the nurse that the woman is experiencing uterine hyperstimulation? Choose all that apply.
A) Uterine contractions lasting <90 seconds and occurring >2 minutes in frequency
B) Uterine contractions lasting >90 seconds and occurring <2 minutes in frequency C) Uterine resting tone >20 mm Hg
D) Uterine resting tone <20 mm Hg
E) Increased uterine activity accompanied by a nonreassuring fetal heart rate (FHR) pattern
B) Uterine contractions lasting >90 seconds and occurring <2 minutes in frequency C) Uterine resting tone >20 mm Hg
E) Increased uterine activity accompanied by a nonreassuring fetal heart rate (FHR) pattern
A woman arrive in the admission area of L&D. She is complaining of severe abdominal pain which she thinks are contractions and vaginal bleeding. You notice the sheet on the bed is about 1/3 covered with port wine fluid. You would do all of the following EXCEPT:
A) Take a complete medical history and measure her vital signs.
B) Position on her side and give her oxygen if the fetal heart rate was category II.
C) NOtify the charge nurse and patient’s provider.
D) Start an IV
E) Put her on the monitor
A) Take a complete medical history and measure her vital signs.
The nurse is caring for a client whose labor is being augmented with oxytocin. He or she recognizes that the oxytocin should be discontinued immediately if there is evidence of:
A) Uterine contractions occurring every 8 to 10 minutes
B) Rupture of the client’s amniotic membranes.
C) A fetal heart rate (FHR) of 180 with absence of variability.
D) The client needing to void.
C) A fetal heart rate (FHR) of 180 with absence of variability.
With regard to the use of tocolytic therapy to suppress premature uterine activity, nurses should be aware that:
A) Its most important function is to afford the opportunity to administer antenatal glucocorticoids.
B) The drugs can be given efficaciously up to the designated beginning of term at 37 weeks.
C) If the client develops pulmonary edema while on tocolytics, intravenous (IV) fluids should be given.
D) There are no important maternal (as opposed to fetal) contraindications.
A) Its most important function is to afford the opportunity to administer antenatal glucocorticoids.
With regard to the process of augmentation of labor, the nurse should be aware that it:
A) Augmentation is the use of medications to start labor that has not begun yet.
B) Relies on more invasive methods when oxytocin and amniotomy have failed.
C) Is part of the active management of labor that is instituted when the labor process is unsatisfactory.
D) Is a modern management term to cover up the negative connotations of forceps-assisted birth
C) Is part of the active management of labor that is instituted when the labor process is unsatisfactory.
Choose ALL that are true about post dates pregnancy.
A) All women should be induced within a few days past their due date.
B) Additional tests of fetal well being are ordered after the due date and include a nonstress test, fetal movement counting, and biophysical profile or Amniotic fluid Index.
C) A low amniotic fluid index of less than 8 is associated with a higher incidence of low Apgar scores of 7 or lower.
D) Post dates pregnancy is associated with larger babies, prolonged labor, fetal distressi in labor, meconium aspiration syndrome and more cesarean births.
B) Additional tests of fetal well being are ordered after the due date and include a nonstress test, fetal movement counting, and biophysical profile or Amniotic fluid Index.
D) Post dates pregnancy is associated with larger babies, prolonged labor, fetal distressi in labor, meconium aspiration syndrome and more cesarean births.
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? (Note: see power point on complications of Labor for homework part 1 on preterm labor)
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.
A woman in preterm labor at 30 weeks of gestation receives two 12-mg doses of betamethasone intramuscularly. The purpose of this pharmacologic treatment is to:
A) Suppress uterine contractions.
B) Maintain adequate maternal respiratory effort and ventilation during magnesium sulfate therapy.
C) Stimulate fetal surfactant production.
D) Reduce maternal and fetal tachycardia associated with ritodrine administration
C) Stimulate fetal surfactant production.
Prepidil (prostaglandin gel) has been ordered for a pregnant woman at 43 weeks of gestation. The nurse recognizes that this medication will be administered to:
A) Increase amniotic fluid volume.
B) Stimulate the amniotic membranes to rupture.
C) Enhance uteroplacental perfusion in an aging placenta.
D) Ripen the cervix in preparation for labor induction.
D) Ripen the cervix in preparation for labor induction.
Which of the following is true about labor dystocia.
A) Labor dystocia would be defined if it took longer than an hour to dilate 1 cm during active labor in a first time laboring woman.
B) In a nulliparous women with an arrest of labor, the use of pitocin will only help about 25% of women achieve a vaginal birth.
C) second stage is abnormally long if it takes longer than 1 hour in a first time mother.
D) When a woman has weak and infrequent contractions it is an indication that the baby is too large and she needs to have a Cesarean soon.
A) Labor dystocia would be defined if it took longer than an hour to dilate 1 cm during active labor in a first time laboring woman.
In evaluating the effectiveness of oxytocin induction, the nurse would expect:
A) Contractions lasting 40 to 90 seconds, 2 to 3 minutes apart.
B) Labor to progress at least 2 cm/hr dilation.
C) At least 30 mU/min of oxytocin will be needed to achieve cervical dilation
D) The intensity of contractions to be at least 110 to 130 mm Hg.
A) Contractions lasting 40 to 90 seconds, 2 to 3 minutes apart.
Select ALL that are true about post dates pregnancy.
A) After the due date, women should have assessments of fetal well beings which could include fetal movement counting, biophysical profile and non stress test.
B) All women should be induced within a few days part their due date.
C) Risks associated with going past 42 weeks gestation include a large baby, low amniotic fluid, meconium aspiration syndrome, and fetal distress in labor.
D) An amniotic fluid index of less than 8 has been associated with a higher incidence of Apgar scores less than 7 at 5 minutes.
A) After the due date, women should have assessments of fetal well beings which could include fetal movement counting, biophysical profile and non stress test.
C) Risks associated with going past 42 weeks gestation include a large baby, low amniotic fluid, meconium aspiration syndrome, and fetal distress in labor.
Nurses should know some basic definitions concerning preterm birth, preterm labor, and low birth weight. For instance
A) Preterm labor is defined as cervical changes and uterine contractions occurring between 20 and 37 weeks of pregnancy.
B) In the United States early in this century, preterm birth accounted for 18% to 20% of all births.
C) Low birth weight is anything below 3.7 pounds.
D) The terms preterm birth and low birth weight can be used interchangeably.
A) Preterm labor is defined as cervical changes and uterine contractions occurring between 20 and 37 weeks of pregnancy.
The nurse providing care for a woman with preterm labor on terbutaline would include which intervention to identify side effects of the drug?
A) Assessing for dyspnea and crackles
B) Assessing for bradycardia
C) Assessing deep tendon reflexes (DTRs)
D) Assessing for hypoglycemia
A) Assessing for dyspnea and crackles
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) Placental abruption.
B) Rupture of the uterus.
C) Placenta previa.
D) Eclamptic seizure.
A) Placental abruption.
A pregnant woman has been receiving a magnesium sulfate infusion for treatment of severe preeclampsia for 24 hours. On assessment the nurse finds the following vital signs: temperature of 37.3° C, pulse rate of 88 beats/min, respiratory rate of 10 breaths/min, blood pressure (BP) of 148/90 mm Hg, absent deep tendon reflexes, and no ankle clonus. The client complains, “I’m so thirsty and warm.” The nurse:
A) Discontinues the magnesium sulfate infusion.
B) Administers oxygen.
C) Calls for a stat magnesium sulfate level.
D) Prepares to administer hydralazine.
A) Discontinues the magnesium sulfate infusion.
The labor of a pregnant woman with preeclampsia is going to be induced. Before initiating the Pitocin infusion, the nurse reviews the woman’s latest laboratory test findings, which reveal a platelet count of 90,000, an elevated aspartate transaminase (AST) level, and decreased serum haptoglobin. The nurse notifies the physician because the laboratory results are indicative of:
A) Eclampsia.
B) Idiopathic thrombocytopenia.
C) Disseminated intravascular coagulation (DIC).
D) HELLP syndrome.
D) HELLP syndrome.
Your client has been on magnesium sulfate for 20 hours for treatment of preeclampsia. She just delivered a viable infant girl 30 minutes ago. What uterine findings would you expect to observe/assess in this client?
A) Absence of uterine bleeding in the postpartum period
B) A fundus firm below the level of the umbilicus
C) Scant lochia flow
D) A boggy uterus with heavy lochia flow
D) A boggy uterus with heavy lochia flow
A primigravida is being monitored in her prenatal clinic for preeclampsia. What finding should concern her nurse?
A) A dipstick value of 3+ for protein in her urine
B) Pitting pedal edema at the end of the day
C) Blood pressure (BP) increase to 138/86 mm Hg
D) Weight gain of 0.5 kg during the past 2 weeks
A) A dipstick value of 3+ for protein in her urine
A woman with preeclampsia has a seizure. The nurse’s primary duty during the seizure is to:
A) Stay with the client and call for help.
B) Insert an oral airway.
C) Administer oxygen by mask.
D) Suction the mouth to prevent aspiration.
A) Stay with the client and call for help.
Your client is being induced because of her worsening preeclampsia. She is also receiving magnesium sulfate. It appears that her labor has not become active despite several hours of oxytocin administration. She asks the nurse, “Why is it taking so long?” The most appropriate response by the nurse would be:
A) “Your baby is just being stubborn.”
B) “The length of labor varies for different women.”
C) “The magnesium is relaxing your uterus and competing with the oxytocin. It may increase the duration of your labor.”
D) “I don’t know why it is taking so long.”
C) “The magnesium is relaxing your uterus and competing with the oxytocin. It may increase the duration of your labor.”
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 175/112 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.
Magnesium sulfate is given to women with preeclampsia and eclampsia to:
A) Improve patellar reflexes and increase respiratory efficiency.
B) Shorten the duration of labor.
C) Prevent and treat convulsions.
D) Prevent a boggy uterus and lessen lochial flow.
C) Prevent and treat convulsions.
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 lease 1 week.”
C) “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.
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
RATIONAL:
A transient headache and +1 proteinuria are signs of preeclampsia and should be monitored. Seizure activity and hyperreflexia are signs of eclampsia.
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:
A. Weight gain of 1 to 3 pounds.
B. Quickening.
C. Fatigue and lethargy.
D. Bloody show.
D. Bloody show.
RATIONAL:
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:
A. Progressive uterine contractions.
B. Lightening.
C. Rupture of membranes.
D. Passage of the mucous plug (operculum).
A. 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?
A. The fetal presenting part is 1 cm above the ischial spines.
B. Effacement is 4 cm from completion.
C. Dilation is 50% completed.
D. The fetus has achieved passage through the ischial spines.
A. 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:
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.
RATIONAL:
The woman is exhibiting signs of hyperventilation. This leads to a decreased carbon dioxide level and respiratory alkalosis. Rebreathing her air would increase the carbon dioxide level.
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?
A. Encourage her to empty her bladder.
B. Decrease her intravenous (IV) rate to a keep vein-open rate.
C. Turn the woman to the left lateral position or place a pillow under her hip.
D. No action is necessary since a decrease in the woman’s blood pressure is expected.
C. Turn the woman to the left lateral position or place a pillow under her hip.
RATIONAL:
Turing the woman to her left side is the best action to take in this situation since this will increase placental perfusion to the infant while waiting for the doctor’s or nurse midwife’s instruction.
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:
A. Maternal hyperthyroidism.
B. Initiation of epidural anesthesia that resulted in maternal hypotension.
C. Maternal infection accompanied by fever.
D. Alteration in maternal position from semirecumbent to lateral.
B. Initiation of epidural anesthesia that resulted in maternal hypotension.
RATIONAL:
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. Assumption of a lateral position enhances placental perfusion and should result in a reassuring FHR pattern.
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:
A. Describe the finding in the nurse’s notes.
B. Reposition the woman onto her side.
C. Call the physician for instructions.
D. Administer oxygen at 8 to 10 L/min with a tight face mask.
A. Describe the finding in the nurse’s notes.
RATIONAL:
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?
A. FHR does not change as a result of fetal activity.
B. Average baseline rate ranges between 100 and 140 beats/min.
C. Mild late deceleration patterns occur with some contractions.
D. Variability averages between 6 to 10 beats/min.
D. Variability averages between 6 to 10 beats/min.
RATIONAL:
Variability indicates a well-oxygenated fetus with a functioning autonomic nervous system. Late deceleration patterns are never reassuring, although early and mild variable decelerations are expected, reassuring findings.
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:
A. Change the woman’s position.
B. Stop the Pitocin.
C. Elevate the woman’s legs.
D. Administer oxygen via a tight mask at 8 to 10 L/min.
B. Stop the Pitocin.
RATIONAL:
Late deceleration patterns noted are most likely related to alteration in uteroplacental perfusion associated with the strong contractions described. The immediate action would be to stop the Pitocin infusion since Pitocin is an oxytocic that stimulates the uterus to contract. Elevation of her legs would be appropriate if hypotension were present.
Which characteristic is associated with false labor contractions?
A. Painless
B. Decrease in intensity with ambulation
C. Regular pattern of frequency established
D. Progressive in terms of intensity and duration
B. Decrease in intensity with ambulation
RATIONAL:
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?
A. “My husband and I have agreed that my sister will be my coach since he becomes anxious with regard to medical procedures and blood. He will be nearby and check on me every so often to make sure everything is OK.”
B. “We plan to use the techniques taught in the Lamaze classes to reduce the pain experienced during labor.”
C. “We want the labor and birth to take place in a birthing room. My husband will come in the minute the baby is born.”
D. “We do not want the fetal monitor used during labor since it will interfere with movement and doing effleurage.”
D. “We do not want the fetal monitor used during labor since it will interfere with movement and doing effleurage.”
RATIONAL:
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?
A. Cleanse the vulva and perineum before and after the examination as needed
B. Wear a clean glove lubricated with tap water to reduce discomfort
C. Perform the examination every hour during the active phase of the first stage of labor
D. Perform immediately if active bleeding is present
A. Cleanse the vulva and perineum before and after the examination as needed
RATIONAL:
Cleansing will reduce the possibility of secretions and microorganisms ascending into the vagina to the cervix. Maternal comfort will also be enhanced. Examinations are never done by the nurse if vaginal bleeding is present since the bleeding could be a sign of placenta previa and a vaginal examination could result in further separation of the low-lying placenta.
The nurse should realize that the most common and potentially harmful maternal complication of epidural anesthesia is:
A. Severe postpartum headache.
B. Limited perception of bladder fullness.
C. Increase in respiratory rate.
D. Hypotension.
D. Hypotension.
RATIONAL:
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:
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.
RATIONAL:
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).
A woman is evaluated to be using an effective bearing-down effort if she:
A. Begins pushing as soon as she is told that her cervix is fully dilated and effaced.
B. Takes two deep, cleansing breaths at the onset of a uterine contraction and at the end of the contraction.
C. Uses the Valsalva maneuver by holding her breath and pushing vigorously for a count of 12.
D. Continues to push for short periods between uterine contractions throughout the second stage of labor.
B. Takes two deep, cleansing breaths at the onset of a uterine contraction and at the end of the contraction.
RATIONAL:
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. Women should avoid closed-glottis pushing (Valsalva maneuver) since uteroplacental perfusion is usually reduced. Open-glottis pushing is recommended. The woman should push with contractions to combine the force of both powers of labor: uterine and abdominal.
Following rupture of membranes, a prolapse of the cord was noted on vaginal examination. A recommended action to prevent cord compression would be to:
A. Place woman in a supine position and elevate legs from the hips.
B. Insert a Foley catheter to keep the bladder empty.
C. Keep the protruding cord moist with warm sterile normal saline compresses.
D. Attempt to reinsert the cord.
C. Keep the protruding cord moist with warm sterile normal saline compresses.
After giving birth to a healthy infant boy, a primiparous woman, 16, is admitted to the postpartum unit. An appropriate nursing diagnosis for her at this time is risk for impaired parenting related to deficient knowledge of newborn care. In planning for the woman’s discharge, what should the nurse be certain to include in the plan of care?
a. Tell the woman how to feed and bathe her infant.
b. Give the woman written information on bathing her infant.
c. Advise the woman that all mothers instinctively know how to care for their infants.
d. Provide time for the woman to bathe her infant after she views an infant bath demonstration.
ANS: D
Having the mother demonstrate infant care is a valuable method of assessing the client’s understanding of her newly acquired knowledge, especially in this age group, because she may inadvertently neglect her child. Although verbalizing how to care for the infant is a form of client education, it is not the most developmentally appropriate teaching for a teenage mother. Although providing written information is useful, it is not the most developmentally appropriate teaching for a teenage mother. Advising the woman that all mothers instinctively know how to care for their infants is an inappropriate statement; it is belittling and false
The nurse observes several interactions between a postpartum woman and her new son. What behavior, if exhibited by this woman, would the nurse identify as a possible maladaptive behavior regarding parent-infant attachment?
a. Talks and coos to her son
b. Seldom makes eye contact with her son
c. Cuddles her son close to her
d. Tells visitors how well her son is feeding
ANS: B
The woman should be encouraged to hold her infant in the en face position and make eye contact with the infant. Normal infant-parent interactions include talking and cooing to her son, cuddling her son close to her, and telling visitors how well her son is feeing.
The nurse observes that a 15-year-old mother seems to ignore her newborn. A strategy that the nurse can use to facilitate mother-infant attachment in this mother is to:
a. Tell the mother she must pay attention to her infant.
b. Show the mother how the infant initiates interaction and pays attention to her.
c. Demonstrate for the mother different positions for holding her infant while feeding.
d. Arrange for the mother to watch a video on parent-infant interaction.
ANS: B
Pointing out the responsiveness of the infant is a positive strategy for facilitating parent-infant attachment. Telling the mother that she must pay attention to her infant may be perceived as derogatory and is not appropriate. Educating the young mother in infant care is important, but pointing out the responsiveness of her baby is a better tool for facilitating mother-infant attachment. Videos are an educational tool that can demonstrate parent-infant attachment, but encouraging the mother to recognize the infant’s responsiveness is more appropriate.
The nurse hears a primiparous woman talking to her son and telling him that his chin is just like his dad’s chin. This woman’s statement reflects:
a. Mutuality. c. Claiming.
b. Synchrony. d. Reciprocity.
ANS: C
Claiming refers to the process by which the child is identified in terms of likeness to other family members. Mutuality occurs when the infant’s behaviors and characteristics call forth a corresponding set of maternal behaviors and characteristics. Synchrony refers to the “fit” between the infant’s cues and the parent’s responses. Reciprocity is a type of body movement or behavior that provides the observer with cues.
New parents express concern that, because of the mother’s emergency cesarean birth under general anesthesia, they did not have the opportunity to hold and bond with their daughter immediately after her birth. The nurse’s response should convey to the parents that:
a. Attachment, or bonding, is a process that occurs over time and does not require early contact.
b. The time immediately after birth is a critical period for people.
c. Early contact is essential for optimum parent-infant relationships.
d. They should just be happy that the infant is healthy.
ANS: A
Attachment, or bonding, is a process that occurs over time and does not require early contact. The formerly accepted definition of bonding held that the period immediately after birth was a critical time for bonding to occur. Research since has indicated that parent-infant attachment occurs over time. A delay does not inhibit the process. Parent-infant attachment involves activities such as touching, holding, and gazing; it is not exclusively eye contact. A response that conveys that the parents should just be happy that the infant is healthy is inappropriate because it is derogatory and belittling.
During a phone follow-up conversation with a woman who is 4 days’ postpartum, the woman tells the nurse, “I don’t know what’s wrong. I love my son, but I feel so let down. I seem to cry for no reason!” The nurse would recognize that the woman is experiencing:
a. Taking-in. c. Postpartum (PP) blues.
b. Postpartum depression (PPD). d. Attachment difficulty.
ANS: C
During the PP blues women are emotionally labile, often crying easily and for no apparent reason. This lability seems to peak around the fifth PP day. The taking-in phase is the period after birth when the mother focuses on her own psychologic needs. Typically this period lasts 24 hours. PPD is an intense, pervasive sadness marked by severe, labile mood swings; it is more serious and persistent than the PP blues. Crying is not a maladaptive attachment response; it indicates PP blues
The nurse can help a father in his transition to parenthood by:
a. Pointing out that the infant turned at the sound of his voice.
b. Encouraging him to go home to get some sleep.
c. Telling him to tape the infant’s diaper a different way.
d. Suggesting that he let the infant sleep in the bassinet.
ANS: A
Infants respond to the sound of voices. Because attachment involves a reciprocal interchange, observing the interaction between parent and infant is very important. Separation of the parent and infant does not encourage parent-infant attachment. Educating the parent in infant care techniques is important, but the manner in which a diaper is taped is not relevant and does not enhance parent-infant interactions.
Parent-infant attachment involves touching, holding, and cuddling. It is appropriate for a father to want to hold the infant as the baby sleeps.
The nurse notes that a Vietnamese woman does not cuddle or interact with her newborn other than to feed him, change his diapers or soiled clothes, and put him to bed. In evaluating the woman’s behavior with her infant, the nurse realizes that:
a. What appears to be a lack of interest in the newborn is in fact the Vietnamese way of demonstrating intense love by attempting to ward off evil spirits.
b. The woman is inexperienced in caring for newborns.
c. The woman needs a referral to a social worker for further evaluation of her parenting behaviors once she goes home with the newborn.
d. Extra time needs to be planned for assisting the woman in bonding with her newborn.
ANS: A
The nurse may observe a Vietnamese woman who gives minimal care to her infant and refuses to cuddle or interact with her infant. The apparent lack of interest in the newborn is this cultural group’s attempt to ward off evil spirits and actually reflects an intense love and concern for the infant. It is important to educate the woman in infant care, but it is equally important to acknowledge her cultural beliefs and practices.
Many first-time parents do not plan on their parents’ help immediately after the newborn arrives. What statement by the nurse is the most appropriate when counseling new parents about the involvement of grandparents?
a. “You should tell your parents to leave you alone.”
b. “Grandparents can help you with parenting skills and also help preserve family traditions.”
c. “Grandparent involvement can be very disruptive to the family.”
d. “They are getting old. You should let them be involved while they can.”
ANS: B
“Grandparents can help you with parenting skills and also help preserve family traditions” is the most appropriate response. Intergenerational help may be perceived as interference, but a statement of this sort is not therapeutic to the adaptation of the family. Not only is “Grandparent involvement can be very disruptive to the family” invalid, it also is not an appropriate nursing response. Regardless of age, grandparents can help with parenting skills and preserve family traditions. Talking about the age of the grandparents is not the most appropriate statement, and it does not demonstrate sensitivity on the part of the nurse.
When the infant’s behaviors and characteristics call forth a corresponding set of maternal behaviors and characteristics, this is called:
a. Mutuality. c. Claiming.
b. Bonding. d. Acquaintance.
ANS: A
Mutuality extends the concept of attachment to include this shared set of behaviors. Bonding is the process over time of parents forming an emotional attachment to their infant. Mutuality refers to a shared set of behaviors that is a part of the bonding process.
Claiming is the process by which parents identify their new baby in terms of likeness to other family members and their differences and uniqueness. Mutuality refers to a shared set of behaviors that is part of the bonding process. Like mutuality, acquaintance is part of attachment. It describes how parents get to know their baby during the immediate postpartum period through eye contact, touching, and talking.
In follow-up appointments or visits with parents and their new baby, it may be useful if the nurse can identify parental behaviors that can either facilitate or inhibit attachment. What is a facilitating behavior?
a. The parents have difficulty naming the infant.
b. The parents hover around the infant, directing attention to and pointing at the infant.
c. The parents make no effort to interpret the actions or needs of the infant.
d. The parents do not move from fingertip touch to palmar contact and holding.
ANS: B
Hovering over the infant and obviously paying attention to the baby are facilitating behaviors. Inhibiting behaviors include difficulty naming the infant, making no effort to interpret the actions or needs of the infant, and not moving from fingertip touch to palmar contact and holding.
With regard to parents’ early and extended contact with their infant and the relationships built, nurses should be aware that:
a. Immediate contact is essential for the parent-child relationship.
b. Skin-to-skin contact is preferable to contact with the body totally wrapped in a blanket.
c. Extended contact is especially important for adolescents and low-income women because they are at risk for parenting inadequacies.
d. Mothers need to take precedence over their partners and other family matters.
ANS: C
Nurses should encourage any activity that optimizes family extended contact. Immediate contact facilitates the attachment process but is not essential; otherwise, adopted infants would not establish the affectionate ties they do. The mode of infant-mother contact does not appear to have any important effect. Mothers and their partners are considered equally important.
In the United States the en face position is preferred immediately after birth. Nurses can facilitate this process by all of these actions except:
a. Washing both the infant’s face and the mother’s face.
b. Placing the infant on the mother’s abdomen or breast with their heads on the same plane.
c. Dimming the lights.
d. Delaying the instillation of prophylactic antibiotic ointment in the infant’s eyes.
ANS: A
To facilitate the position in which the parent’s and infant’s faces are approximately 8 inches apart on the same plane, allowing them to make eye contact, the nurse can place the infant at the proper height on the mother’s body, dim the light so that the infant’s eyes open, and delay putting ointment in the infant’s eyes.
Other early sensual contacts between infant and mother involve sound and smell. Nurses should be aware that, despite what folk wisdom might say:
a. High-pitched voices irritate newborns.
b. Infants can learn to distinguish their mother’s voice from others soon after birth.
c. All babies in the hospital smell alike.
d. A mother’s breast milk has no distinctive odor.
ANS: B
Infants know the sound of their mother’s voice early. Infants respond positively to high-pitched voices. Each infant has a unique odor. Infants quickly learn to distinguish the odor of their mother’s breast milk.
After birth a crying infant may be soothed by being held in a position in which the newborn can hear the mother’s heartbeat. This phenomenon is known as:
a. Entrainment. c. Synchrony.
b. Reciprocity. d. Biorhythmicity.
ANS: D
The newborn is in rhythm with the mother. The infant develops a personal biorhythm with the parents’ help over time. Entrainment is the movement of newborns in time to the structure of adult speech. Reciprocity is body movement or behavior that gives cues to the person’s desires. These take several weeks to develop with a new baby. Synchrony is the fit between the infant’s behavioral cues and the parent’s responses.
Of the many factors that influence parental responses, nurses should be aware that all of these statements regarding age are true except:
a. An adolescent mother’s egocentricity and unmet developmental needs interfere with her ability to parent effectively.
b. An adolescent mother is likely to use less verbal instruction, be less responsive, and interact less positively than other mothers.
c. Adolescent mothers have a higher documented incidence of child abuse.
d. Mothers older than 35 often deal with more stress related to work and career issues and decreasing libido.
ANS: C
Adolescent mothers are more inclined to have a number of parenting difficulties that benefit from counseling, but a higher incidence of child abuse is not one of them. Midlife mothers have many competencies but are more likely to have to deal with career and sexual issues than are younger mothers.
When dealing with parents who have some form of sensory impairment, nurses should realize that all of these statements are true except:
a. One of the major difficulties visually impaired parents experience is the skepticism of health care professionals.
b. Visually impaired mothers cannot overcome the infant’s need for eye-to-eye contact.
c. The best approach for the nurse is to assess the parents’ capabilities rather than focusing on their disabilities.
d. Technologic advances, including the Internet, can provide deaf parents with a full range of parenting activities and information.
ANS: B
Other sensory output can be provided by the parent, other people can participate, and other coping devices can be used. The skepticism, open or hidden, of health care professionals places an additional and unneeded hurdle for the parents. After the parents’ capabilities have been assessed (including some the nurse may not have expected), the nurse can help find ways to assist the parents that play to their strengths. The Internet affords an extra teaching tool for the deaf, as do videos with subtitles or nurses signing. A number of electronic devices can turn sound into light flashes to help pick up a child’s cry. Sign language is acquired readily by young children.
With regard to the adaptation of other family members, mainly siblings and grandparents, to the newborn, nurses should be aware that:
a. Sibling rivalry cannot be dismissed as overblown psychobabble; negative feelings and behaviors can take a long time to blow over.
b. Participation in preparation classes helps both siblings and grandparents.
c. In the United States paternal and maternal grandparents consider themselves of equal importance and status.
d. Since 1990 the number of grandparents providing permanent care to their grandchildren has been declining.
ANS: B
Preparing older siblings and grandparents helps with everyone to adapt. Sibling rivalry should be expected initially, but the negative behaviors associated with it have been overemphasized and stop in a comparatively short time. In the United States, in contrast to other cultures, paternal grandparents frequently consider themselves secondary to maternal grandparents. The number of grandparents providing permanent child care has been rising.
Nursing activities that promote parent-infant attachment are many and varied. One activity that should not be overlooked is the management of the environment. While providing routine mother-baby care, the nurse should ensure that:
a. The baby is able to return to the nursery at night so that the new mother can sleep.
b. Routine times for care are established to reassure the parents.
c. The father should be encouraged to go home at night to prepare for mother-baby discharge.
d. An environment that fosters as much privacy as possible should be created.

