1
Q
Fourth Stage =
A
Puerperium (starts at the time they’ve delivered the placenta)
2
Q
Close observation during the ___ hour of fourth stage
A
1st hour
checking for hemorrhage, complications
3
Q
Normal maternal temp during fourth stage of labor
A
up to 100.4
4
Q
Is a bit of bradycardia WNL during fourth stage of labor?
A
yes
5
Q
bonding vs. attachment
A
bonding is by the parents to the baby - parents identifying “this baby is mine”
attachment is reciprocal between baby and parents - establishing relationship, understanding cues and responding to them
6
Q
3 steps of the attachment process
A
- Taking-in period – dependent
- Taking-hold period – dependent/interdependent
- Letting-go - interdependent/independent
7
Q
What happens during the taking-in period of the attachment process?
A
- Mom wants care for herself
- Bodily concerns – food/sleep/comfort
Mom is dependent
First day or so after birth
8
Q
What happens during the taking-hold period of the attachment process?
A
Strives to master infant-care skills
9
Q
What happens during the letting-go period of the attachment process? When does this period happen?
A
- Postpartum depression may occur
- Might return to work or relinquish a portion of child’s care to other caregivers
5-6 weeks after birth
10
Q
BUBBLE-HE maternal assessment
A
Breasts Uterus Bladder Bowel Lochia Episiotomy/Laceration
11
Q
What are you assessing for breastfeeding vs non-breastfeeding moms in the “breast” component of the BUBBLE-HE assessment?
A
Breastfeeding moms:
- Colostrum
- Tenderness or engorgement
Non-breastfeeding moms:
- Engorgement
12
Q
Mastitis
A
“Breastmilk Stasis”
13
Q
Mastitis precipitating factors
A
Inadequate breast drainage:
- Plugged duct
- Poor let-down
- Not rotating infant positions
Cracked nipple, fissures
Sometimes: infection
- Staph Aureus, E. coli
14
Q
Mastitis — signs and symptoms
A
- Diffuse myalgias, “flu-like” symptoms, breast pain
- Wedge-shaped, erythematous, tender, flaking skin
- Usually unilateral -> Upper, outer quadrant most common
- Fever – low grade temperature does not indicate systemic infection, do not stop breastfeeding
- Observe carefully for signs of abscess formation (patient teaching)
15
Q
Should a mom stop breastfeeding if she has a low-grade fever?
A
no
low grade temperature does not indicate systemic infection, do not stop breastfeeding
16
Q
If mild Mastitis, how do you treat?
A
symptoms occur for less than 24-36 hr
may resolve with frequent nursing or pumping and supportive measures: bed rest, fluids, analgesics
17
Q
When does milk come down?
A
multi - within 1-2 days
primi - can take longer
18
Q
How to treat engorgement?
A
Warm or cool showers (warm is better to stimulate milk flow)
Start baby breastfeeding on opposite breasts each time despite what might seem like “baby’s choice”
Ice packs on the breast
19
Q
If Mastitis and fever of 102˚, how do you treat?
A
call the provider
may be tx with antibiotics
dicloxicillin
cephalexin
clindamycin – up to 14 days
20
Q
With, Mastitis, should you stop breastfeeding on affected breast?
A
DO NOT stop breastfeeding on the affected side –> empty the breast
21
Q
Where should the fundus be located immediately postpartum?
A
halfway between the symphysis pubis and the umbilicus
22
Q
Where should the fundus be located 2-4 hrs postpartum?
A
level of the umbilicus or one fingerbreadth above
23
Q
How is postpartum hemorrhage defined for vaginal and c/s deliveries?
A
Vag: Blood loss >500 ml
C/S: Blood loss > 1000 ml
24
Q
How is postpartum hemorrhage classified?
A
Early, acute or primary: Within 24 hrs (most common)
Late or secondary: 24 hrs to 6 wks after delivery
25
uterus 4 Ts
TONE: uterine atony
TISSUE: retained placenta
TRAUMA: lacerations/uterine rupture
CLOTTING: coagulation
26
Where is mastitis most common?
upper outer quadrant of breast
27
Uterine ATONY =
relaxed uterus
28
What is the leading cause of PPH?
uterine atony
leading cause (70-90%) of PPH complicating 1/20 births (5% of all births)
29
Potential causes of uterine atony (7)
1. Overdistention
- full-term multiples
- macrosomia
2. Prolonged labor (most common)
3. Induction and augmentation with piton
4. Anesthesia
5. Prolonged third stage (more than 30 mins)
6. Preeclampsia
7. Vacuum/forceps delivery (manipulation of uterus)
30
Does uterus or fundus ever go back to pre-pregnancy size?
no
31
What are the 3 Less frequent causes of PPH?