ANS: D

Care providers need to knock before gaining entry. Nursing care activities should be grouped. Once the baby has demonstrated adjustment to extrauterine life (either in the mother’s room or the transitional nursery), all care should be provided in one location. This important principle of family-centered maternity care fosters attachment by giving parents the opportunity to learn about their infant 24 hours a day. One nurse should provide care to both mother and baby in this couplet care or rooming-in model. It is not necessary for the baby to return to the nursery at night. In fact, the mother will sleep better with the infant close by. Care should be individualized to meet the parents’ needs, not the routines of the staff. Teaching goals should be developed in collaboration with the parents. The father or other significant other should be permitted to sleep in the room with the mother. The maternity unit should develop policies that allow for the presence of significant others as much as the new mother desires.

The early postpartum period is a time of emotional and physical vulnerability. Many mothers can easily become psychologically overwhelmed by the reality of their new parental responsibilities. Fatigue compounds these issues. Although the baby blues are a common occurrence in the postpartum period, about one-half million women in America experience a more severe syndrome known as postpartum depression (PPD). Which statement regarding PPD is essential for the nurse to be aware of when attempting to formulate a nursing diagnosis?
a. PPD symptoms are consistently severe.
b. This syndrome affects only new mothers.
c. PPD can easily go undetected.
d. Only mental health professionals should teach new parents about this condition.
ANS: C
PPD can go undetected because parents do not voluntarily admit to this type of emotional distress out of embarrassment, fear, or guilt. PPD symptoms range from mild to severe, with women having both good and bad days. Both mothers and fathers should be screened. PPD in new fathers ranges from 1% to 26%. The nurse should include information on PPD and how to differentiate this from the baby blues for all clients on discharge. Nurses also can urge new parents to report symptoms and seek follow-up care promptly if they occur
What concerns about parenthood are often expressed by visually impaired mothers? Choose all that apply.
a. Infant safety
b. Transportation
c. The ability to care for the infant
d. Missing out visually
e. Needing extra time for parenting activities to accommodate the visual limitations
ANS: A, B, D, E
Concerns expressed by visually impaired mothers include infant safety, extra time needed for parenting activities, transportation, handling other people’s reactions, providing proper discipline, and missing out visually. Blind people sense reluctance on the part of others to acknowledge that they have a right to be parents. However, blind parents are fully capable of caring for their infants.
A pregnant woman at 37 weeks of gestation has had ruptured membranes for 26 hours. A cesarean section is performed for failure to progress. The fetal heart rate (FHR) before birth is 180 beats/min with limited variability. At birth the newborn has Apgar scores of 6 and 7 at 1 and 5 minutes and is noted to be pale and tachypneic. On the basis of the maternal history, the cause of this newborn’s distress is most likely to be:
a. Hypoglycemia. c. Respiratory distress syndrome.
b. Phrenic nerve injury. d. Sepsis.
ANS: D
The prolonged rupture of membranes and the tachypnea (before and after birth) both suggest sepsis. An FHR of 180 beats/min is also indicative. This infant is at high risk for sepsis.
The most important nursing action in preventing neonatal infection is:
a. Good handwashing. c. Separate gown technique.
b. Isolation of infected infants. d. Standard Precautions.
ANS: A
Virtually all controlled clinical trials have demonstrated that effective handwashing is responsible for the prevention of nosocomial infection in nursery units. Measures to be taken include Standard Precautions, careful and thorough cleaning, frequent replacement of used equipment, and disposal of excrement and linens in an appropriate manner. Overcrowding must be avoided in nurseries. However, the most important nursing action for preventing neonatal infection is effective handwashing.
A pregnant woman presents in labor at term, having had no prenatal care. After birth her infant is noted to be small for gestational age with small eyes and a thin upper lip. The infant also is microcephalic. On the basis of her infant’s physical findings, this woman should be questioned about her use of which substance during pregnancy?
a. Alcohol c. Heroin
b. Cocaine d. Marijuana
ANS: A
The description of the infant suggests fetal alcohol syndrome, which is consistent with maternal alcohol consumption during pregnancy. Fetal brain, kidney, and urogenital system malformations have been associated with maternal cocaine ingestions. Heroin use in pregnancy frequently results in intrauterine growth restriction. The infant may have a shrill cry and sleep cycle disturbances and present with poor feeding, tachypnea, vomiting, diarrhea, hypothermia or hyperthermia, and sweating. Studies have found a higher incidence of meconium staining in infants born of mothers who used marijuana during pregnancy.
A plan of care for an infant experiencing symptoms of drug withdrawal should include:
a. Administering chloral hydrate for sedation.
b. Feeding every 4 to 6 hours to allow extra rest.
c. Swaddling the infant snugly and holding the baby tightly.
d. Playing soft music during feeding.
ANS: C
The infant should be wrapped snugly to reduce self-stimulation behaviors and protect the skin from abrasions. Phenobarbital or diazepam may be administered to decrease central nervous system (CNS) irritability. The infant should be fed in small, frequent amounts and burped well to diminish aspiration and maintain hydration. The infant should not be stimulated (such as with music) because this will increase activity and potentially increase CNS irritability.
Human immunodeficiency virus (HIV) may be perinatally transmitted:
a. Only in the third trimester from the maternal circulation.
b. By a needlestick injury at birth from unsterile instruments.
c. Only through the ingestion of amniotic fluid.
d. Through the ingestion of breast milk from an infected mother.
ANS: D
Postnatal transmission of HIV through breastfeeding may occur. Transmission of HIV from the mother to the infant may occur transplacentally at various gestational ages. Transmission close to or at the time of birth is thought to account for 50% to 80% of cases.
The abuse of which of the following substances during pregnancy is the leading cause of cognitive impairment in the United States?
a. Alcohol c. Marijuana
b. Tobacco d. Heroin
ANS: A
Alcohol abuse during pregnancy is recognized as one of the leading causes of cognitive impairment in the United States.
During a prenatal examination, the woman reports having two cats at home. The nurse informs her that she should not be cleaning the litter box while she is pregnant. When the woman asks why, the nurse’s best response would be:
a. “Your cats could be carrying toxoplasmosis. This is a zoonotic parasite that can infect you and have severe effects on your unborn child.”
b. “You and your baby can be exposed to the human immunodeficiency virus (HIV) in your cats’ feces.”
c. “It’s just gross. You should make your husband clean the litter boxes.”
d. “Cat feces are known to carry Escherichia coli, which can cause a severe infection in both you and your baby.”
ANS: A
Toxoplasmosis is a multisystem disease caused by the protozoal Toxoplasma gondii parasite, commonly found in cats, dogs, pigs, sheep, and cattle. About 30% of women who contract toxoplasmosis during gestation transmit the disease to their offspring. Clinical features ascribed to toxoplasmosis include hydrocephalus or microcephaly, chorioretinitis, seizures, or cerebral calcifications. HIV is not transmitted by cats. Although suggesting that the woman’s husband clean the litter boxes may be a valid statement, it is not appropriate, does not answer the client’s question, and is not the nurse’s best response. E. coli is found in normal human fecal flora. It is not transmitted by cats.
A primigravida has just delivered a healthy infant girl. The nurse is about to administer erythromycin ointment in the infant’s eyes when the mother asks, “What is that medicine for?” The nurse responds:
a. “It is an eye ointment to help your baby see you better.”
b. “It is to protect your baby from contracting herpes from your vaginal tract.”
c. “Erythromycin is given prophylactically to prevent a gonorrheal infection.”
d. “This medicine will protect your baby’s eyes from drying out over the next few days.”

ANS: C

With the prophylactic use of erythromycin, the incidence of gonococcal conjunctivitis has declined to less than 0.5%. Eye prophylaxis is administered at or shortly after birth to prevent ophthalmia neonatorum. Erythromycin has no bearing on enhancing vision, is used to prevent an infection caused by gonorrhea, not herpes, and is not used for eye lubrication.