```
1. Retained placenta:
Nondherent retained placenta
Adherent retained placenta
Inversion of uterus
Subinvolution of uterus
```
2. Traumatic injury:
Lacerations of genital tract
Uterine rupture
Excessive force on umbilical cord - delivery of placenta
3. Coagulation Disorder:
Prolonged clotting - rare
32
Risk for ___ with partially empty bladder PP
UTI
33
Properly anticipating maternal diuresis means knowing that Urine volume and flow returns to pre-pregnant by ___
2-3 days
should be 2-3L/day
34
Signs of bladder Retention/Distended
- Bladder discomfort
- Bulge of bladder above symphysis
- Frequent voids of less than 150 ml of urine
- Contributes to boggy fundus (uterus not contracting)
35
What hormone depressed bowel motility PP?
Relaxin
36
Strategies to prevent constipation PP?
Early ambulation
Abundant fluids
High-fiber diet
37
Composition of lochia includes
Endometrial tissue, blood, lymph
38
3 Stages of Lochia (characteristics and duration)
1. Rubra (red): 1 to 3 days
2. Serosa (pink, brown-tinged): 3 to 10 days
3. Alba (yellowish-white): 10 to 14 days, but can last 3 to 6 weeks and remain normal
39
Why is there an Increased risk for respiratory problems post-Cesarean?
anesthesia, sedentary
40
The postpartum nurse assess a patient in the early morning, noticing the perineal pad is completely saturated. What should the nurse do first?
Ask patient when she last changed her pad
41
What is post-Cesarean pain like?
- incisional, rather than perineum discomfort
| - may have long-acting morphine from epidural
42
Compression methods post-Cesarean
- SCDs (sequential compression device)
- Venodyne boots
- TED stockings
43
If patient has full bladder, the ___ will likely be displaced
fundus
have her void before you do the assessment
44
Lochia is ___ post-Cesarean
limited
45
Abdominal distention post-Cesarean may be
normal or indicate infection
46
Major risks of Cesarean
Respiratory Depression:
- Anesthetic gases or medications (epi/spinal)
- Maternal or Newborn respiratory depression
Infection:
-> Pre-operative prevention (patient must have antibiotic within 2 hours of incision occuring)
47
Nursing Interventions for Thromboembolic Disease
- Complete bedrest with bathroom privileges
- Measure leg circumference
- Anticoagulation therapy
- Analgesics
- Increase fluids
- Elevate extremity; TED hose; apply moist, warm packs
48
Should patients with Thromboembolic Disease be on bedrest?
yes - Complete bedrest with bathroom privileges
49
Episiotomy Or Laceration REEDA assessment:
```
Redness
Edema
Ecchymosis
Discharge
Approximation
```
50
No vaginal sex for how long PP?
First 6 weeks
51
Hematoma points
unremitting pain and pressure
can become size of fist (needs to be drained)
can compress urethra
careful assessment
implement pain relief measures
52
it is ___ for hemorrhoids to develop during pregnancy
common
53
If patient has hemorrhoids, what do you need to teach?
Shift position
Manual reinsertion
Application of creams
54
Thrombophlebitis - DVT - risk for
Pulmonary Embolism
55
Thrombophlebitis continuum
Thrombophlebitis
--> Deep Vein Thrombus
--> Thromboembolism -->
Pulmonary Emboli
56
Why are pregnant patients more at risk for DVT?