With regard to skeletal injuries sustained by a neonate during labor or birth, nurses should be aware that:
a. A newborn’s skull is still forming and fractures fairly easily.
b. Unless a blood vessel is involved, linear skull fractures heal without special treatment.
c. Clavicle fractures often need to be set with an inserted pin for stability.
d. Other than the skull, the most common skeletal injuries are to leg bones.
ANS: B
About 70% of neonatal skull fractures are linear. Because the newborn skull is flexible, considerable force is required to fracture it. Clavicle fractures need no special treatment. The clavicle is the bone most often fractured during birth.
With regard to injuries to the infant’s plexus during labor and birth, nurses should be aware that:
a. If the nerves are stretched with no avulsion, they should recover completely in 3 to 6 months.
b. Erb palsy is damage to the lower plexus.
c. Parents of children with brachial palsy are taught to pick up the child from under the axillae.
d. Breastfeeding is not recommended for infants with facial nerve paralysis until the condition resolves.
ANS: A
If the nerves are stretched with no avulsion, they should recover completely in 3 to 6 months. However, if the ganglia are disconnected completely from the spinal cord, the damage is permanent. Erb palsy is damage to the upper plexus and is less serious than brachial palsy. Parents of children with brachial palsy are taught to avoid picking up the child under the axillae or by pulling on the arms. Breastfeeding is not contraindicated, but both the mother and infant will need help from the nurse at the start.
With regard to central nervous system injuries to the infant during labor and birth, nurses should be aware that:
a. Intracranial hemorrhage (ICH) as a result of birth trauma is more likely to occur in the preterm, low-birth-weight infant.
b. Subarachnoid hemorrhage (the most common form of ICH) occurs in term infants as a result of hypoxia.
c. In many infants signs of hemorrhage in a full-term infant are absent and diagnosed only through laboratory tests.
d. Spinal cord injuries almost always result from forceps-assisted deliveries.
ANS: C
Abnormalities in lumbar punctures or red blood cell counts, for instance, or in visuals on computed tomography scan might reveal a hemorrhage. ICH as a result of birth trauma is more likely to occur in the full-term, large infant. Subarachnoid hemorrhage in term infants is a result of trauma; in preterm infants it is a result of hypoxia. Spinal cord injuries are almost always from breech births; they are rare today because cesarean birth often is used for breech presentation
With regard to the classification of neonatal bacterial infection, nurses should be aware that:
a. Congenital infection progresses slower than nosocomial infection.
b. Nosocomial infection can be prevented by effective handwashing; early-onset infections cannot.
c. Infections occur with about the same frequency in boy and girl infants, although female mortality is higher.
d. The clinical sign of a rapid, high fever makes infection easier to diagnose.
ANS: B
Handwashing is an effective preventive measure for late-onset (nosocomial) infections because these infections come from the environment around the infant. Early-onset, or congenital, infections are caused by the normal flora at the maternal vaginal tract and progress more rapidly than nosocomial (late-onset) infections. Infection occurs about twice as often in boys and results in higher mortality. Clinical signs of neonatal infection are nonspecific and similar to noninfectious problems, making diagnosis difficult.
Near the end of the first week of life an infant who has not been treated for any infection develops a copper-colored, maculopapular rash on the palms and around the mouth and anus. The newborn is showing signs of:
a. Gonorrhea. c. Congenital syphilis.
b. Herpes simplex virus infection. d. Human immunodeficiency virus.
ANS: C
The rash is indicative of congenital syphilis. The lesions may extend over the trunk and extremities
What bacterial infection is definitely decreasing because of effective drug treatment?
a. Escherichia coli infection c. Candidiasis
b. Tuberculosis d. Group B streptococcal infection
ANS: D
Penicillin has significantly decreased the incidence of group B streptococcal infection. E. coli may be increasing, perhaps because of the increasing use of ampicillin (resulting in a more virulent E. coli resistant to the drug). Tuberculosis is increasing in the United States and Canada. Candidiasis is a fairly benign fungal infection.
In caring for the mother who has abused (or is abusing) alcohol and for her infant, nurses should be aware that:
a. The pattern of growth restriction of the fetus begun in prenatal life is halted after birth, and normal growth takes over.
b. Two thirds of newborns with fetal alcohol syndrome (FAS) are boys.
c. Alcohol-related neurodevelopmental disorders not sufficient to meet FAS criteria (learning disabilities, speech and language problems) are often not detected until the child goes to school.
d. Both the distinctive facial features of the FAS infant and the diminished mental capacities tend toward normal over time.
ANS: C
Some learning problems do not become evident until the child is at school. The pattern of growth restriction persists after birth. Two thirds of newborns with FAS are girls. Although the distinctive facial features of the FAS infant tend to become less evident, the mental capacities never become normal.
A careful review of the literature on the various recreational and illicit drugs reveals that:
a. More longer-term studies are needed to assess the lasting effects on infants when mothers have taken or are taking illegal drugs.
b. Heroin and methadone cross the placenta; marijuana, cocaine, and phencyclidine (PCP) do not.
c. Mothers should get off heroin (detox) any time they can during pregnancy.
d. Methadone withdrawal for infants is less severe and shorter than heroin withdrawal.
ANS: A
Studies on the effects of marijuana and cocaine use by mothers are somewhat contradictory. More long-range studies are needed. Just about all of these drugs cross the placenta, including marijuana, cocaine, and PCP. Drug withdrawal is accompanied by fetal withdrawal, which can lead to fetal death. Therefore detoxification from heroin is not recommended, particularly later in pregnancy. Methadone withdrawal is more severe and more prolonged than heroin withdrawal.
With regard to the understanding and treatment of infants born to mothers who are substance abusers, nurses should be aware that:
a. Infants born to addicted mothers are also addicted.
b. Mothers who abuse one substance likely will use or abuse another, compounding the infant’s difficulties.
c. The NICU Network Neurobehavioral Scale (NNNS) is designed to assess the damage the mother has done to herself.
d. No laboratory procedures are available that can identify the intrauterine drug exposure of the infant.
ANS: B
Multiple substance use (even just alcohol and tobacco) makes it difficult to assess the problems of the exposed infant, particularly with regard to withdrawal manifestations. Infants of substance-abusing mothers may have some of the physiologic signs but are not addicted in the behavioral sense. “Drug-exposed newborn” is a more accurate description than “addict.” The NNNS is designed to assess the neurologic, behavioral, and stress/abstinence function of the neonate. Newborn urine, hair, or meconium sampling may be used to identify an infant’s intrauterine drug exposure.
Providing care for the neonate born to a mother who abuses substances can present a challenge for the health care team. Nursing care for this infant requires a multisystem approach. The first step in the provision of this care is:
a. Pharmacologic treatment.
b. Reduction of environmental stimuli.
c. Neonatal abstinence syndrome scoring.
d. Adequate nutrition and maintenance of fluid and electrolyte balance.

ANS: C

Neonatal abstinence syndrome (NAS) is the term used to describe the cohort of symptoms associated with drug withdrawal in the neonate. The Neonatal Abstinence Scoring System evaluates CNS, metabolic, vasomotor, respiratory, and gastrointestinal disturbances. This evaluation tool enables the care team to develop an appropriate plan of care. The infant is scored throughout the length of stay, and the treatment plan is adjusted accordingly. Pharmacologic treatment is based on the severity of withdrawal symptoms. Symptoms are determined by using a standard assessment tool. Medications of choice are morphine, phenobarbital, diazepam, or diluted tincture of opium. Swaddling, holding, and reducing environmental stimuli are essential in providing care to the infant who is experiencing withdrawal. These nursing interventions are appropriate for the infant who displays central nervous system (CNS) disturbances. Poor feeding is one of the gastrointestinal symptoms common to this client population. Fluid and electrolyte balance must be maintained, and adequate nutrition provided. These infants often have a poor suck reflex and may need to be fed via gavage.

While completing a newborn assessment, the nurse should be aware that the most common birth injury is:
a. To the soft tissues.
b. Caused by forceps gripping the head on delivery.
c. Fracture of the humerus and femur.
d. Fracture of the clavicle.
ANS: D
The most common birth injury is fracture of the clavicle (collarbone). It usually heals without treatment, although the arm and shoulder may be immobilized for comfort.
The most common cause of pathologic hyperbilirubinemia is:
a. Hepatic disease. c. Postmaturity.
b. Hemolytic disorders in the newborn. d. Congenital heart defect.
ANS: B
Hemolytic disorders in the newborn are the most common cause of pathologic jaundice. Hepatic damage may be a cause of pathologic hyperbilirubinemia, but it is not the most common cause. Prematurity would be a potential cause of pathologic hyperbilirubinemia in neonates, but it is not the most common cause. Congenital heart defect is not a common cause of pathologic hyperbilirubinemia in neonates.
Which infant would be more likely to have Rh incompatibility?
a. Infant of an Rh-negative mother and a father who is Rh positive and homozygous for the Rh factor
b. Infant who is Rh negative and whose mother is Rh negative
c. Infant of an Rh-negative mother and a father who is Rh positive and heterozygous for the Rh factor
d. Infant who is Rh positive and whose mother is Rh positive
ANS: A
If the mother is Rh negative and the father is Rh positive and homozygous for the Rh factor, all the offspring will be Rh positive. Only Rh-positive offspring of an Rh-negative mother are at risk for Rh incompatibility. If the mother is Rh negative and the father is Rh positive and heterozygous for the factor, there is a 50% chance that each infant born of the union will be Rh positive and a 50% chance that each will be born Rh negative.
A major nursing intervention for an infant born with myelomeningocele is to:
a. Protect the sac from injury.
b. Prepare the parents for the child’s paralysis from the waist down.
c. Prepare the parents for closure of the sac at around 2 years of age.
d. Assess for cyanosis.
ANS: A
A major preoperative nursing intervention for a neonate with a myelomeningocele is protection of the protruding sac from injury to prevent its rupture and the resultant risk of central nervous system infection. The long-term prognosis in an affected infant can be determined to a large extent at birth with the degree of neurologic dysfunction related to the level of the lesion, which determines the nerves involved. A myelomeningocele should be surgically closed within 24 hours. Although the nurse would assess for multiple potential problems in this infant, the major nursing intervention would be to protect the sac from injury.
The priority nursing diagnosis for a newborn diagnosed with a diaphragmatic hernia would be:
a. Risk for impaired parent-infant attachment.
b. Imbalanced nutrition: less than body requirements.
c. Risk for infection.
d. Impaired gas exchange.
ANS: D
Herniation of the abdominal viscera into the thoracic cavity may cause severe respiratory distress and represent a neonatal emergency. Oxygen therapy, mechanical ventilation, and the correction of acidosis are necessary in infants with large defects. Although the nursing diagnoses of Risk for impaired parent-infant attachment, Imbalanced nutrition: less than body requirements, and Risk for infection may be factors in providing care to a newborn with a diaphragmatic hernia, the priority nursing diagnosis relates to the oxygenation issues arising from the lung hypoplasia that occurs with diaphragmatic hernia.
An infant diagnosed with erythroblastosis fetalis would characteristically exhibit:
a. Edema. c. Enlargement of the heart.
b. Immature red blood cells. d. Ascites.
ANS: B
Erythroblastosis fetalis occurs when the fetus compensates for the anemia associated with Rh incompatibility by producing large numbers of immature erythrocytes to replace those hemolyzed. Edema would occur with hydrops fetalis, a more severe form of erythroblastosis fetalis. The fetus with hydrops fetalis may exhibit effusions into the peritoneal, pericardial, and pleural spaces. The infant with hydrops fetalis displays signs of ascites.
With regard to hemolytic diseases of the newborn, nurses should be aware that:
a. Rh incompatibility matters only when an Rh-negative offspring is born to an Rh-positive mother.
b. ABO incompatibility is more likely than Rh incompatibility to precipitate significant anemia.
c. Exchange transfusions frequently are required in the treatment of hemolytic disorders.
d. The indirect Coombs’ test is performed on the mother before birth; the direct Coombs’ test is performed on the cord blood after birth.
ANS: D
An indirect Coombs’ test may be performed on the mother a few times during pregnancy. Only the Rh-positive offspring of an Rh-negative mother is at risk. ABO incompatibility is more common than Rh incompatibility but causes less severe problems; significant anemia, for instance, is rare with ABO. Exchange transfers are needed infrequently because of the decrease in the incidence of severe hemolytic disease in newborns from Rh incompatibility.
With regard to congenital anomalies of the cardiovascular and respiratory systems, nurses should be aware that:
a. Cardiac disease may be manifested by respiratory signs and symptoms.
b. Screening for congenital anomalies of the respiratory system need only be done for infants having respiratory distress.
c. Choanal atresia can be corrected by a suction catheter.
d. Congenital diaphragmatic hernias are diagnosed and treated after birth.
ANS: A
The cardiac and respiratory systems function together. Screening for congenital respiratory system anomalies is necessary even for infants who appear normal at birth.
Choanal atresia requires emergency surgery. Congenital diaphragmatic hernias are discovered prenatally on ultrasound.
When attempting to diagnose and treat developmental dysplasia of the hip (DDH), the nurse should:
a. Be able to perform the Ortolani and Barlow tests.
b. Teach double or triple diapering for added support.
c. Explain to the parents the need for serial casting.
d. Carefully monitor infants for DDH at follow-up visits.
ANS: D
Because DDH often is not detected at birth, infants should be monitored carefully at follow-up visits. The Ortolani and Barlow tests must be performed by experienced clinicians to prevent fracture or other damage to the hip. Double or triple diapering is not recommended because it promotes hip extension, thus worsening the problem. Serial casting is done for clubfeet, not DDH.
Cleft lip or palate is a common congenital midline fissure, or opening, in the lip or palate resulting from failure of the primary palate to fuse. Multiple genetic and to a lesser extent environmental factors may lead to the development of a cleft lip or palate. Such factors include (choose all that apply):
a. Alcohol consumption.
b. Female gender.
c. Use of some antiepileptics.
d. Maternal cigarette smoking.
e. Antibiotic use in pregnancy.
ANS: A, C, D
Factors that are associated with the potential development of cleft lip or palate are maternal infections, radiation exposure, corticosteroids, anticonvulsants, male gender, Native American or Asian descent, and smoking during pregnancy. Cleft lip is more common in male infants. Antibiotic use in pregnancy is not associated with the development of cleft lip or palate
Many common drugs of abuse cause significant physiologic and behavioral problems in infants who are breastfed by mothers currently using (choose all that apply):
a. Amphetamine.
b. Heroin.
c. Nicotine.
d. PCP.
e. Morphine.
ANS: A, B, C, D
Amphetamine, heroin, nicotine, and PCP are contraindicated during breastfeeding because of the reported effects on the infant. Morphine is a medication that often is used to treat neonatal abstinence syndrome.
A macrosomic infant is born after a difficult forceps-assisted delivery. After stabilization the infant is weighed, and the birth weight is 4550 g (9 pounds, 6 ounces). The nurse’s most appropriate action is to:
a. Leave the infant in the room with the mother.
b. Take the infant immediately to the nursery.
c. Perform a gestational age assessment to determine whether the infant is large for gestational age.
d. Monitor blood glucose levels frequently and observe closely for signs of hypoglycemia.
ANS: D
This infant is macrosomic (over 4000 g) and is at high risk for hypoglycemia. Blood glucose levels should be monitored frequently, and the infant should be observed closely for signs of hypoglycemia. Observation may occur in the nursery or in the mother’s room, depending on the condition of the fetus. Regardless of gestational age, this infant is macrosomic
Infants of mothers with diabetes are at higher risk for developing:
a. Anemia. c. Respiratory distress syndrome.
b. Hyponatremia. d. Sepsis.
ANS: C
IDMs are at risk for macrosomia, birth trauma, perinatal asphyxia, respiratory distress syndrome, hypoglycemia, hypocalcemia, hypomagnesemia, cardiomyopathy, hyperbilirubinemia, and polycythemia. They are not at risk for anemia, hyponatremia, or sepsis.
An infant was born 2 hours ago at 37 weeks of gestation, weighing 4.1 kg. The infant appears chubby with a flushed complexion and is very tremulous. The tremors are most likely the result of:
a. Birth injury. c. Hypoglycemia.
b. Hypocalcemia. d. Seizures.
ANS: C
Hypoglycemia is common in the macrosomic infant. Signs of hypoglycemia include jitteriness, apnea, tachypnea, and cyanosis.
An infant at 36 weeks of gestation has increasing respirations (80 to 100 breaths/min with marked substernal retractions). The infant is given oxygen by continuous nasal positive airway pressure. Which arterial oxygen level would indicate hypoxia?
a. PaO2 of 67 c. PaO2 of 45
b. PaO2 of 89 d. PaO2 of 73
ANS: C
A PaO2 of 45 is below the normal range for a normal neonate. The normal range for arterial oxygen pressure is 60 to 70 mm Hg. The laboratory value of PaO2 of 45 indicates hypoxia in this infant
On day 3 of life, a newborn continues to require 100% oxygen by nasal cannula. The parents ask if they can hold their infant during his next gavage feeding. Given that this newborn is physiologically stable, what response would the nurse give?
a. “Parents are not allowed to hold infants who depend on oxygen.”
b. “You may only hold your baby’s hand during the feeding.”
c. “Feedings cause more physiologic stress, so the baby must be closely monitored. Therefore, I don’t think you should hold the baby.”
d. “You may hold your baby during the feeding.”
ANS: D
“You may hold your baby during the feeding” is an accurate statement. Parental interaction via holding is encouraged during gavage feedings so that the infant will associate the feeding with positive interactions. Nasal cannula oxygen therapy allows for easier feedings and psychosocial interactions. The parent can swaddle the infant during gavage feedings to help the infant associate the feeding with positive interactions. Some parents like to do kangaroo care while gavage feeding their infant. Swaddling or kangaroo care during feedings provides positive interactions for the infant.
A premature infant with respiratory distress syndrome receives artificial surfactant. How would the nurse explain surfactant therapy to the parents?
a. “Surfactant improves the ability of your baby’s lungs to exchange oxygen and carbon dioxide.”
b. “The drug keeps your baby from requiring too much sedation.”
c. “Surfactant is used to reduce episodes of periodic apnea.”
d. “Your baby needs this medication to fight a possible respiratory tract infection.”
ANS: A
Surfactant can be administered as an adjunct to oxygen and ventilation therapy. With administration of artificial surfactant, respiratory compliance is improved until the infant can generate enough surfactant on his or her own. Surfactant has no bearing on the sedation needs of the infant. Surfactant is used to improve respiratory compliance, including the exchange of oxygen and carbon dioxide. The goal of surfactant therapy in an infant with respiratory distress syndrome (RDS) is to stimulate production of surfactant in the type 2 cells of the alveoli. The clinical presentation of RDS and neonatal pneumonia may be similar. The infant may be started on broad-spectrum antibiotics to treat infection.
When providing an infant with a gavage feeding, which of the following should be documented each time?
a. The infant’s abdominal circumference after the feeding
b. The infant’s heart rate and respirations
c. The infant’s suck and swallow coordination
d. The infant’s response to the feeding
ANS: D
Documentation of a gavage feeding should include the size of the feeding tube, the amount and quality of the residual from the previous feeding, the type and quantity of the fluid instilled, and the infant’s response to the procedure. Abdominal circumference is not measured after a gavage feeding. Vital signs may be obtained before feeding. However, the infant’s response to the feeding is more important. Some older infants may be learning to suck, but the important factor to document would be the infant’s response to the feeding (including attempts to suck
An infant is to receive gastrostomy feedings. What intervention should the nurse institute to prevent bloating, gastrointestinal reflux into the esophagus, vomiting, and respiratory compromise?
a. Rapid bolusing of the entire amount in 15 minutes
b. Warm cloths to the abdomen for the first 10 minutes
c. Slow, small, warm bolus feedings over 30 minutes
d. Cold, medium bolus feedings over 20 minutes

ANS: C

Feedings by gravity are done slowly over 20- to 30-minute periods to prevent adverse reactions. Rapid bolusing of the entire amount in 15 minutes would most likely lead to the adverse reactions listed. Temperature stability in the newborn is critical. This type of warming would not be appropriate because it is not a thermoregulated environment. Additionally, abdominal warming is not indicated with feedings of any kind. Small feedings at room temperature are recommended to prevent adverse reactions.