- Increased blood volume
- Venous stasis in lower extremities
- Hypercoagulation
- Compression of inferior vena cava in 3rd trimester
57
PPH Prioritized Nursing Interventions
- Fundal massage (calling for help and getting O2 with other hand)
- Administer oxygen
- IV fluids
- Medications
1. Oxytocin (Pitocin)
2. Methylergonovine (Methergine)
3. Carboprost (Hemabate)
4. Misoprostol (Cytotec) - dilates the cervix and stimulates uterine contractions - administered rectally
- Vital signs
- Insert foley
- Accurate I/O
- Obtain lab test
58
Internal Tamponade (Bimanual) vs device
bimanual is provider doing: providing compression to decrease bleeding, may also go into uterus and feel for retained placenta
device: like a reverse foley, nurse can instill saline or sterile water to inflate the balloon so it compresses all around the sides of the uterus
59
Postpartum blues
- 50-85% of mothers in first 2 weeks postpartum
- Symptoms: irritability, anxiety, fluctuating mood, increased emotional reactivity
- Mild and spontaneously remits, not considered psychiatric disorder (within 2 weeks)
60
Postpartum depression
- 10 to 15% women
- Loss of interest, apathy
lack of emotional response
- Feelings unworthiness, shame, guilt
- Sleep disturbances, hopelessness, anxiety
- Panic attacks, suicidal thoughts
- Symptoms > present at least 2 wks
- May not pick up on infant’s cues or smiles
- Negative infant reaction
61
Postpartum psychosis
- 0.01% mothers in first 3 months postpartum
- Symptoms: mixed or rapid cycling, agitation, delusions, hallucinations, disorganized behavior, cognitive impairment, low insight
- Severe, considered psychiatric emergency - necessitates hospitalization
62
Safe antidepressants for breastfeeding
Sertraline (Zoloft)
Paraxetine (Paxil)
Clomipramine (Anafranil)
63
Drugs of concern for breastfeeding
Fluoxetine (Prozac)
Due to long half-life
Reports of colic, tremors, and insomnia in newborns
64
What happens in the first breath?
Intrapulmonary fluid absorbed
- Reduces pulmonary resistance to blood flow
- Facilitates initiation of air breathing
Surfactant
- Decreases surface tension within alveoli
65
Cardiopulmonary Transition in the seconds/minutes after delivery -- what are the effects?
Conversion from fetal to neonatal circulation: ductus venous closes, foramen oval closes
- Skin color goes from gray to pink
- RR and breathing pattern established
66
immediate assessment after baby is born
ABCs
1. Establish airway
2. Stimulate neonate to breathe deeply and cry
- Observe respiratory effort, color, muscle tone
- Provide warmth
3. Assess heart rate
- Check umbilical cord vessels
- Note obvious abnormalities
67
APGAR
```
Activity
Pulse
Grimace (reflex irritability)
Appearance (color)
Respiration
```
68
puerperium
first 6 weeks after the birth of an infant (known as the postpartum period)
69
involution
the changes that the reproductive organs, particularly the uterus, undergo after childbirth to return to their non pregnant size
70
uterine involution 3 processes:
1. contraction of muscle fibers
2. catabolism
3. regeneration of uterine epithelium
71
catabolism
the process of converting cells into simpler compounds
72
decidua
the endometrium during pregnancy
73
afterpains
intermittent uterine contractions after birth
74
Why are afterpains more acute for multiparas?
because repeated stretching of muscle fibers leads
| to loss of muscle tone that causes repeated contraction and relaxation of the uterus
75
What hormone stimulates the milk-ejection reflex?
Oxytocin
76
days 1-3 lochia is
rubra
Bloody; small clots; fleshy, earthy odor; dark red
or red-brown
77
days 3-10 lochia is
serosa
Decreased amount; serosanguinous; pink or
brown-tinged
78
days 10-14 (or up to 3rd to 6th week) lochia is
alba
White, cream, or light yellow color; decreasing
amounts
79
dyspareunia
discomfort during intercourse
80
episiotomy
surgical incision of perineal area
81
reciprocal attachment behaviors
Newborn infants have the ability to:
•Make eye contact and engage in prolonged, intense, mutual gazing.
•Move their eyes and attempt to “track” the parent’s face.
•Grasp and hold the parent’s finger.
•Move synchronously in response to rhythms and patterns of the parent’s voice (called entrainment).
•Root, latch onto the breast, and suckle.
•Be comforted by the parent’s voice or touch.
82
entrainment
reciprocal attachment behavior
baby is able to move synchronously in response to rhythms and patterns of the parent’s voice
83
en face position
the infant’s face in the same vertical plane as mom own so they can have eye contact.