An infant at 26 weeks of gestation arrives from the delivery room intubated. The nurse weighs the infant, places him under the radiant warmer, and attaches him to the ventilator at the prescribed settings. A pulse oximeter and cardiorespiratory monitor are placed. The pulse oximeter is recording oxygen saturations of 80%. The prescribed saturations are 92%. The nurse’s most appropriate action would be to:
a. Listen to breath sounds and ensure the patency of the endotracheal tube, increase oxygen, and notify a physician.
b. Continue to observe and make no changes until the saturations are 75%.
c. Continue with the admission process to ensure that a thorough assessment is completed.
d. Notify the parents that their infant is not doing well.
ANS: A
Listening to breath sounds and ensuring the patency of the endotracheal tube, increasing oxygen, and notifying a physician appropriate nursing interventions to assist in optimal oxygen saturation of the infant. Oxygenation of the infant is crucial. O2 saturation should be maintained above 92%. Oxygenation status of the infant is crucial. The nurse should delay other tasks to stabilize the infant. Notifying the parents that the infant is not doing well is not an appropriate action. Further assessment and intervention are warranted before determination of fetal status
A newborn was admitted to the neonatal intensive care unit after being delivered at 29 weeks of gestation to a 28-year-old multiparous, married, Caucasian female whose pregnancy was uncomplicated until premature rupture of membranes and preterm birth. The newborn’s parents arrive for their first visit after the birth. The parents walk toward the bedside but remain approximately 5 feet away from the bed. The nurse’s most appropriate action would be to:
a. Wait quietly at the newborn’s bedside until the parents come closer.
b. Go to the parents, introduce himself or herself, and gently encourage them to come meet their infant; explain the equipment first, and then focus on the newborn.
c. Leave the parents at the bedside while they are visiting so they can have some privacy.
d. Tell the parents only about the newborn’s physical condition and caution them to avoid touching their baby.
ANS: B
The nurse is instrumental in the initial interactions with the infant. The nurse can help the parents “see” the infant rather than focus on the equipment. The importance and purpose of the apparatus that surrounds their infant also should be explained to them. Parents often need encouragement and recognition from the nurse to acknowledge the reality of the infant’s condition. Parents need to see and touch their infant as soon as possible to acknowledge the reality of the birth and the infant’s appearance and condition. Encouragement from the nurse is instrumental in this process. Telling the parents only about the newborn’s physical condition and cautioning them to avoid touching their baby is an inappropriate action.
Necrotizing enterocolitis (NEC) is an inflammatory disease of the gastrointestinal mucosa. The signs of NEC are nonspecific. Some generalized signs include:
a. Hypertonia, tachycardia, and metabolic alkalosis.
b. Abdominal distention, temperature instability, and grossly bloody stools.
c. Hypertension, absence of apnea, and ruddy skin color.
d. Scaphoid abdomen, no residual with feedings, and increased urinary output.
ANS: B
Some generalized signs of NEC include decreased activity, hypotonia, pallor, recurrent apnea and bradycardia, decreased oxygen saturation values, respiratory distress, metabolic acidosis, oliguria, hypotension, decreased perfusion, temperature instability, cyanosis, abdominal distention, residual gastric aspirates, vomiting, grossly bloody stools, abdominal tenderness, and erythema of the abdominal wall. The infant may display hypotonia, bradycardia, and metabolic acidosis. Hypotension, apnea, and pallor are signs of NEC, as are abdominal distention, residual gastric aspirates, and oliguria.
An infant is being discharged from the neonatal intensive care unit after 70 days of hospitalization. The infant was born at 30 weeks of gestation with several conditions associated with prematurity, including respiratory distress syndrome, mild bronchopulmonary dysplasia, and retinopathy of prematurity requiring surgical treatment. During discharge teaching the infant’s mother asks the nurse if her baby will meet developmental milestones on time, as did her son who was born at term. The nurse’s most appropriate response is:
a. “Your baby will develop exactly like your first child did.”
b. “Your baby does not appear to have any problems at the present time.”
c. “Your baby will need to be corrected for prematurity. Your baby is currently 40 weeks of postconceptional age and can be expected to be doing what a 40-week-old infant would be doing.”
d. “Your baby will need to be followed very closely.”
ANS: C
The age of a preterm newborn is corrected by adding the gestational age and the postnatal age. The infant’s responses are evaluated accordingly against the norm expected for the corrected age of the infant. Although it is impossible to predict with complete accuracy the growth and development potential of each preterm infant, certain measurable factors predict normal growth and development. The preterm infant experiences catch-up body growth during the first 2 to 3 years of life. The growth and developmental milestones are corrected for gestational age until the child is approximately 2.5 years old. Stating that the baby doesn’t appear to have any problems at the present time is inaccurate. Development will need to be evaluated over time. The growth and developmental milestones are corrected for gestational age until the child is approximately 2.5 years old.
A pregnant woman was admitted for induction of labor at 43 weeks of gestation with sure dates. A nonstress test (NST) in the obstetrician’s office revealed a nonreactive tracing. On artificial rupture of membranes, thick, meconium-stained fluid was noted. The nurse caring for the infant after birth should anticipate:
a. Meconium aspiration, hypoglycemia, and dry, cracked skin.
b. Excessive vernix caseosa covering the skin, lethargy, and respiratory distress syndrome.
c. Golden yellow- to green stained-skin and nails, absence of scalp hair, and an increased amount of subcutaneous fat.
d. Hyperglycemia, hyperthermia, and an alert, wide-eyed appearance.
ANS: A
Meconium aspiration, hypoglycemia, and dry, cracked skin are consistent with a postmature infant. Excessive vernix caseosa covering the skin, lethargy, and respiratory distress syndrome would be consistent with a very premature infant. The skin may be meconium stained, but the infant would most likely have longer hair and decreased amounts of subcutaneous fat. Postmaturity with a nonreactive NST would indicate hypoxia. Signs and symptoms associated with fetal hypoxia are hypoglycemia, temperature instability, and lethargy
For diagnostic and treatment purposes nurses should know the birth weight classifications of high risk infants. For example, extremely low birth weight (ELBW) is the designation for an infant whose weight is:
a. Less than 1500 g. c. Less than 2000 g.
b. Less than 1000 g. d. Dependent on the gestational age.
ANS: B
At a weight of less than 1000 g, problems are so numerous that ethical issues regarding when to treat arise. The designation for very low birth rate is less than 1500 g; ELBW is less than 1000 g. A weight of less than 2000 g is less than low but too high for extremely low, which is less than 1000 g. Gestational age is a factor with weight in the condition of the preterm birth, but it is not part of the birth weight categorization.
In the continuing assessment of a preterm infant, the nurse notices continued respiratory distress even though oxygen and ventilation have been provided. The nurse should suspect:
a. Hypovolemia and/or shock. c. Central nervous system injury.
b. A nonneutral thermal environment. d. Pending renal failure.
ANS: A
The nurse should suspect hypovolemia and/or shock. Other symptoms might include hypotension, prolonged capillary refill, and tachycardia followed by bradycardia. Intervention is necessary.
Premature infants who exhibit 5 to 10 seconds of respiratory pauses followed by 10 to 15 seconds of compensatory rapid respiration are:
a. Suffering from sleep or wakeful apnea.
b. Experiencing severe swings in blood pressure.
c. Trying to maintain a neutral thermal environment.
d. Breathing in a respiratory pattern common to premature infants.
ANS: D
This pattern is called periodic breathing and is common to premature infants. It may still require nursing intervention of oxygen and/or ventilation. Apnea is a cessation of respirations for 20 seconds or longer. It should not be confused with periodic breathing.
In appraising the growth and development potential of a preterm infant, nurses should:
a. Tell parents their child won’t catch up until about age 10 (girls) to 12 (boys).
b. Correct for milestones such as motor competencies and vocalizations until the child is approximately 3 years of age.
c. Know that the greatest catch-up period is between 9 and 15 months postconceptual age.
d. Know that the length and breadth of the trunk is the first part of the infant to experience catch-up growth.
ANS: B
Corrections are made with a formula that adds gestational age and postnatal age. The infant, girl or boy, experiences catch-up body growth during the first 2 to 3 years of life. Maximum catch-up growth occurs between 36 and 40 weeks postconceptual age. The head is the first to experience catch-up growth.
The nurse practicing in the perinatal setting should promote kangaroo care regardless of an infant’s gestational age. This intervention:
a. Is adopted from classical British nursing traditions.
b. Helps infants with motor and central nervous system impairment.
c. Helps infants to interact directly with their parents and enhances their temperature regulation.
d. Gets infants ready for breastfeeding.
ANS: C
Kangaroo care is skin-to-skin holding in which the infant, dressed only in a diaper, is placed directly on the parent’s bare chest and then covered. The procedure helps infants interact with their parents and regulates their temperature, among other developmental benefits.
For clinical purposes preterm and postterm infants are defined as:
a. Preterm before 34 weeks if appropriate for gestational age (AGA); before 37 weeks if small for gestational age (SGA).
b. Postterm after 40 weeks if large for gestational age (LGA); beyond 42 weeks if AGA.
c. Preterm before 37 weeks, postterm beyond 42 weeks, no matter the size for gestational age at birth.
d. Preterm, SGA before 38 to 40 weeks; postterm, LGA beyond 40 to 42 weeks.
ANS: C
Preterm and postterm are strictly measures of time—before 37 weeks and beyond 42 weeks respectively—regardless of size for gestational age.
With regard to small for gestational age (SGA) infants and intrauterine growth restrictions (IUGR), nurses should be aware that:
a. In the first trimester diseases or abnormalities result in asymmetric IUGR.
b. Infants with asymmetric IUGR have the potential for normal growth and development.
c. In asymmetric IUGR weight will be slightly more than SGA, whereas length and head circumference will be somewhat less than SGA.
d. Symmetric IUGR occurs in the later stages of pregnancy.
ANS: B
IUGR is either symmetric or asymmetric. The symmetric form occurs in the first trimester; SGA infants have reduced brain capacity. The asymmetric form occurs in the later stages of pregnancy. Weight is less than the 10th percentile; head circumference is greater than the 10th percentile. Infants with asymmetric IUGR have the potential for normal growth and development
With regard to eventual discharge of the high risk newborn or transfer to a different facility, nurses and families should be aware that:
a. Infants will stay in the neonatal intensive care unit (NICU) until they are ready to go home.
b. Once discharged to home, the high risk infant should be treated like any healthy term newborn.
c. Parents of high risk infants need special support and detailed contact information.
d. If a high risk infant and mother need transfer to a specialized regional center, it is better to wait until after birth and the infant is stabilized.
ANS: C
High risk infants can cause profound parental stress and emotional turmoil. Parents need support, special teaching, and quick access to various resources available to help them care for their baby. Parents and their high risk infant should get to spend a night or two in a predischarge room, where care for the infant is provided away from the NICU. Just because high risk infants are discharged does not mean that they are normal, healthy babies. Follow-up by specialized practitioners is essential. Ideally the mother and baby are transported with the fetus in utero; this reduces neonatal morbidity and mortality.
Necrotizing enterocolitis (NEC) is an acute inflammatory disease of the gastrointestinal mucosa that can progress to perforation of the bowel. Approximately 2% to 5% of premature infants succumb to this fatal disease. Care is supportive; however, there are known interventions that may decrease the risk of NEC. To develop an optimal plan of care for this infant, the nurse must understand that which intervention has the greatest effect on lowering the risk of NEC?
a. Early enteral feedings c. Exchange transfusion
b. Breastfeeding d. Prophylactic probiotics
ANS: B
A decrease in the incidence of NEC is directly correlated with exclusive breastfeeding. Breast milk enhances maturation of the gastrointestinal tract and contains immune factors that contribute to a lower incidence or severity of NEC, Crohn’s disease, and celiac illness. The neonatal intensive care unit nurse can be very supportive of the mother in terms of providing her with equipment to pump, ensuring privacy, and encouraging skin-to-skin contact. Early enteral feedings of formula or hyperosmolar feedings are a risk factor known to contribute to the development of NEC. The mother should be encouraged to pump or feed breast milk exclusively. Exchange transfusion may be necessary; however, it is a known risk factor for the development of NEC. Although still early, a study in 2005 found that the introduction of prophylactic probiotics appeared to enhance the normal flora of the bowel and therefore decrease the severity of NEC when it did occur. This treatment modality is not as widespread as encouraging breastfeeding; however, it is another strategy that the care providers of these extremely fragile infants may have at their disposal.
As a result of large body surface in relation to weight, the preterm infant is at high risk for heat loss and cold stress. By understanding the four mechanisms of heat transfer (convection, conduction, radiation, and evaporation), the nurse can create an environment for the infant that prevents temperature instability. While evaluating the plan that has been implemented, the nurse knows that the infant is experiencing cold stress when he or she exhibits:
a. Decreased respiratory rate.
b. Bradycardia followed by an increased heart rate.
c. Mottled skin with acrocyanosis.
d. Increased physical activity.
ANS: C
The infant has minimal-to-no fat stores. During times of cold stress the skin will become mottled, and acrocyanosis will develop, progressing to cyanosis. Even if the infant is being cared for on a radiant warmer or in an isolette, the nurse’s role is to observe the infant frequently to prevent heat loss and respond quickly if signs and symptoms occur. The respiratory rate increases followed by periods of apnea. The infant initially tries to conserve heat and burns more calories, after which the metabolic system goes into overdrive. In the preterm infant experiencing heat loss the heart rate initially increases followed by periods of bradycardia. In the term infant the natural response to heat loss is increased physical activity. However, in a term infant experiencing respiratory distress or in a preterm infant, physical activity is decreased.
Risk factors associated with necrotizing enterocolitis (NEC) include (choose all that apply):
a. Polycythemia.
b. Anemia.
c. Congenital heart disease.
d. Bronchopulmonary dysphasia.
e. Retinopathy.
ANS: A, B, C
Risk factors for NEC include asphyxia, respiratory distress syndrome, umbilical artery catheterization, exchange transfusion, early enteral feedings, patent ductus arteriosus, congenital heart disease, polycythemia, anemia, shock, and gastrointestinal infection.
Bronchopulmonary dysphasia and retinopathy are not associated with NEC.
A woman gave birth to a healthy 7-pound, 13-ounce infant girl. The nurse suggests that the woman place the infant to her breast within 15 minutes after birth. The nurse knows that breastfeeding is effective during the first 30 minutes after birth because this is the:
a. Transition period. c. Organizational stage.
b. First period of reactivity. d. Second period of reactivity.
ANS: B
The first period of reactivity is the first phase of transition and lasts up to 30 minutes after birth. The infant is highly alert during this phase. The transition period is the phase between intrauterine and extrauterine existence. There is no such phase as the organizational stage. The second period of reactivity occurs roughly between 4 and 8 hours after birth, after a period of prolonged sleep.
Part of the health assessment of a newborn is observing the infant’s breathing pattern. A full-term newborn’s breathing pattern is predominantly:
a. Abdominal with synchronous chest movements.
b. Chest breathing with nasal flaring.
c. Diaphragmatic with chest retraction.
d. Deep with a regular rhythm.
ANS: A
In normal infant respiration the chest and abdomen rise synchronously, and breaths are shallow and irregular. Breathing with nasal flaring is a sign of respiratory distress. Diaphragmatic breathing with chest retraction is a sign of respiratory distress. Infant breaths are not deep with a regular rhythm
While assessing the newborn, the nurse should be aware that the average expected apical pulse range of a full-term, quiet, alert newborn is:
a. 80 to 100 beats/min. c. 120 to 160 beats/min.
b. 100 to 120 beats/min. d. 150 to 180 beats/min.
ANS: C
The average infant heart rate while awake is 120 to 160 beats/min. The newborn’s heart rate may be about 85 to 100 beats/min while sleeping. The infant’s heart rate typically is a bit higher when alert but quiet. A heart rate of 150 to 180 beats/min is typical when the infant cries.
A newborn is placed under a radiant heat warmer, and the nurse evaluates the infant’s body temperature every hour. Maintaining the newborn’s body temperature is important for preventing:
a. Respiratory depression. c. Tachycardia.
b. Cold stress. d. Vasoconstriction.
ANS: B
Loss of heat must be controlled to protect the infant from the metabolic and physiologic effects of cold stress, and that is the primary reason for placing a newborn under a radiant heat warmer. Cold stress results in an increased respiratory rate and vasoconstriction.
An African-American woman noticed some bruises on her newborn girl’s buttocks. She asks the nurse who spanked her daughter. The nurse explains that these marks are called:
a. Lanugo. c. Nevus flammeus.
b. Vascular nevi. d. Mongolian spots.
ANS: D
A Mongolian spot is a bluish black area of pigmentation that may appear over any part of the exterior surface of the body. It is more commonly noted on the back and buttocks and most frequently is seen on infants whose ethnic origins are Mediterranean, Latin American, Asian, or African. Lanugo is the fine, downy hair seen on a term newborn. A vascular nevus, commonly called a strawberry mark, is a type of capillary hemangioma. A nevus flammeus, commonly called a port-wine stain, is most frequently found on the face.
While examining a newborn, the nurse notes uneven skin folds on the buttocks and a click when performing the Ortolani maneuver. The nurse recognizes these findings as a sign that the newborn probably has:
a. Polydactyly. c. Hip dysplasia.
b. Clubfoot. d. Webbing
ANS: C
The Ortolani maneuver is used to detect the presence of 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. Webbing, or syndactyly, is a fusing of the fingers or toes.
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:
a. Acrocyanosis. c. Harlequin color.
b. Erythema neonatorum. d. Vernix caseosa.
ANS: A
Acrocyanosis, or the appearance of slightly cyanotic hands and feet, is caused by vasomotor instability, capillary stasis, and a high hemoglobin level. Acrocyanosis is normal and appears intermittently over the first 7 to 10 days. Erythema toxicum (also called erythema neonatorum) is a transient newborn rash that resembles flea bites. The harlequin sign is a benign, transient color change in newborns. Half of the body is pale, and the other half is ruddy or bluish red with a line of demarcation. Vernix caseosa is a cheeselike, whitish substance that serves as a protective covering.
The nurse assessing a newborn knows that the most critical physiologic change required of the newborn is:
a. Closure of fetal shunts in the circulatory system.
b. Full function of the immune defense system at birth.
c. Maintenance of a stable temperature.
d. Initiation and maintenance of respirations.
ANS: D
The most critical adjustment of a newborn at birth is the establishment of respirations. The cardiovascular system changes markedly after birth as a result of fetal respiration, which reduces pulmonary vascular resistance to the pulmonary blood flow and initiates a chain of cardiac changes that support the cardiovascular system. The infant relies on passive immunity received from the mother for the first 3 months of life. After the establishment of respirations, heat regulation is critical to newborn survival.
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:
a. “Infants can see very little until about 3 months of age.”
b. “Infants can track their parent’s eyes and distinguish patterns; they prefer complex patterns.”
c. “The infant’s eyes must be protected. Infants enjoy looking at brightly colored stripes.”
d. “It’s important to shield the newborn’s eyes. Overhead lights help them see better.”
ANS: B
“Infants can track their parent’s eyes and distinguish patterns; they prefer complex patterns” is an accurate statement. Development of the visual system continues for the first 6 months of life. Visual acuity is difficult to determine, but the clearest visual distance for the newborn appears to be 19 cm. Infants prefer to look at complex patterns, regardless of the color. Infants prefer low illumination and withdraw from bright light.
While evaluating the reflexes of a newborn, the nurse notes that with a loud noise the newborn symmetrically abducts and extends his arms, his fingers fan out and form a “C” with the thumb and forefinger, and he has a slight tremor. The nurse would document this finding as a positive:
a. Tonic neck reflex. c. Babinski reflex.
b. Glabellar (Myerson) reflex. d. Moro reflex.
ANS: D
The characteristics displayed by the infant are associated with a positive Moro reflex. The tonic neck reflex occurs when the infant extends the leg on the side to which the infant’s head simultaneously turns. The glabellar reflex is elicited by tapping on the infant’s head while the eyes are open. A characteristic response is blinking for the first few taps. The Babinski reflex occurs when the sole of the foot is stroked upward along the lateral aspect of the sole and then across the ball of the foot. A positive response occurs when all the toes hyperextend, with dorsiflexion of the big toe.
While assessing the integument of a 24-hour-old newborn, the nurse notes a pink, papular rash with vesicles superimposed on the thorax, back, and abdomen. The nurse should:
a. Notify the physician immediately.
b. Move the newborn to an isolation nursery.
c. Document the finding as erythema toxicum.
d. Take the newborn’s temperature and obtain a culture of one of the vesicles.
ANS: C
Erythema toxicum (or erythema neonatorum) is a newborn rash that resembles flea bites. This is a normal finding that does not require notification of the physician, isolation of the newborn, or any additional interventions
A client is 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.”
ANS: 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” 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
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?” The nurse’s best response is:
a. “That’s meconium, which is your baby’s first stool. It’s normal.”
b. “That’s transitional stool.”
c. “That means your baby is bleeding internally.”
d. “Oh, don’t worry about that. It’s okay.”
ANS: A
“That’s meconium, which is your baby’s first stool. It’s normal” is an accurate statement and the most appropriate response. Transitional stool is greenish brown to yellowish brown and usually appears by the third day after initiation of feeding. “That means your baby is bleeding internally” is not accurate. “Oh, don’t worry about that. It’s okay” is not an appropriate statement. It is belittling to the father and does not educate him about the normal stool patterns of his daughter.
The transition period between intrauterine and extrauterine existence for the newborn:
a. Consists of four phases, two reactive and two of decreased responses.
b. Lasts from birth to day 28 of life.
c. Applies to full-term births only.
d. Varies by socioeconomic status and the mother’s age.
ANS: B
Changes begin right after birth; the cutoff time when the transition is considered over (although the baby keeps changing) is 28 days. The transition period has three phases: first reactivity, decreased response, and second reactivity. All newborns experience this transition regardless of age or type of birth. Although stress can cause variation in the phases, the mother’s age and wealth do not disturb the pattern.
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.
ANS: D
The first phase is an active phase in which the baby is alert. Decreased activity and sleep mark the second phase. The first phase is the shortest, lasting less than 30 minutes. Such exploratory behaviors include spontaneous startle reactions. In the first phase the newborn also produces saliva.
With regard to the respiratory development of the newborn, nurses should be aware that:
a. The first gasping breath is an exaggerated respiratory reaction within 1 minute of birth.
b. Newborns must expel the fluid from the respiratory system within a few minutes of birth.
c. Newborns are instinctive mouth breathers.
d. Seesaw respirations are no cause for concern in the first hour after birth.
ANS: A
The first breath produces a cry. Newborns continue to expel fluid for the first hour of life. Newborns are natural nose breathers; they may not have the mouth-breathing response to nasal blockage for 3 weeks. Seesaw respirations instead of normal abdominal respirations are not normal and should be reported.
With regard to the newborn’s developing cardiovascular system, nurses should be aware that:
a. The heart rate of a crying infant may rise to 120 beats/min.
b. Heart murmurs heard after the first few hours are cause for concern.
c. The point of maximal impulse (PMI) often is visible on the chest wall.
d. Persistent bradycardia may indicate respiratory distress syndrome (RDS).
ANS: C
The newborn’s thin chest wall often allows the PMI to be seen. The normal heart rate for infants who are not sleeping is 120 to 160 beats/min. However, a crying infant temporarily could have a heart rate of 180 beats/min. Heart murmurs during the first few days of life have no pathologic significance; an irregular heart rate past the first few hours should be evaluated further. Persistent tachycardia may indicate RDS; bradycardia may be a sign of congenital heart blockage.
By knowing about variations in infants’ blood count, nurses can explain to their clients that:
a. A somewhat lower than expected red blood cell count could be the result of delay in clamping the umbilical cord.
b. The early high white blood cell (WBC) count is normal at birth and should decrease rapidly.
c. Platelet counts are higher than in adults for a few months.
d. Even a modest vitamin K deficiency means a problem with the ability of the blood to clot properly.
ANS: B
The WBC count is high the first day of birth and then declines rapidly. Delayed clamping of the cord results in an increase in hemoglobin and the red blood cell count. The platelet count essentially is the same for newborns and adults. Clotting is sufficient to prevent hemorrhage unless the vitamin K deficiency is significant.
What infant response to cool environmental conditions is either NOT effective or NOT available to them?
a. Constriction of peripheral blood vessels
b. Metabolism of brown fat
c. Increased respiratory rates
d. Unflexing from the normal position
ANS: D
The newborn’s flexed position guards against heat loss because it reduces the amount of body surface exposed to the environment. The newborn’s body is able to constrict the peripheral blood vessels to reduce heat loss. Burning brown fat generates heat. The respiratory rate may rise to stimulate muscular activity, which generates heat.
With regard to the functioning of the renal system in newborns, nurses should be aware that:
a. The pediatrician should be notified if the newborn has not voided in 24 hours.
b. Breastfed infants likely will void more often during the first days after birth.
c. “Brick dust” or blood on a diaper is always cause to notify the physician.
d. Weight loss from fluid loss and other normal factors should be made up in 4 to 7 days.
ANS: A
A newborn who has not voided in 24 hours may have any of a number of problems, some of which deserve the attention of the pediatrician. Formula-fed infants tend to void more frequently in the first 3 days; breastfed infants void less during this time because the mother’s breast milk has not come in yet. Brick dust may be uric acid crystals; blood spotting could be caused by withdrawal of maternal hormones (pseudomenstruation) or a circumcision. The physician must be notified only if there is no apparent cause of bleeding. Weight loss from fluid loss might take 14 days to regain.
With regard to the gastrointestinal (GI) system of the newborn, nurses should be aware that:
a. The newborn’s cheeks are full because of normal fluid retention.
b. The nipple of the bottle or breast must be placed well inside the baby’s mouth because teeth have been developing in utero, and one or more may even be through.
c. Regurgitation during the first day or two can be reduced by burping the infant and slightly elevating the baby’s head.
d. Bacteria are already present in the infant’s GI tract at birth, because they traveled through the placenta.
ANS: C
Avoiding overfeeding can also reduce regurgitation. The newborn’s cheeks are full because of well-developed sucking pads. Teeth do develop in utero, but the nipple is placed deep because the baby cannot move food from the lips to the pharynx. Bacteria are not present at birth, but they soon enter through various orifices.
All of these statements about physiologic jaundice are true except:
a. Neonatal jaundice is common, but kernicterus is rare.
b. The appearance of jaundice during the first 24 hours or beyond day 7 indicates a pathologic process.
c. Because jaundice may not appear before discharge, parents need instruction on how to assess it and when to call for medical help.
d. Breastfed babies have a lower incidence of jaundice.
ANS: D
Breastfeeding is associated with an increased incidence of jaundice. Neonatal jaundice occurs in 60% of newborns; the complication called kernicterus is rare. Jaundice in the first 24 hours or that persists past day 7 is cause for medical concern. Parents need to know how to assess jaundice.
The cheeselike, whitish substance that fuses with the epidermis and serves as a protective coating is called:
a. Vernix caseosa c. Caput succedaneum
b. Surfactant d. Acrocyanosis