84
fingertipping
the mother may gently explore the infant’s face, fingers, and toes with her fingertips
85
Engrossment
an intense fascination and face-to-face
observation between the father and newborn. It is characterized by the
father’s intense interest in how the infant looks and responds and a
desire to touch and hold the baby.
86
fetal lung fluid
that expands the alveoli and is essential for normal development of the lungs
87
asphyxia
insufficient oxygen and excess carbon dioxide in the blood and tissues
88
The primary method of heat production in infants is ____
nonshivering thermogenesis (NST), the metabolism of brown fat to produce heat.
89
Hazards of cold stress in newborns
```
Increased oxygen need
Decreased surfactant production
Respiratory distress
Hypoglycemia
Metabolic acidosis
Jaundice
```
90
neutral thermal environment
In healthy, unclothed, full-term newborns, an environmental temperature of 32° to 33.5°C (89.6° to 92.3°F) provides a thermoneutral zone
91
polycythemia
an abnormally high erythrocyte count
in newborns, this is above 65%
92
Newborns are at risk for clotting deficiency during the first few days of life because _____
they have low levels of vitamin K, which is necessary to
activate several of the clotting factors
this is why Vitamin K is administered intramuscularly
93
bilirubin encephalopathy
a neurologic condition resulting
from bilirubin toxicity.
if chronic can cause permanent neurological injury called kernicterus
94
first period of reactivity
begins at birth and lasts for 30 minutes.
Infants are active at this time and appear wide awake, alert, and interested in their surroundings.
95
second period of reactivity
lasts 4 to 6 hours.
Infants have alert periods
become interested in feeding and may pass meconium.
may be tachycardia and rapid respirations
Mucous secretions increase, and infants may gag or regurgitate
96
Increases in blood oxygen levels, shifts in pressure in the heart and lungs, and clamping of the umbilical vessels cause closure of the ____, ____, and ____ at birth
ductus arteriosus, foramen ovale, and ductus venosus
97
Laboratory values for erythrocytes, hemoglobin, and hematocrit are higher for newborns than for adults because ____
less oxygen was available in fetal life than after birth
98
Physiologic jaundice occurs in normal newborns after the first 24 hours of life as a result of ____ and ____
hemolysis of red blood cells and immaturity of the liver.
99
Newborns receive passive immunity when ___ crosses the placenta in utero
IgG
100
Newborns progress through six behavioral states:
```
quiet sleep
active sleep
drowsy
quiet alert
active alert
crying
```
101
periodic breathing
pauses in breathing lasting 5 to 10 seconds without other changes followed by rapid respirations for 10 to 15 seconds
more common in preterm infants
102
apnea
a pause in breathing lasting 20 seconds or more, or accompanied by cyanosis, pallor, bradycardia, or decreased muscle tone
103
Tachypnea
a respiratory rate of more than 60 breaths per minute
is the most common sign of respiratory distress in infants
104
Choanal atresia
blockage or narrowing of one or both nasal passages by bone or tissue
105
point of maximal impulse for babies
at the third or fourth intercostal space, lateral to the midclavicular line
106
Molding
to changes in the shape of the head that
| allow it to pass through the birth canal.
107
craniosynostosis
a hard, ridged area not resulting from molding may indicate premature closure of the sutures.
This condition may impair brain growth and the shape of the head and requires surgery.
108
caput succedaneum
an area of localized edema that appears over the vertex of the newborn’s head as a result of pressure against the mother’s cervix during labor
109
cephalhematoma
bleeding between the periosteum and the skull, is the result of pressure during birth
usually over parietal bones
110
polydactyly
extra digits
111
syndactyly
webbing between digits
112
pseudomenstruation
A small amount of vaginal bleeding that may occur from the sudden withdrawal of the mother’s hormones at birth.
113
cryptorchidism
undescended testes
114
chordee
a condition in which fibrotic tissue causes the penis to curve downward
115
erythema toxicum
red, blotchy areas with white or yellow papules or vesicles
| in the center ("newborn rash")
116
Nevus flammeus
port-wine stain (permanent) - flat, pink to dark reddish-purple mark that varies in size and location and does
not blanch with pressure
117
nevus simplex
is also called salmon patch, stork bite, or telangiectatic nevus
It is a flat, pink discoloration from dilated capillaries that occurs on the eyelids, just above the bridge of the nose, or at the nape of the neck.
The color blanches when the area is pressed and is more prominent during crying
118
Nevus vasculosus
strawberry hemangioma
consists of enlarged capillaries in the outer layers of skin. It is dark red and raised with a rough surface, giving a strawberry-like appearance.
119
Early signs of hypoglycemia in infants
```
jitteriness
poor muscle tone
respiratory distress
sweating
low temperature
poor suck
```
120
vitamin K–deficiency bleeding
hemorrhagic disease of the newborn
121
Infants who are circumcised should have pain relief provided. _____ along with nonpharmacologic methods
of pain relief such as oral sucrose are often used.
Dorsal penile nerve block
122
Parents of uncircumcised infants should be taught not to retract the foreskin until _____
it becomes separated from the glans later in childhood.
123
phimosis
a tightening of the prepuce which prevents retraction and thus requires circumcision
124
plagiocephaly
Infants who spend long periods in the supine position may develop flattening or asymmetry of the back of the head
125
Lactogenesis II
begins 2 to 3 days after birth
Transitional milk, milk that gradually changes from colostrum to mature milk, appears over about 10 days
126
Lactogenesis I
- begins during pregnancy and continues during the early days after giving birth
- colostrum
127
Lactogenesis III
Mature milk replaces transitional milk
Mature milk contains approximately 20 kcal/oz and nutrients sufficient to meet the infant’s needs
128
Engorgement
congestion and increased vascularity, edema from
obstruction of lymphatic drainage, and accumulation of milk as lactation is established.
Engorged breasts may be hard and tender, with taut,
shiny skin.
129
foremilk vs. hindmilk
fore milk: the watery first milk that quenches the infant’s thirst
hind milk: comes at the end of the feeding. richer in fat, more satisfying, and leads to
weight gain.
Feeding for too short a time prevents the infant from
getting the hindmilk and decreases weight gain.
130
Full-term breastfed infants need ____kcal/lb daily and formula-fed infants need ___ kcal/lb daily.
full term: 39 to 45 kcal/lb
formula-fed: 45 to 50 kcal/lb
131
Breast milk contains factors that help establish the normal intestinal flora and prevent infection. These include: (5)
bifidus factor, leukocytes, lysozymes, lactoferrin, and immunoglobulins.
132
The mother should feed the infant ____ times each day for an average of at least 10 to 15 minutes of effective suckling on each side, or until the infant is satisfied.
8 to 12
133
miliaria
prickly heat
rash results from occlusion and inflammation of the sweat (eccrine) glands. It has a red base with papules or clear vesicles in the center
134
Seborrheic dermatitis
a chronic inflammation of the scalp or other
| areas of the skin characterized by yellow, scaly, oily lesions
135
Why are babies susceptible to cold stress? (4)
Large body area
Limited subcutaneous fat
Limited ability to shiver
Thin skin and blood vessels close to surface
136
with regards to Thermogenic Adaptation, we know that newborns are
homeothermic
137
4 baby heat loss mechanisms
convection
conduction
radiation
evaporation
138
convection - what's the mechanism of heat loss and how do you prevent?
the flow of heat from the body surface to cooler surrounding air
eliminating drafts such as windows or air conditioning reduces convection
139
conduction - what's the mechanism of heat loss and how do you prevent?
the transfer of body heat to a cooler solid object in contact with baby
covering surfaces with warmed blanket or towel helps to minimize
140
radiation - what's the mechanism of heat loss and how do you prevent?
transfer of heat to a cooler object not in contact with the baby (i.e. cold window surface or air conditioner)
moving as far away from the cold surface reduces heat loss
141
evaporation - what's the mechanism of heat loss and how do you prevent?