ANS: A

This protection, vernix caseosa, is needed because the infant’s skin is so thin. Surfactant is a protein that lines the alveoli of the infant’s lungs. Caput succedaneum is the swelling of the tissue over the presenting part of the fetal head. Acrocyanosis is cyanosis of the hands and feet, resulting in a blue coloring.

What marks on a baby’s skin may indicate an underlying problem that requires notification of a physician?
a. Mongolian spots on the back
b. Telangiectatic nevi on the nose or nape of the neck
c. Petechiae scattered over the infant’s body
d. Erythema toxicum anywhere on the body
ANS: C
Petechiae (bruises) scattered over the infant’s body should be reported to the pediatrician because they may indicate underlying problems. Mongolian spots are bluish-black spots that resemble bruises but fade gradually over months and have no clinical significance. Telangiectatic nevi (stork bites, angel kisses) fade by the second year and have no clinical significance. Erythema toxicum is an appalling-looking rash, but it has no clinical significance and requires no treatment.
An examiner who discovers unequal movement or uneven gluteal skin folds during the Ortolani maneuver would then:
a. Tell the parents that one leg may be longer than the other, but they will equal out by the time the infant is walking.
b. Alert the physician that the infant has a dislocated hip.
c. Inform the parents and physician that molding has not taken place.
d. Suggest that, if the condition does not change, surgery to correct vision problems might be needed.
ANS: B
The Ortolani maneuver is a technique for checking hip integrity. Unequal movement suggests that the hip is dislocated. The physician should be notified.
One reason the brain is vulnerable to nutritional deficiencies and trauma in early infancy is the:
a. Incompletely developed neuromuscular system.
b. Primitive reflex system.
c. Presence of various sleep-wake states.
d. Cerebellum growth spurt.
ANS: D
The vulnerability of the brain likely is to the result of the cerebellum growth spurt. The neuromuscular system is almost completely developed at birth. The reflex system is not relevant. The various sleep-wake states are not relevant.
The nurse caring for the newborn should be aware that the sensory system least mature at the time of birth is:
a. Vision. c. Smell.
b. Hearing. d. Taste.
ANS: A
The visual system continues to develop for the first 6 months. As soon as the amniotic fluid drains from the ear (minutes), the infant’s hearing is similar to that of an adult. Newborns have a highly developed sense of smell. The newborn can distinguish and react to various tastes.
During life in utero oxygenation of the fetus occurs through transplacental gas exchange. When birth occurs, four factors combine to stimulate the respiratory center in the medulla. The initiation of respiration then follows. Which is NOT one of these essential factors?
a. Chemical c. Thermal
b. Mechanical d. Psychologic

ANS: D

A psychologic factor is not one of the essential factors in the initiation of breathing; the fourth factor is sensory. The sensory factors include handling by the provider, drying by the nurse, lights, smells, and sounds. Chemical factors are essential for the initiation of breathing. During labor decreased levels of oxygen and increased levels of carbon dioxide seem to have a cumulative effect that is involved in the initiation of breathing. Clamping of the cord may also contribute to the start of respirations. Prostaglandins are known to inhibit breathing. Clamping of the cord results in a drop in the level of prostaglandins. Mechanical factors also are necessary to initiate respirations. As the infant passes through the birth canal, the chest is compressed. With birth the chest is relaxed, which allows for negative intrathoracic pressure that encourages air to flow into the lungs. The profound change in temperature between intrauterine and extrauterine life stimulates receptors in the skin to communicate with the receptors in the medulla. This also contributes to the initiation of breathing

A collection of blood between the skull bone and its periosteum is known as a cephalhematoma. To reassure the new parents whose infant develops such a soft bulge, it is important that the nurse be aware that this condition:
a. May occur with spontaneous vaginal birth.
b. Only happens as the result of a forceps or vacuum delivery.
c. Is present immediately after birth.
d. Will gradually absorb over the first few months of life.
ANS: A
Bleeding may occur during a spontaneous vaginal delivery as a result of the pressure against the maternal bony pelvis. The soft, irreducible fullness does not pulsate or bulge when the infant cries. Low forceps and other difficult extractions may result in bleeding. However, these can also occur spontaneously. The swelling may appear unilaterally or bilaterally and is usually minimal or absent at birth. It increases over the first 2 to 3 days of life. Cephalhematomas disappear gradually over 2 to 3 weeks. A less common condition results in calcification of the hematoma, which may persist for months.
1. What are modes of heat loss in the newborn? Choose all that apply.
a. Perspiration
b. Convection
c. Radiation
d. Conduction
e. Urination
ANS: B, C, D
Convection, radiation, evaporation, and conduction are the four modes of heat loss in the newborn. Perspiration and urination are not modes of heat loss in newborns.
A 42-year-old is at the clinic for her first prenatal visit. The nurse is doing the initial assessment and is aware that the woman is at risk for
A. Having a spontaneous abortion prior to 12 weeks
B. Having a sexually transmitted disease
C. Developing abnormalities of the reproductive organs
D. Not obtaining adequate prenatal care
A. Having a spontaneous abortion prior to 12 weeks
Women older than 40 years have a 26% risk of spontaneous abortion.
When comparing threatened abortion to inevitable abortion, inevitable abortion has
A. Increased cramping
B. Increased nausea
C. Cervical dilation
D. Lower levels of beta-human chorionic gonadotropin
C. Cervical dilation
A woman is seeing her primary physician for complaints of frequent nosebleeds. She states she thought she was pregnant about 3 months ago, but her periods started and the symptoms disappeared. The health care provider should be alert for what complication of a missed abortion?
A. Infection
B. Infertility
C. DIC
D. Thrombocytopenia
C. DIC
When doing an initial assessment on a newly diagnosed pregnant woman, she tells the nurse, “In my younger days, I did some stupid things and had different types of STDs and once had a pelvic inflammatory disease.” The nurse is aware that the woman is at risk for
A. More STDs
B. Preeclampsia
C. Ectopic pregnancy
D. Gestational diabetes
C. Ectopic pregnancy
A woman has been admitted to the birthing unit with a diagnosis of spontaneous abortion. She has increased bleeding and is having her pads weighed to estimate the blood loss. The weight of an unused pad is 1.5 grams, the pads used between 7 AM and 9 AM weigh 4.5, 6.5, 10, 15, and 11.5 grams. What is the estimated blood loss?
A. 20 mL
B. 40 mL
C. 60 mL
D. Unable to determine with the information provided
B. 40 mL
When taking an initial prenatal history on a woman, she admitted to cocaine use during the early days of the pregnancy. The nurse is aware that this would put her at risk for
A. Placenta previa
B. Abruptio placentae
C. Large for gestational age baby
D. Both a and b
D. Both a and b
A woman is admitted with a diagnosis of hyperemesis gravidarum. The nurse is assessing for deficient fluid and signs of dehydration. (Choose all that apply.)
A Decreased urinary output
B. Urine specific gravity of 1.015
C. Nonelastic skin turgor
D. Constipation
A Decreased urinary output
C. Nonelastic skin turgor
D. Constipation
A woman with preeclampsia is being treated with bed rest and intravenous magnesium sulfate. The drug classification of this medication is
A. Tocolytic
B. Anticonvulsant
C. Antihypertensive
D. Diuretic
B. Anticonvulsant
What is the only known cure for preeclampsia?
A. Magnesium sulfate
B. Antihypertensive medications
C. Delivery of the fetus
D. Administration of ASA every day of the pregnancy
C. Delivery of the fetus
The classic sign of placenta previa is the sudden onset of ___________ uterine bleeding in the latter half of pregnancy.
painless
What is Maternal-Child nursing?
The care of women through pregnancy, childbirth, and postpartum. It is also the care of the child from birth through the teenage years
In the early 1900’s, what percentage of births were in the home?
More than 90%
What were some of the dramatic changes made from the 1900’s to the 1940’s in medical science?
1. Hospitals were built. 2. Healthcare moved from home environment to hospital setting. 3.Improvements in anesthesia led to more use in spinal blocks and inhaled meds that produced “twilight sleep” for painless deliveries
During the 1960’s-1980’s it was discovered that large doses of meds caused resp depression in neonates and ineffective pushing in mothers. This led to the use of what tool and caused an increase in what?
Forceps; C-sections
Why were prenatal classes formed?
To teach about pregnancy, nutrition, and natural childbirth
How is an epidural different from a spinal block?
It has fewer adverse effects
What could be a result of postponing childbirth until later adult hood?
Greater risk of complications of fetal anomalies
When is the risk of having a child with Down Syndrome greater?
Having a child after age 40
What is pediatrics?
The medical science related to the diagnosis and treatment of childhood illness
What is Aid to Families with Dependent Children?
Est by the Social Security Act of 1935 to provide money for needy children without fathers
Why was Medicaid est in 1965?
To reduce the financial barriers to health care for the poor.
Why was WIC started in 1974?
To provide nutritious foods and education to low-income pregnant, postpartum, and lactating women and to infants and children up to age 5
How is nursing described today?
As a knowledge-based process discipline where the licensed nurse’s specialized education, professional judgment, and discretion are essential for quality nursing care
How does the ANA define nursing practice?
As “the nursing diagnosis and treatment of human response to actual or potential health problems”
In maternal child nursing, who does “client” refer to?
The whole family
As an LPN, what do you do when assessing?
Monitor changes at the bedside in a client; compare data with given normal ranges; decide whether findings should be reported
Nursing diagnoses were defined and developed by who?
NANDA
What is a desired outcome?
The clients goal that relates to a specific nursing diagnosis
What are nursing interventions?
Nursing actions possible to assist the client toward an improvement in health
What are medical diagnoses?
Statements about a disease process or disorder
In the nursing process, what is implementing?
The nursing and medical plan of care. LPN must stay within scope of practice
Nutritional needs of lactation vs. nutritional needs of pregnancy
The lactating women needs more CALORIES but the same amount of calcium, protein and fluids are needed.
Example two week old full term neonate – normal findings
– regained initial weight loss within 14 days
– 1 to 3 BM/day
– 6 to 8 wet diapers indicated the baby is well hydrated
– breastfed 8x /day
Oxytocin
– used to stimulate an active labor pattern
– naturally occuring hormone released by POSTERIOR PITUITARY
– synthetic form is used to stimulate or augment UC during labor.Therp Class
– oxytocic
– synthetic hormone

Action
– acts on uterine myofibrils to contract

Oxytocin Nursing Care
Nursing care
– admin with infusion pump
– closely monitor mom and fetusIf contractions occur < 2 min. apart, last longer than 60-90 seconds, or sig change in FHR
– STOP INFUSION and turn client to left side

Oxytocin Indications
– to induce / augment labor
– in pts with PIH, prolonged gestation, maternal diabetes. Rh sensitization, PROM or PPROM, incomplete or inevitable abortion
– to control bleeding and enhance UC AFTER the placenta is delivered
– rare cases in nonstress contraction test (>31 weeks) if nipple stimulation fails to produce contractions
Oxytocin Nursing Implications / Care
Admin IV with infusion pump
– starting primary IV line
– insert tubing of admin set through infusion pumpset drip rate to prescribed dosage and infusion rate
– infusion rate: 0.5 to 1.0 ml/minute
– labor starting dose: 10 units of oxytocin in 100 mL isotonic solution
– maximum dose: 20-40 mU

Admin Oxytocin by piggyback method in IV line
– always given in piggyback, so if hyperstimulation occurs, the drug can be stopped immed. and IV fluid can continue
– also if necessary, drug can be restarted easily to achieve goal

Oxytocin Nursing Implications / Care continued
Using external electronic fetal monitoring methods
– monitor for FHR decelerations or fetal distress and stop infusion immed. if these occurBe prepared to monitor UC as drug acts immed
-regulate infusion rate to achieve contractions that mimic labor

Increase oxytocin dose as ordered
– DONT increase more than 1-2 mU/min once every 16 to 60 min.

Before each increase
– assess contraction
– maternal VS
– fetal HR/rhythm
– verify uterine relaxation btw/ contractions by external or internal fetal monitor

Monitor maternal HR
– if HTN occurs, stop infusion and notify doctor

Assist with comfort measure
– repositioning pt on her side prn

Review infusion rate to prevent uterine hyperstimulation
– if hyperstim occurs, D/C oxytocin and admin O2
– increase uterine blood flow by changing the pts position and increasing infusion rate of primary IV line
– resume oxytocin infusion, per policy after hyperstim is resolved

Monitor I&O, water for signs of water intox (HA/vomitting)
– limit IV fluids to 150 mL/hr

prepare pt for birth

Oxytocin Expected Outcomes
– contractions begin and follow pattern of natural labor
– pt suffers NO adverse effects from drug
– fetus suffers NO distress
– Fetus is delivered successfully
Oxytocin Action
– increases UC by increasing circulation of free intracellular calcium
– oxytocin receptors increase during preg, esp in 3rd trimester and in LATENT phase of labor due to influence of estrogen, progesterone, prostaglandin- with increased # of receptors, amt of oxytocin needed for labor DECREASES

– continuous infusion of oxytocin raises circualting blood level slowly over 20-30 min

– half life is only 1-5 min. so stopping infusion results in RAPID DECREASE in effect

Oxytocin Adverse Effects
– N/V (water intox)
– cardiac arrhythmias
– uterine hypertonicity
– titanic contractions
– uterine rupture (excessive dosages)
– severe water intox
– fetal BRADYCARDIA
If a woman’s membranes rupture, what is the nurses FIRST action?

– observe for prolapsed cord or menconium stained fluid

these are signs of potentially life threatening complications to the fetus that may require emergency delivery

Patient is in labor and appears peaceful and there is an increase in bloody show, what stage of labor is she in?
2nd stage
– a short period of peace and an increase in bloody show occur immed. BEFORE the baby is born and at the beginning of 2nd stage of labor
Stages of Labor
1st stage – 1 to 10 cm dilitation
2nd Stage – peaceful time, bloody show
3rd Stage – delivery of placenta
4th Stage – 1st 2 hours of delivery
Stage 1 of labor
begins with onset of regular contractions and ENDS when cervix is completely effaced and dilated
Stage 2 of labor
from complete dilatation of cervix to the birth of the infant
Stage 3 of labor
from birth of infant to delivery of placenta
Stage 4 of labor
from 1-4 hours post birth
How to recognize the onset of labor
– may feel a gush of water at the beginning of labor
– may have blood tinged vag discharge
– regular UC that become stronger- FM remains UNCHANGED during true labor

Gush of water at the beginning of labor indicated what?
– ruptured membranes
– labor usually begins within 24 hours of SROM
Bloody show is a sing of what?
preceding labor
Other signs of preceding labor include
– lightening
– urinary frequency
– backache
– surge of energy
– stronger Braxton Hicks contractions
Regular uterine contractions that become stronger indicates what?

– true labor

discomfort radiates from back to the abdomen
contractions dont decrease with rest
cervix progressively effaces and dilates

cheesy white vaginal discharge indicates what?

candidiasis

other Sx
– vaginal pruritus

Tx with anti fungal prep

During labor induction with oxytocin, contractions are observed at 2 min intervals and last > 90 seconds, what should the nurse do?

stop the infusion!

its extrem important to continually assess contractions for pt receiving oxytocin drip

if contractions occur too freq, (intervals of <2 min) or last too long (>90 secs), they may endanger mom and fetus

nurse should STOP infusion, and notify doctor

Patient is in labor and with regular contractions and her cervix is 9cm dilated, what stage of labor is she in?

1st stage

from the beginning of labor until the cervix is completely dilated = 1ST STAGE

subdivided into
Latent Phase (0-3cm)
Active Phase (4-7cm)
Transition Phase (8-10cm)

Second Stage

from complete dilitation to the birth of the baby

Phase 1 = 0 to +2 station
Phase 2 = +2 to +4 station
Phase 3 = +4 to birth

Third stage
delivery of placenta, slight gush of blood and lengthening of umbilical cord
Fourth Stage
– 2 hours following birth of baby
Normal amount and character of lochia
– bright red and less than a heavy menstrual period
12 hours after deliver the fundus should be

1 cm above the umbilicus within 12 hours of birth

> 12 hours, the fundus should descend 1-2 cm /day

Heredity can be a factor for LGA infants, true or false?
true
Macrosomia of insulin dependent diabetic mothers is caused by what
poor maternal control
infant has round face, chubby body, flushed complexion
What are macrosomia infants at risk for?
hypoglycemia
hypocalcemiahyperbilirubinemia

Gravida

total number of pregnancies regardless of duration

includes
– present pregnancy

a pregnant woman

Parity

number of past pregnancies that have gone beyond the period of viability (capability of fetus to survive outside of the uterus)

after 20 weeks gestation or > 500 grams

regardless of # of fetuses or whether the infant was born dead or alive

Gravid
the state of being pregnant
Para
a woman who has carried 1 or more viable offspring to 20 weeks or more
Gravida/Parity

– the # of pregnancies a woman had, including the current pregnancy = gravida

– the # of children a woman has borne at 20 weeks or later = para

– ex. a woman who’s preg for the 2nd time and who has 1 child = gravida 2, para 1

Primigravida
woman who is pregnant for the 1st time
Multigravida
a woman who has previously been pregnant
Nulligravida
woman has never been and is not pregnant
Primpipara
a woman who has borne 1 child in past 20 weeks
Multipara
a woman who has borne 2 or more children in the past 20 weeks
GTAL and GTPALM provide more detailed info about a womans preg Hx
G = gravida remains the same
T = number of full term infants
P = number of preterm infants
A = number of abortions
L = number of living children
M= number of multiple pregs
RDS

altered resp state d/t surfactant deficiency in lungs

labored resp after several min. or hours of normal respirations initially

cyanosis, grunting, nasal flare, retractions, tachypnea

Cold stress

– mottled skin and metabolic/resp acidosis

– excessive loss of heat that results in increased resp and nonshivering thermogenesis

– metabolic acidosis occurs

– place in heated environment

Perinatal Asphysxia
occurs in utero
chronic hypoxiaoccurs in fetus that is
– SGA
– maternal Hx of heavy cig smoking

Prepare for aggressive ventilatory assistance
keep airway open

Hypovolemia
low blood volume
Cold Stress

excessive heat loss in newborns

in order to maintain core temp, infant uses metabolic processes to generate heat

Indications include
– increased resp
– mottling of skin / cyanosis
– abnormal blood gases (metabolic acidosis)

Nursing Care for Cold Stress
– place infant in heated environ immed after birth
– maintain neutral environment
– monitor temp
– fabric insulated cap for head
Gonorrhea can may you unable to have children, true or false?

TRUE

– bc it causes pelvic inflamm disease which is one of the most common causes of sterility

How is Gonorrhea treated?
with antibiotics
Gonorrhea can cause
– preterm labor
– premature ROM
– PP endometriosisMay cause the following the infant:
– sepsis
– conjunctivitis
– preterm birth

How to care for the newborns umbilical cord
– clean the cord and skin around it with water
– contact doctor if there’s white or yellow discharge from cordDO NOT
– bathe baby in tub (until it falls off)
– cover the cord with diaper (fold diaper below umbilicus to maintain dry area)
– will on cord when it becomes loose (allow it to fall off)
– apply petroleum jelly to base of cord

Newborn Cord Care

– umbilical cord surrounding the skin need be kept clean, dry and open to air until it falls off (usually 7-14 days after delivery)

– cord is left clamped (to prevent oozing of blood) until it dries, usually 24 hours post delivery

– clean cord with WATER
– no bath tubs allowed
– diapers folded below base to facilitate drying
– report redness, edema, purulent drainage which may indicate infection

Once cord falls off, remaining stump needs another 3-5 days of care

Newborn Cord Care expected outcomes
– shriveled and blackened umbilical cord falls of in 7-10 days and the umbilicus heals completely
Newborn Cord Care Implementation
– assess area freq for blood / signs of infection
– follow facility policy on cleansing and applying any appropriate agent at every diaper change
– ensure edge of diaper is BELOW the cord area to prevent irritation and promote drying
– remove cord clamp ONLY AFTER CORD IS FULLY DRY
Newborn Cord Care – Patient Teaching
– apply alcohol or recommended solution to cord site at each diaper change
– monitor for bleeding, redness, drainage, or foul odor
– dont give infant a tub bath until cord has fallen off or healed
– fold diapers below stump
– observe color change from yellow to brown to black
– allow cord to fall off on its own
Newborn Cord Care Unexpected Outcomes and Associated Interventions
Hemorrhage
– ensure cord is clamped securely until after thrombosis obliterates the umbilical vesselsInfection
– keep cord stump dry and clean and dont use creams, lotions, oils near cord

Ulcerous area remaining 1 week after the cord falls off
– may require cautery with silver nitrate to speed healing

FHR during labor is 59bpm, what should the nurse do?
turn the mom onto her left side
admin oxygen by nasal cannula
start IV
Bradycardia in fetus indicates what

– fetal distress

persistent bradycardia may indicate
– cord compression / separation of placenta

When is a woman most likely to become pregnant?

10-14 days after the onset of her menstrual period

this is the time of ovulation (around 14th day)

if pt has intercourse 2-3 days before this time or 2-3 days after this time, its possible that she will become pregnant, since the sperm lives for about 48 hours.

Secretory phase occurs when

between the day of ovulation and about 3 days prior to next menstrual period

large amounts of progesterone are produced

Implantation of fertilized ovum occurs when
7-10 days after ovulation
Ovulation

periodic ripening and rupture of mature graafian follicle and discharge of ovum

occurs approx 14 days prior to next menstrual period

Fertilization occurs when?

approx 24 hours after ovulation

usually in outer third of fallopian tube

Ovulation

rupture of mature follicle, which releases an ovum

– occurs at about 14 days BEFORE menstruation
– low levels of estrogen and progesterone stimulate secretion of gonatotropin releasing hormone which stimulates the secretion of LSH which spurs the development of follicle

LH surges, leading to ovulation within 48 hours

gonadotropin releasing hormone

this hormone stimulates the anterior pituitary to secrete FSH and LH

goes to the anterior pituitary gland and makes it release FSH and LH, prolactin

responsible for sex maturation

Follicle stimulating hormone
WOMEN: initiates growth of ovarian follicles each month and stimulates ovulation; MEN: stimulates sperm production
Lutenizing Hormone
stimulates the formation of corpus luteum, estrogen and progesterone in females and testosterone in males
Sex intercourse within 72 hours of ovulation aids in what?
conception
Ovulation Assessment
– menstrual history, to determine regularity and length of cycle
– evaluation of hormone levels (serum progesterone, FHS, LH, prolactin
– Progesterone test to confirm ovulation
– Eval of thyroid hormones to determine thyroid functioning and pituitary glandsHypothyroid condition can interfere with
– pituitary feedback cycle and disrupt secretion by pituitary of FSHand LH

Cervical mucus assessment
– at ovulation peak, mucus is thin, watery, transparent and stretches when pulled

Measurement of women’s BBT
– temp rises with ovulation

Painless vaginal bleeding indicates what? for example at 29 weeks gestation
placenta previa
placenta previa

placenta thats abnormally implanted in the lower uterine segment

pt will be Tx with
– bedrest
– no vag exams
– IVs to restore blood volume
– monitor FWB

Severe abdominla cramps and PAINFUL bleeding indicates what?

abruptio placenata

– premature separation of a normally implanted placenta

Placenta Previa

– implanted near or over the cervical opening

Indications
– PAINLESS bright red vaginal bleeding accompanied by soft uterus usually in 3rd trimester btw 29-30 weeks

Caused by
– scarring of uterus from preg
– tumor

PLacenta Previa Tx
– bedrest
– US to locate placenta
– no vag/rectal exams before fetal viability
– amniocentesis for lung maturity
– daily Hgb and Hct
– 2 U of cross matched blood avail
Diabetes S/S
– fatigue/weakness
– irritability
– polyuria
– polydipsia
– polyphagia
– nocturia
– blurred vision
– slowly healing lesions
– numbness of hands and feet
– weight loss
– dry skin
Type 1 DM TX

-strict diet to meet nutrient needs, control bg levels, recduce acidosis

– injected insulin, implantable insulin pumps, inhaled insulin

Type 2 DM
– meal planning to control blood glucose levels
– weight loss to decrease insulin resistance
– reg exercise to lower bg, increase insulin effectiveness, reduce cardiovasc risk
– injected insulin
Gestational Diabetes Tx
– diet modification
– blood glucose monitoring
– insulin if necessary (oral antidiabetic agents arent used in women)
Diabetes Nursing Care
– monitor pts blood glucose freq during insulin infusion
– plan pts usual insulin regimen after any crisis
– monitor pts electrolyte levels closely and admin K+ replacement if needed
– design meal plan
– monitor insulin complications (hypo/hyper glycemia)
– check for history for conditions such as pregnancy, breastfeeding stress or illness, which can increase insulin requirements
– check pts urine for ketones, esp if he is ketosis prone with type 1 dm
– show pt how to check their own glucose
– monitor A1C
Gestational Diabetes

– insulin resistance results from SECRETION OF PLACENTAL HORMONES

– in most instances, blood glucose levels return to normal after delivery, but these women are at risk for Type 2 DM later in life

The baby’s anterior fontanelle should close after how long?
about a year and a half
18 months- diamond shaped, 3×2 cm
– junction of saggital, coronal and frontal sutures

Posterior Fontanelle
triangular n shape
jx of sutures of the 2 parietal bones and 1 occiptal bonecloses 6-8 weeks post delivery

when is the most critical time for fetal development?
the first 3 months
1st 2 weeks of pregnancy

preembryonic stage

lasts from conception to 14 days

initial development of embryonic membranes and establishment of primary germ layers occur

The first 3 months of pregnancy
– 1st trimester aka first 3 months
– all major systems of the fetus are developed
– exposure of mother to noxious environmental agents can interfere with proper development of fetus
The 4th-6th months of pregnancy
the systems are all developed at this time
The last month of preg
fetus increases in weight
at 36 weeks, able to adjust to extrauterine life
Fetal Development at 4 weeks
– fetal heart begins to beat
Fetal Development at 8 weeks
– all body organs are formed
Fetal Development at 8-12 weeks
fetal heart rate can be heard by doppler device
Fetal Development at 16 weeks
baby’s sex can be seen
fetus looks like a baby
Fetal Development at 20 weeks
– heartbeat heard with fetoscope
– mom feels movement
– baby develops regular schedule of sleeping, sucking, kicking
– vernix/lanugo present
Fetal Development at 24 weeks
– increased activity, weighs 1lb 10oz
– resp movement begins
Fetal Development at 28 weeks
– eyes open and close
– can breathe at this time
– surfactant needed for the baby to breath at birth is formed
– 2/3 final size
Fetal Development at 32 weeks
– has fingernails, toenails, subcut fat formed
Fetal Development at 38-40 weeks
fills uterus
Fetal Development begins with conception and continues until birth, its typically divided into 3 periods:
1. Pre-embryonic Period (fertilization to week2)
2. Embryonic Period (weeks 3-7)
3. Fetal Period (week 8 – birth)
Pre-embryonic Period

fertilization to week 2

– fertilized ovum advances through the fallopian tube toward the uterus and undergoes miotic division, becoming a ZYGOTE