loss of heat through conversion of a liquid to a vapor
from amniotic fluid - baby should be dried immediately
142
babies temperatures ____ in the event of infection during the newborn period
drop
143
if baby temp is less than ____ it's problematic
36 C/ 97.6 F
144
Conditions Affecting SGA/IUGR
Hypothermia
Hypoglycemia
Polycythemia (high RBC)
Pain
145
In newborns, every stress leads to
____ and ____
and then results in _____
hypoglycemia and hypothermia
respiratory distress
146
Physiologic jaundice onset
2 to 3 days after birth
transient normal hemolysis of RBCs
bruising increases hyperbilirubinemia
147
Pathologic jaundice, onset and 2 causes
present at birth or within 24 hours
2 causes:
1. Rh hemolytic
(Rh- mom, Rh+ dad, Rh+ baby) --
antepartal treatment
2.ABO incompatibility
(Type O mom, Type A, B, or AB baby) --
no antepartal treatment
148
Breastfeeding “jaundice”
basically just dehydration
onset 2 to 4 days
get baby feeding regularly and hydrated - check fontanels and wet diapers
149
Breast milk jaundice
rare
| onset 7-10 days; peaks at 2 wks – 3 wks
150
Unconjugated bilirubin vs. conjugated bilirubin
Unconjugated bilirubin (fat soluble) formed by the normal breakdown of RBCs is unready for excretion.
Conjugated bilirubin (water soluble) has been converted in the liver and is ready for excretion in stool and urine.
151
Kernicterus
bilirubin-induced brain dysfunction
yellow stain
152
Visual assessment for Hyperbilirubinemia is ____. What is the best practice to assess?
subjective and unreliable
all babies should be assessed with transcutaneous bilimeter
If transcutaneous bili is too high (based on hospital policy) a total serum bilirubin should be drawn
153
Tx for Hyperbilirubinemia
phototherapy
eye patches are required
154
babies with pathological jaundice are at risk for developing (2):
1. Erythroblastosis fetalis: all red blood cells are destroyed
2. Hydrops fetalis: multi-system failure
155
Hypoglycemia for babies =
156
Indications for heelstick blood sugar
- Pre or Post term
- IDM
- LGA, SGA, IUGR
- Delivery:
Decelerations
Nuchal cord
Meconium-stained amniotic fluid
157
S+S of Hypoglycemia in babies
jitteriness, hypotonia, irritability, apnea, lethargy, temperature instability
158
signs that bonding is delayed
- Using negative terms describing newborn
- Discussing newborn in impersonal terms
- Failing to call newborn by name – check culture
- Refusing to hold newborn
- Lack of eye contact with newborn
- Increasing length of time of newborn in the nursery
159
Breastfeeding: how often, how long, how much?
How often? 8 to 12 times per day
How long? As long as vigorously sucking, then burp (and switch breast) until too drowsy to suck
Is it enough? For the first week, each day should have one more than the day before, half with stool
160
Initial assessment
In first 2 hrs by nursery/postpartum nurse
After assessment, if temp is stable, then baby is bathed (ideally ~6 hr), and double-wrapped in blankets until temp returns to normal x2
Precautions maintained until after the bath
161
If no prenatal care, gestational age is determined by
Ballard Score or Dubowitz
162
Large for Gestational Age means that
Infant's over the 90th percentile on the growth chart
163
nurses generally ___ advise patents on procedure. who is provider who generally performs circumcision?
do NOT (they should speak with the main provider)
OB
164
Conditions Affecting LGA (8)
```
Chronic hyperglycemic state
Transient tachypnea of the newborn
Hypoglycemia
Hypocalcemia
Hypomagnesemia
Birth injuries
Brachial plexus injuries and Erb’s palsy
Fractures - clavicle
```
165
Hyperglycemia of IDM includes (3)
Hypoglycemia
Hypocalcemia
Hypomagnesemia
166
Risk factors for Unstable Blood Glucose Level
```
Infant of diabetic mother (IDM)
LGA or SGA or IUGR
Post-term or Preterm
Hypothermia
Neonatal infection
Respiratory distress
Neonatal resuscitation
Birth stress or trauma
```
167
Interventions and assessments for ineffective thermal regulation
- Assess baby temp
- Place under radiant warmer — best practice is to unwrap/uncover the baby and use the temperature probe— until his temperature has stabilized OR do skin-to-sin
- Assess baby’s HR, RR, and glucose rate
- Reassess axillary temp every 30-60 min (or use skin probe to obtain constant skin temp for the next 2 hours and is stable)
- Wrap in 2 blankets and cover head with hat
postpone bath until they can maintain normal temp for longer than a half hour
- check temp pre and post bath
- family teaching: how to monitor for ineffective thermoregulation, show them how to check his axillary temp, teach strategies to keep him warm (blanketing, skin-to-skin, etc.)