– zygote reaches the uterus about day 3 after fertilization

Called a blastocyst when it reaches the uterus,
– trophoblast layer develops into fetal membranes and the placenta
– inner cell mass then forms the embryo

By the end of the 1st week of fertilization, the blastocyst attaches to the ENDOMETRIUM

– During the next week, the invading blastocyst sinks below the endometrium’s surface
– the penetration site seals, restoring the continuity of the endometrial surface

Embryonic Period

weeks 3-7

– blasotcyst becomes an embryo

Embryonic Period – ectoderm develops into the
Epidermis
Nervous system
Pituitary gland
Tooth enamel
Salivary gland
Optic lens
Lining of the lower portion of anal canal
Hair
Embryonic Period – Mesoderm develops into
– connective tissue and supporting tissue
– the blood and vasc system
– musculature
– teeth
– mesothelial lining of pleural, and peritoneal cavities
– kidneys / ureters
Embryonic Period – Endoderm develops into
– epithelial lining of pharynx and trachea
– auditory canal
– ailmentary canal
– liver
– pancreas
– bladder and urethra
– prostate
Embryonic Period – at the end of the month

the head, trunk and tiny buds that will become arms, legs = are discernible

CV system has begin to function
umbilical cord is visible in its primitive form

Embryonic Period – during the 2nd month,
it grows to 1 and 1 gram
head and facial features develop
arms / legs take shape
external genitalia are present
CV function is complete
umbilical cord has a definite form
Fetal Period

week 8-birth

– during the 3rd month, the fetus is 3 and 1 ounce
– teeth and bones begin to appear
– kidneys start to function
– fetus opens mouth
– grasps with fully developed hands
– preps for breathing by inhaling and exhaling

gender is distinguishable by THE END OF THE 3RD MONTH

Growth and development of fetus follows what type of pattern?
cephalocaudal (head to toe)
proximal to distal pattern
Implantation occurs where?
the upper uterus
Embryo develops into a fetus, which grows and develops at a predictable rate
– heart beats regularly by week 5
– resembles a human being at the end of week 8
– weight quadruples during the 4th month
– FM detected by mother during the 4th month
– Fetal heart sounds can be detected by stethoscope during 5th month
– muscles are well developed by week 20
– lungs begin to produce surfactant during the 6th month
– fetus reaches 15 inches in length during the 7th month – increased CNS control over body fx occurs during the 8th month
– fetus is considered full term at 38 weeks
– fetus fills uterus during 9th month
Adequate amounts of amniotic fluid
– maintain a consistent body temp
– protects fetus from trauma
– promotes symmetric growth and development
– protects from umbilical cord compression
– allow for FM to enhance MS development
The placenta
– forms the trophoblasts
– attaches to the uterus& provides the following functions:
– acts as a transfer organ btw mom and fetus
– produces hormones necessary for a normal preg (hCG, hPL, estrogen, progesterone, relaxin)
– protects fetus from mom’s immune system
– removes waste products from fetus
– triggers mom’s body to provide more food to placenta
– produces hormones that mature fetal organs in prep for birth

The umbilical cord is formed from amnion and is made of how many veins / arteries?
1 large vein
2 small arteriessurrounded by Whartons jelly to protect the blood vessels from compression
– acts as a lifeline from fetus to mom
– approx 22 inches long and 1 in wide at term

Oligohydraminos

< 500 mL of amniotic fluid

associated with
– utero-placental insufficiency
– fetal renal abnorms

Hydraminos

> 2,000 mL of amniotic fluid at term

Associated with
– maternal diabetes
– neural tube defects
– chromosomal deviations
– malformations of CNS/GI that prevent fetus from swallowing amniotic fluid

Teratogens, infections, radiation, nutrient deficiencies
are the most dangerous during embryonic period bc of rapid growth, and forming of organs / structures
Chromosomal abnorms
– numeric or structural abnroms
Downs, fragile X syndrome
Autosomal Dominant inherited disorders

– abnormal gene pair causes disease even if the matching pair from the other parent is normal

– familial hypercholesterolemia
– breast and ovarian cancer r/t BRCA genes

Autosomal Recessive inherited disorders
– both gene pairs are mutated, causing disease
sickle cell, cystic fibrosis
mom addicted to narcotics gives birth to day, when is the most likely time to observe symptoms of narcotic withdrawal?

within 24-72 hours after birth

infant wil be jittery, hyperactive, high pitch cry, diaphoresis, tachypnea

if mom is taking methadone, infant demonstrates signs of withdrawal when
about 7 days after birth
Toxoplasmosis

protozoan infection

caused by eating infected undercooked meat or after handling infected kitty litter

infection can cross placenta and infect the fetus

preg woman shouldnt clean cat liter box, if she must, wear latex gloves and wash hands after

How long does the 4th stage of labor last?
from delivery of placenta until 6 weeks
What is the taking in period?
2nd-10th day, mom is insecure and needs reassurance, begins to initiate action with baby
What is the Letting go phase?
redefines her new role as mother, extends and continues into the child’s growing years
What is development of parental love?
initially little contact is normal, gradually mom begins to touch infant more
Abandonment
Mom feels this because all the attention is on the baby.
Disappointment
could be because of the birth process, had to have c-section, or take pain meds, sexo of baby, isn’t what she expected
What are Postpartal Blues?
80% of mom’s get it, unexplained sadness, assurance needed, could be hormonal changes, could be exhaustion, they need to know it’s normal, allow her to verbalize her feelings.
Involution
the area where the placenta was implanted seals off and bleeding is prevented. Organ is reduced to approximately it’s pre-gestational size. Takes 6 weeks
Placental Sealing
rapid contraction of the uterus immediately after delivery of the placenta. Pinches the blood vessels entering the area and controls bleeding. There’s no scar tissue with the uterus.
Uterine Shrinking
Contractions immediately after birth, reduces the bulk of the uterus. It’s half it’s pregnancy size in a week! The walls thicken and contract. Never returns completely to prepregnancy stat. At birth it weighs 1000grams, End of first week, 500 grams. End of postpartal period, 50 grams
Predictable Uterine Involution
within in minutes of birth it’s halfway between umbilicus and symphysis pubi. 1 hour after birth it rises to level of umbilicus and 24 hours each day after it lowers 1 cm per day. 10-14th day it is no longer palpable withdrawn into pelvis
Fundus position
it should always be midline in the abdomen, sometimes a little to the right because of constipation (sigmoid colon), full bladder can keep it contracted. Involution can be delayed by multiples, hydramnios, exhaustion, grand multiparity, retained placenta or membranes, full bladder
How the Fundus feels
it should be firm and easy to find, if it’s boggy the 1st hour after delivery the mom will lose blood VERY RAPIDLY
Lochia Rubra
bright red, until 3rd postpartal day
Lochia Serosa
pink brown, 4th-10th postpartal day
Lochia Alba
11th day, colorless or white 3-6 days
Documentation of Lochia
Don’t use super absorbent pads so we can assess how much blood is leaving
Scant Lochia
1″ stain
Light Lochia
1″-4″
Moderate Lochia
4″-6″
Heavy Lochia
SATURATED clots should be no bigger than grapes
Saturating a pad in…
<1 hour is abnormal, no large clots, don’t go back in lochia stages, no offensive odors, 1-3 weeks postpartum
What should cervix be like after birth?
soft + malleable immediately after birth and internal + external os is open. 7th PP day, external os is narrowed to size of pencil + is firm, internal os will close completely but external os will remain slightly open + appear as a slit (no longer open)
What does the vagina look like after birth?
Takes entire PP period for vagina to go back to normal, walls thicken with renewed estrogen stimulation, vaginal outlet may remain more distended so encourage KEGELS!
Perineum
May show bruising (ecchymosis) because of capillary rupture.
Labia
Never return to prepregnancy state, Edema can cause difficult void
1st Degree Laceration
thru skin to muscles
2nd Degree Laceration
thru muscles + perineal body, can be sutured
3rd Degree Laceration
thru anal sphincter, incontinence
4th Degree Laceration
thru anal sphincter, anterior anal wall, you have to see specialist
Typical Episiotomy
1-2 cm, extended if lacerated, fused by 24 hours postpartum
Nursing care for Episiotomy
pain relief, ice, perineal cleansing, sitz bath cold + hot therapy, REETA
Post-Partum Hormonal Changes
Pregnancy hormones decrease as soon as as placenta is gone. HCG+hPL (Lactogen) are undectectable by 24 hours. Week 1 PP estrone+estradiol are at pre-pregnancy state. FSH (dictates ovulation)remains low for 12 days then rises to initiate new menses
Urinary System Post partum
head puts pressure on bladder+urethra, leaving bladder with loss of tone+edema. Edema makes voiding difficult, women have diminished sensation to void. OVER DISTENTION ASSESSMENT IS NECESSARY. Full bladder sounds resonant, firm area above symphysis pubis and may displace uterus
Ureters Post Partum
Size remains for 4 weeks PP, urinary stasis and UTI’s common. Extensive diuresis occurs almost immediately after birth
Blood Volume PP
returns to normal 1-2 weeks PP
Hematocrit PP
returns to normal 6 weeks
Plasma Fibrinogen PP
elevated during PP to protect against hemorrhaging, increased risk for clots especially for women on bed rest
WBC PP
increase is normal, above 25000 is high
Varicosities PP
recede slightly
GI PP
hunger+thirst are most common immediately after birth, hemorrhoids, relaxin still present so bowels are slowed, sometimes painful stool because of sutures or ‘roids
Skin PP
pigment + elasticity fade + return 6 weeks PP
Weight Loss PP
5.5kg/[email protected], 2.3-3.6 kgs/5-8.8 lbs over days 2-5, encourage rest and fluid intake
Temperature PP
Slight elevation in temperature because of dehydration or when mild comes in, temp >100.4 is a fever and PP infection (after 24 hours) should be suspected
Pulse PP
slightly decreased
Blood Pressure PP
returns to pre-pregnancy baseline
Lactation
colostrum for 2 days, 3rd day milk comes, primary engorgement, continued milk production, depends on nipple stimulation, warm packs for engorgement
FUNDAL CHECKS PP
palpate every 15 minutes for 1st hour PP, support the fundus, use side of hand, document as U-1, U-2, U-3, U-4, firm, boggy, midline
FUNDAL MASSAGE
What’s the only independent nursing action when there’s a boggy uterus?
BUBBLEHE
Breasts, Uterus, Bladder, Bowels, Lochia, Episiotomy, Hormones, Emotions/Bonding
Who is at high risk for post partum complications?
Pregnancy hypertension, diabetes, cardiac disease, c-section, overdistention of uterus,precipitous labor, prolonged labor, difficult birth/pushing
PP Hemorrhage
any blood loss from the uterus greater than 500 ml in 24 hours (1000ml is considered a hemorrhage in most hospitals), can occur early or late, BIGGEST RISK IN FIRST 24 HOURS
What is the #1 cause of PP Hemorrhage?
UTERINE ATONY-relaxation of the uterus
Causes of Hemorrhage
uterine atony, multiparity >5, retained placenta, unresolved lacerations, previous history, failure of labor to progress during second stage, LGA, instrument delivery, induction, C-section, clotting disorders, subinvolution of uterus, anesthesia
Counting Pads
saturating >1 per hour is above average, turn mom on her side to assess for blood pooling
Interventions for Hemorrhages
pitocin or IM methergine, bimanual massage, prostaglandin massage, blood replacement, hysterectomy
Perineal Lacerations
small are common, larger can be problematic
Cervical Lacerations
sides of cervix near branches of uterine artery, difficult to repair, you need to go into OR with anesthesia
Increased HCG PP
means there are retained placental fragments
Puerperal Infection
infection of the reproductive tract, serious+can lead to peritonitis or septicemia, treated with antibiotics, check for vaginal odor, it’s the #1 symptom
Endometritis
infection of endometrium, fever on 3rd or 4th day, oral temp of >100.4 for 2 days excluding PP day 1, increased WBC’s, as long as no drainage new born contact is all right, treat with vaginal culture, antibiotics, fluids, fowler’s position+ambulation, document color, consistency, +odor of discharge
Peritonitis
greatest complication of childbearing, infection of peritoneal cavity, high mortality rate, spreads thru lymphatic system or thru GI tract
S+S of Peritonitis
Rigid abdomen, abdominal pain, high fever, increased pulse, vomiting
Treatment of Peritonitis
if there’s an ileus present then NG tube, IVF or Total parenteral nutrition +antibiotics
Fallopian Tube Adhesions
common, if they are scarred they can’t conceive again
phlebitis
inflammation of the lining of a blood vessel
Thrombophlebitis PP
phlebitis with BLOOD CLots, occurs PP because of increased fibronigen, dilation of of lower extremities, inactivity, classified as deep or superficial, usually on left side, Homan’s side, palpation of calves, ambulation, stockings, anticoagulation therapy
Femoral Thrombophlebitis PP
larger central clot in femoral, saphenous, or popliteal vein, leads to arterial spasm where the artery can’t get blood thru area, leg appears white
S+S of Femoral Thrombophlebitis PP
elevated temperature, around 10th PP day, chills, pain in the area, leg swollen, appears taut
Treatment for PP Thrombophlebitis PP
bedrest with affected leg elevated, anitcoagulants, heparin if mom is breastfeeding, coumadin for non-breastfeeding, moist heat, anlagesia, antibiotics, possibly thrombolytic agent, clots can move
PP Pulmonary Embolus
obstruction of pulmonary artery with a blood clot, complication of thrombophlebitis, EMERGENCY, S+S are sharp pain, tachypnea, tachycardia+orthopnea+cyanosis, O2 ICU transfer, CPR
Mastitis
infection of boob, crack +fissured nipples (handwashing), baby is not latching appropriately
S+S of Mastitis
unilateral pain, swelling, redness, fever, decreased breast milk
Treatment of Mastitis
antibiotics, nursing (unless there’s an abcess), ice or warm, supportive bra
PP Urinary Disorders
Retention with forceps can increase incidence, treat with antibiotics, catheterization can give UTI’s
PP Cardiovascular disorders
PP Hyptertension, pre-existing hypertension can increase during 1st few hours or days after delivery
S+S of PP Cardiovascular disorders
proteinuria, edema, hypertension, convulsions, treatment is same as antepartal PIH, magnesium sulfate
Reproductive tract displacement PP
if supports of uterus are weakened than ligaments, might not keep it in its usual position
Cystocele
vaginal walls weaken and bladder comes into the vagina
Retrocele
uterus collapses, KEGELS!!
Separation of Symphysis Pubis
ligaments tear, bed rest, abdominal binder
Disseminated Intravascular Coagulation (DIC)
occurs if hemorrhage occurs, if you use up all your clotting factors, your body is releasing cells that don’t clot properly, high incidence of death
Subinvolution
uterus doesn’t return, can lead to death
Perineal Hematomas
collection of blood in the Subcutaneous tissue of perineum
S+S of perineal hematoma
severe pain, purple, swelling, tender to palpation, document size +degree of discomfort, mild analgesic, ice pack, site incised
PP Depression
blues common, beyond a few days is concerning
PP Psychosis
1/500 women, exceptional sadness, loses contact with reality, deny newborn exists, infanticide fantasies, anger, immediate psych treatment, do not leave patient alone
Fetal Loss
see+hold infant, bathe+dress, privacy as long as needed, visitation by others, religious rituals, special memories, pictures, encourage grieving
Newborn assessment
immediately after birth+continues with every contact until discharge ABC’s, while I assess I’m teaching parents to assess
INITIAL Assessment
delivery room, bed+blanket prewarmed, emergency equipment available (O2, suction, blue bag) APGAR scoring @1+5 minutes, how well they’re transitioning is 5 minute, how happy they were inutero is 1 minute socre, heart rate, respiratory effort, muscle tone, reflex irritability+color each rated 0,1,2 the 5 scores are added (10 highest), 1 minute >7 is normal
Gestational Age Assessment
usher scale, mini dubawitz
Safety and identification
match # to baby bracelets, mother+father bracelets, some do footprints but not for identification, alarm bracelets on cord clamp
Alveolar Surfactant
Keeps them (lungs) from complete expansion
What happens if you delay cord clamping?
Decreases blood volume
Normal Newborn weight
2500-4000 (5lbs-8lbs-13 oz)
Normal Newborn Length
19-21″ or 48-53 cms
Normal Newborn Head circumference
13-14″ or 35-35.5 cms (measure right above eyebrows)
Normal Newborn Chest circumference
12-13″ or 30.5-33 cms (measure at nipple line)
Normal Newborn BPM
120-160 BPM apical, up to 180 if stressed, will settle to 120-140, frequently breathing is irregular and transient murmurs are heard as fetal circulation closes down, check radial and femor pulses as part of assessment
Normal Newborn Respirations
30-60, may be as high as 80, but will slow down in first hour. Depth, rhythm and rate are irregular. Short periods of apnea without cyanosis or bradycardia are called periodic breathing and are normal. Easiest to count belly breaths, lungs may sound wet for first hour or so
Normal Newborn Blood Pressure
80/46 at birth, up to 100/50 as fetal circulation shuts down. We don’t do BP at birth
Normal Newborn Bilirubin
Monitor bilirubin. It shows breakdown of red blood cells. <12 is normal, peaks on 3rd day of life.
Newborn Thermoregulation
skin is thin and blood is close to the surface, little subQ fat to serve as barrier to heat loss, they have 3x the surface to body mass (because of their head) as an adult, preemies are especially susceptible to heat loss because their tone is poor and then have even less fat and thinner skin than full term
no
Can infants shiver?
Normal Newborn Temperature
36.5-37.5 (97.7-99.5), take axillary temp
Metabolic Rate and Thermoregulation
If there’s more need for O2 they tire easily, they no longer have a constant supply of glucose, if they have an increased metabolic level then they had more glucose and could result in hypoglycemia, Cold Exposure will raise the basel metabolic rate lead to increased work of breathing (tachypnea) Tachycardia
Cold Stress
pre warm objects, dry them, assess them quickly then swaddle!
Evaporation in Newborn
wet surfaces exposed to air, babies are wet when they are born so evaporation will occur easily
Conduction heat loss in Newborn
DIRECT contact with objects cooler than the skin, use overhead warmers, prewarmed blankets (things like the scale, hands, stethoscope, circumcision restraint board)
Convection heat loss in Newborn
heat is transferred to air (drafts from open doors, AC, air current when people move about)
Radiation heat loss in Newborn
not direct contact, heat is transferred to objects cooler than the skin (don’t put baby near outside walls or windows)
Hazards of Cold Stress
increased need for O2, respiratory distress, decreased surfactant production and alveoli become sticky, hypoglycemia, metabolic acidosis (because they’re using so much glucose), jaundice (liver is not able to process as well)
“Neutral Thermal Environment”
helps prevent heat loss in newborns, maintains stable temperature without an increase in O2 or metabolic rate, in healthy unclothed newborns is 89.6-92.3, incubator, remain in overhead warmer as long as they need to maintain normal temperature.
First alert period
15-30 minutes after birth, baby is alert, respirations are regular, responds vigorously to stimulation, bundle them, suction them, irritate them (don’t give antibiotics during this period)
Resting period
30-120 minutes after birth, color and vitals are stabilizing, baby sleeps and is difficult to arouse
Second Alert period
4-8 hours after birth, awakening, becoming responsive to stimuli again, may have a lot of mucous to clear so suction
Dr. Brazelton’s Behavioral States
5 states, developed in 1984, neonatal assessment scale
Brazelton’s Quiet State
quiet, sleep, deep, no eye movement, quiet and slower respirations
Brazelton’s active sleep
REM’s, may move extremities or stretch
Brazelton’s Drowsy
transitional, yawn, eyes glaxed
Brazelton’s quiet alert
infant able to focus on objects or people, tuned into environment
Brazelton’s active alert
restless, starting to fuss, faster respirations, more aware of discomfort, start to get hungry
Brazelton’s Crying
follows quickly if parent doesn’t intervene during active alert state
Respiratory System in Newborn
first breath is initiated by cold receptors, low PO2 and increased PC02, requires far more pressure than subsequent breaths, surfactant (think of it as oil or grease) eases the surface tension to make breathing and inflation of alveoli easier, factors that initiate respirations: 1/3 of amniotic fluid is forced out of lungs by the squeeze of the birth canal, c-section has a lot more work to do to get gunk outta lungs
Newborn Cardiovascular Adaptation
Transition from Fetal to Neonatal Circulation
Fetal Circulation
ductus arteriosus, in between lung bed and aorta, brings blood back from lungs into circulation, has to shut down in order to allow all blood flow to the lungs and empty out, slowest to close (present only during fetal circulation, needs to shut down during neonatal circulation
Foramen Ovale
in between upper 2 chambers of the heart, shuts down to transition from fetal to neonatal circulation
Ductus Venosus
bipasses liver during fetal circulation, has to shut down to transition from fetal to neonatal circulation
Cardiovascular Adaptation at Birth
Ductus Arteriosis closes in response to increased O2 and decreased resistance in the lungs, pulmonary blood vessels dilate in response to demand in the lungs, foramen ovale is forced to close because of increased pressure in left side of heart, ductus venosis consctricts when umbilical cord is clamped allowing for perfusion to the liver
Hematologic adaptation
newborns have an increased level of RBC’s and different concentration than adults, hematocrit is higher than adults (polycythemia), increased risk of jaundice (Jaundic is breakdown of RBC’s)
WBC’s in Newborn
Elevation is normal, infection can cause either increase or decrease of WBC’s with large # of immature WBC’s as their system is adapting
Risk of clotting deficiencies
Vitamin K is synthesized in the intestinal flora, if an infant isn’t getting fed and their intestines are sterile, they don’t have intestinal flora in order to synthesize Vitamin K, give injection @ birth to allow for increased clotting
Kernicterus
>20 bilirubin may cause PERMANENT BRAIN DAMAGE!
Physiologic Jaundice
Normal jaundice, should resolve with proper hydration and feeding, normal bowel and elimination get rid of it
Who is at high risk for jaundice?
Excessive bruising on head (cephalohematoma), LGA babies, twin to twin transfusion, diabetic mom, anything that causes increased H+H
Treatment for Jaundice
early feeding (colostrum has a lax effect) photo therapy
Urinary System in Newborns
usually void within 24 hours, they have immature kidneys, pale colorless, gravity is low, kidneys don’t concentrate urine well, renal system exam is needed or maybe more fluid and feeding if they don’t 15 mls (1/2 oz) at a time, 3-4x in 24hrs. First void could be dark or pink cuz uric acid crystals formed inutero
Newborn Immune System
THEY DON”T HAVE ONE AT BIRTH, unable to form antibodies against invading antigens until 2 months, this why we start immunizations then (except HEP B), They have passive immunity from mom IGG that passes through placenta for certain viruses, very little immunity to herpes, passive immunity lasts longer the longer you breastfeed
Reflexes in newborn
most are protective; if any of these return there is severe neurological insult, very primitive used for protection of infant
Moro or Startle Reflex
head allowed to drop back 30 degrees, arms and legs extend and abduct fingers form a c, response to loud noises
Palmar+Plantar grasp reflexes
curl around tester’s finger
Rooting reflex
when baby is hungry, when corner of mouth is touched the baby will turn, looking for food
Sucking reflex
finger in mouth, they will suck
Archer’s/Tonic/Fencing Position Reflex
when in a supine position, head turns to one side +arm+leg extend, the opposite side flexes
Babinski reflex
supine striking along lateral side of sole to the head of 5th metatarsal, combined extensor response, simultaneous dorsiflexion of the great toe and fanning of the remaining toes
Sensory in newborns
newborn can hear muffling sound in utero, once the amniotic fluid clears, then it becomes acute but can’t localize well because neuro system is immature, but will recognize mom’s voice and turn towards it
Hearing Screening on Newborn’s
before they leave the hospital, check to make sure they can hear
Touch in newborn
well developed, react to positive and negative stimuli
Taste buds in newborn
buds do develop and function prior to birth, prefer sweet to salty or bitter
Skin of newborn
may look ruddy because of RBC’s
Acrocyanosis
core is pink + extremities are bluish (normal)
Gastrointestinal Tract of Newborn
sterile until birth, no bacteria present until it enters thru the mouth, accumulation of bacteria in gut is necessary for digestion and also for synthesis of Vitamin K, they have a limited capacity to digest fat and starch in the first few weeks, feeding intolerance is common, they’ll regurgitate easily because of immature cardiac sphincter
Umbilical Cord
covered with Wharton’s jelly, makes them moist, they have 3 vessels
Stool
First stool is meconium, sticking, tar like, black, odorless, formed from mucous, vernix and lanugo and amniotic fluid, pass within 24-48 hours, if they don’t we worry about an ileus or CF
Formula fed stool
2-3 bright yellow stools per day and can appear seedy, many have strong odor, consistency of toothpaste
Breast fed stool
several small light yellow stools, very little or no odor, breast milk goes in and out so easily because its so easily digested. Bowels settle into normal pattern after a few weeks, remains loose cuz there’s very little undigested
Hepatic system in newborn
liver is 1-3 cm below R costal margin, enlarged at birth and occupies about 40% of abdominal cavity, liver plays a role in iron storage, usually 5-6 months of iron stored before foods containing iron or supplementation is needed, liver synthesizes coagulation factors, liver plays a part in carb metabolism and maintenance of blood glucose levels, as well as glycogen storage for use after birth, plays a role in conjugation of bilirubin, need to understand jaundice, plays a role in drug metabolism
Conjugation of Bilirubin
by product of the break down of RBC’s, released in the unconjugated form, fat soluble so can be absorbed by SubQ fat, in order for liver to conjugate or allow it to be excreted thru urine and stool, it must go thru liver
RBC-Bilirubin
Bilirubin joins with abumin>unconjugated>in the liver bilirubin releases from albumin combines with glucoronic acid “conjugated” to the intestine in bile>bilirubin is converted to urobilinogen>excreted in stool and urine
LIVER MAKES THE BILIRUBIN…
UNCONGUTATED until it can go through the liver it will build up. Newborn liver is VERY immature so it has a hard time breaking down. Bilirubin in the presence of high amounts of RBC’s gives you Jaundice
Jaundice
D/t hyperbilirubinemia, or physiologic jaundice, after first 24 hours, physical response to trauma of birth, 50% of babies get it, peaks @ day 5
Pathologic Jaundice
within first 24 hours, may be due to infection, metabolic or bleeding disorder
What does Jaundice look like?
Yellowing of sclera and skin. Usually in face first, then chest and body and recedes in the same way, RBC’s break into heme+globin.
Globin
is a protein+re-used by the body
Heme
is further broken down into IRON which is reused and indirectly, into bilirubin (which needs to be excreted)
Vernix
you want to clean them, but vernix is moisturizing so leave it in folds of thighs, knees, don’t scrub vigorously to get it off
Milia
little sebaceous blockages, normal, don’t pick, they will resolve on their own
Lanugo
fine downy hair
Mottling
skin folds
Stork Bites
teleangiectatic nevi, light pale pink spots on the back of the neck, end up covered by hair
Port Wine stains
doesn’t blanch hemangioma, vascular tumor
Strawberry Hemangioma
elevated areas, typically fade by age 10
Mongolian spots
collections of melanocytes that appear in grey-ish patches on sacrum or buttocks
Erythemia Toxicum
rash, small pustules, normal, will go away
Fontanels+Sutures
anterior is diamond shaped closes at 18 months, posterior is smaller and triangular closes 2-3 months
Caput Succedaneum
abnormal finding, edema of scalp over presenting part, edema crosses the suture line and will gradually disappear
Cephalohematoma
collection of blood between the periostcum of the skull bone and the bone itself, due to capillary rupture from pressure during birth, swelling often not visible until 24 hours, looks like a little egg and is discolored, does NOT cross suture line
Craniotubes
may take weeks to be absorbed, blood reabsorption can cause jaundice, localized softening of skull bone, dense like a ping pong ball, usually improves with time
New born Eyes
irises almost always are grey or blue, pupils supposed to be dark, no tears at birth, conjunctival hemorrhage is normal, causes vessels breaking during birth and reabsorbs over weeks, periorbital edema, swelling from birth pressure
Ears newborn
we look for placement of ear cartilage, look that they’re equal with eyes and not too low set, low set can be a genetic abnormality and/or chromosomal abnormality trisomy 18
Nose
Baby will grow into their nose, check for chonanal atresia by occluding one nostril at a time, babies are predominately nose breathers and wanna do this so they can feed adequately
Neck
short, thick, can’t support head
Chest
chest looks small cuz head looks large, check for retractions and fractured clavicles
Head circumference
is bigger than chest until age 2,
abdomen
slightly protuberant (all the organs in such a small place), bowel sounds should be heard within 1 hour after birth, liver margin 1-2 cm, check base of umbilicus for hernia or tears, count cord vessels
CORD
1 vein, 2 arteries, congenital cardiac defects present in 1/3 of babies with one artery
Cord clamp
leave clamp on cord for 24 hours or until it looks dry then leave stump exposed to air and keep clean and dry until it falls off
Anus
check for patency, report no stool in 24 hours, if not, concern is for ileus or CF
Penis and Male Genitals
make sure testes have descended, make sure urethral opening is at tip, if it’s on the ventral surface it’s called hypospadias, epispadias is urethra on dorsal surface (they can have problems with impotence + incontinence)
Foreskin
prepuce, do not force it away from the meatus in the newborn period, it will cause irritation, if you have a penile abnormality no circumcision, done after 24 hours cuz of Vitamin K
Female Genitalia
vulva make look swollen because of maternal hormones, may have pseudomenstruation, mucous and vaginal secretion tinged with blood
Vitamin K
1 mg IM (Vastus lateralis) to promote clotting
Eye Treatment
antibiotic eye ointment given to protect against organisms in birth canal
Bathing
due to thermoregulation issues do it quickly and efficiently, quickly wrap baby back up. observe for missed abnormalities, sponge bath until cord falls off
Breastfeeding
we want it exclusively for 6 months, human milk is superior, contains almost as many live cells as blood, nutrients are more easily absorbed,
Lactation
nipple has 15-20 pores thru which milk is transferred, sudden decrease in estrogen and progesterone=release of prolactin (milk comes), lactating breasts never completely empty, milk is constantly produced as infant feeds Oxytocin=essential for lactation
Level 1 high risk new born care
care for minor problems and transitional issues such as transient tachynpne, jaundice, hypothermia-short term
Level 2 high risk new born care
preterm infants >32 weeks, infection,sepsis (will resolve rapidly) mild respiratory distress syndrome
Level 3 high risk new born care
care of severely preterm babies <32 weeks
Level 4 high risk new born care
tertiary center, specialty care, available neo-natal neurologists, surgeons
General nursing considerations for all high risk newborns
assess respiration, thermoregulation, nutrition, fluid+electrolytes, skin, infection+pain
High risk newborns are classified according to:
birth weight, gestational age+pathophysiological problems
High Risk r/t birth weight
infant whose birth weight is below the 10% normal weight for gestational age at any week of gestation,
assymetrical growth restriction
loose subQ fat, lost weight in utero
Symmetric Growth restriction
head to rump, long-term complications because the total # of cells are decreased, caused by congenital anomalies and or exposure to infection or drugs during pregnancy, worse than assymmetric growth restriction
Assymetric Growth restriction
head looks big in comparison to body, GOOD, means the brain is the correct size, probably not enough nutrition or blood flow to fetus in utero, heart size is normal, other organs may be small, growth problems start in 3rd trimester, babies usually catch up in 1-2 years
Etiology of SGS/IUGR
multiple gestation pregnancies, maternal disease, smoking, lack of prenatal care, age extremes, poor people (nutrition), environmental factors-high altitude, xray exposure, excessive exercise by mom, work-related exposure to toxins, placental factors: damage to it, abnormal cord insertion, congenital infections and malformations, chromosomal syndromes, twin to twin transfusion: 1 twin is getting all the nutrients
SGA nursing considerations
hypoglycemia assessment, feed them early and more frequently, hypothermia: extra clothing and blankets, overhead warmers, isolettes
Large for Gestational age newborns
infant who is 90%>at any week of gestation mostly infants of diabetics,
Common complications of LGA’s
birth trauma, c-section, hypoglycemia, breech, shoulder dystocia, asphixia of newborn, brachial palsy, facial nerve paralysis, hematomas
Polycythemia
hypoglycemia results in hypoxia-more RBC’s, blood is thick
Shoulder Dystocia
shoulder is stuck, OB Emergency, O2 supply is compromised because the cord is compressed
Respiratory Distress Syndrome
assess for birth injury (clavicals, brachial palsy, facial paralysis) look for hypoglycemia, RR rate, effort, breath sounds
what is tomorrow
tuesday
Common Complications for Post term newborn
meconium aspiration, hypoglycemia, polycythemia (high h+H), seizures, cold stress/hyperthermia (lost weight so they lost brown fat
Nursing considerations for post term newborn
Assess RR (ABC’s), hypoglycemia, hypothermia, polycythemia
Parent teaching for post term newborn
more feedings, s+s of hypoglycemia (jitteryness), supplement breast feedings
Preterm Infants
1000-1500 grams, 85-90% survival, 500-600 grams 20% survival, #1 cause of neonatal and infant mortality, major causer of childhood disabilities $11.9 billion
Etiology of preterm infants
unknown, lack of early prenatal care, infection, multiple pregnancies, maternal age, history of preterm, hypertension, diabetes and heart disease, poor people, drug users
High risk new born due to infection
1-4:1000, vertical (from mom), horizontal (after birth), group B strep can lead to BIG problems, #1 problem is sepsis due to neonatal infection, e coli in stool, flu, staph, CMV, herpes, HIV, rubella, syphyllis, gonorrhea, toxoplasmosis
S+S of infections
decreased temperature, temperature instability or increased temperature, respiration problems, feeding intolerance, lethargy, hypoglycemia, apnea (late) nurse tests blood, urine, CBC, WBC’s, cerebral spinal fluid, c-reactive protein. Give antibiotics ampicillin, gentamicin (can affect hearing) fluids, O2, warmth, glucose stability
High risk and nutrition
no extra fat, 105-130 kcals in 24 hours, GI doesn’t absorb fat well, aspiration, regurgitation, diarrhea, NG tube feedings
Necrotizing enterocolitis
obstucted bowel, leakage of intestinal content out of body, most common and serious GI disorder among hospitalized preemies, S+S: unstable temperature, bloody stools, no appetite, regurg, bile back up Treatment: can’t eat if they have a blockage, suction, antibiotics, constant stool recordings, CBC, electrolytes, abdominal girth, or removal of part of intestines adn get ostomy until healed
Periventricular/Intraventricular Hemorrhage
<32 weeks, bleeding into brain, shows in 1st few days of life Grade 1+2: damage can be recoverable, Grade 3+4: developmental delays+long term abnormalities Grade 4: poor survival and outcome. Treat it by avoiding increased pressure to the brain, cluster care, quiet environment, cover isolette, stress free, measure head every 2 hours, teach care 4 parents, long term care
retinopathy
O2, may lead to blindness, usually occurs <1500 grams increases O2 states
Maternal SUbstance abuse
id drug exposed infants, lack of prenatal care, placental abruption, behavior of mom, can only do drug test on mom with her permission, but can do it on baby, CPS required to notify, document why you thought they might be
Drug Addicted Infants are:
irritable, jittery, high pitched cry, neurologically irritable, don’t console easily, poor feeding, n+V, on and off sleep patterns, jump readily to loud noises, sneezing is a sign of withdrawal, stuffy, tachypnea, seizures
Treatment of drug addicted infant
decrease stimulation, swaddles and left alone, group care, quiet spot in corner, watch for w/d signs, overly irritable, seizure precautions
Hemolytic disorders
different blood than mom, Rh incompatibility, ABO Comp., additional cellular breakdown, high risk of jaundice, sometimes they have a direct transfusion to rid babies of mom’s blood type
Nursing Care for Preemies
Apnea and Bradycardia (ABC’s), thermoreg, fluid and electrolytes, positioning (head of bed elevated), side for comfort, prone for breathing issues, skin, encourage parental bonding, photographs, name cards, information, involve in all decisions, kangaroo care

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