168
Time frame to assess for withdrawal in babies (cocaine, opiates, alcohol)
opiates – 48-72 hours
cocaine – 2-3 days
alcohol – within 3-12 hours
169
Nursing interventions for babies with Neonatal Abstinence Syndrome
- Assess for sx of drug withdrawal
- Obtain meconium and urine for drug screen
- Feeding – more difficult may need to garage
- Rest – keep stimulation to minimum, reduce noise and lights, calm, slow approach
- Promote bonding
- Teach measures for frantic crying: rock, coo, dark room, avoid stimulation
170
Pre-op requirements for circumcision
consent
Stable VS
NPO
171
What should parents do if there’s purulent drainage post-circumcision and they’ve already gone home with the baby?
call the provider
172
Health Promotion and Disease Prevention points before the baby goes home (7):
- Car Seat Challenge
- Hearing Screening
- LATCH
- Newborn Screening
- Pulse Oximetry
- Transcutaneous Bilimeter
- Vaccination: Hepatitis B
173
For post-circumcision, how long do you keep on the vaseline gauze? What to do for bleeding?
at least 24 hrs (do not remove before then)
normally continues for 4-7 days
clean with just water, no soap needed
if bleeding, apply a bit of pressure on that side
174
Risk factors for SIDS
- Maternal smoking during pregnancy
- Use of soft bedding
- Sleeping prone
- Sibling w/SIDS
- Infections
- Prematurity
- Low birth weight
175
Purpose of Well-Child Visit
- Immunizations
- Anticipatory Guidance
- Assessment of Growth
- Assessment of Developmental Milestones achieved
- Safety
176
Sudden Infant Death Syndrome
(SIDS) - what it is, peak incidence
Unexplained death of infant > 1 month
177
Car Seat Challenge
if the baby is less than 37 weeks gestation, they may not require the services of a neonatal ICU and be able to go home - this is done by putting the baby in the carseat the parents are going to use and monitoring them on a cardiopulmonary monitor for 3-8 hours (making sure they don’t have apnea when they get in that position)
178
baby should go onto solid foods at __ months
6 months
179
Pulse Oximetry is tested when and for what?
pre and post ductal
testing for a coarctation
pre ductal pulse ox will be higher than post
180
Sudden Infant Death Syndrome
(SIDS) is considered a ____ disorder
unpreventable
but risk can be decreased
BACK TO SLEEP
prone to play
181
Plagiocephaly
flat spot on baby's head
develops when a baby spends too much time lying on his or her back.
It doesn't cause brain damage or interfere with a baby's development.
182
First time mom, newly breastfeeding - the provider may want to see the baby in office when? What about a mom with 5 kids all breastfed?
within the first week for new mom
5 kids - 2 weeks
183
normal newborn respirations
30-50
184
normal newborn temp
36.5 to 37.3˚C (97.7 –99.2˚F)
185
problematic newborn glucose would be less than
45
186
normal newborn birthweight range
5 pounds, 8 ounces (2,500 grams) and 8 pounds, 13 ounces (4,000 grams).
187
ortolani sign indicates
hip displasia
188
Babies often lose between ___ and ___% of their birth weight. A loss greater than ___ is considered pathological.
5% and 10%
10%
189
___ breathing is an indication of respiratory distress.
Seesaw
190
The nurse is discussing the neonatal blood screening test with a new mother. The nurse knows that the teaching was successful when the mother states that the test
screens for the presence in the newborn of which of the following diseases? Select all that apply.
1. Hypothyroidism.
2. Sickle cell disease.
3. Galactosemia.
4. Cerebral palsy.
5. Cystic fibrosis.
1, 2, 3, 5
191
The nursery nurse is careful to wear gloves when admitting neonates into the nursery. Which of the following is the scientific rationale for this action?
1. Meconium is filled with enteric bacteria.
2. Amniotic fluid may contain harmful viruses.
3. The high alkalinity of fetal urine is caustic to the skin.
4. The baby is high risk for infection and must be protected.
2. Amniotic fluid may contain harmful viruses.
192
A full-term newborn was just born. Which nursing intervention is important for the nurse to perform first?
1. Remove wet blankets.
2. Assess Apgar score.
3. Insert eye prophylaxis.
4. Elicit the Moro reflex.
1. Remove wet blankets.
193
To reduce the risk of hypoglycemia in a full-term newborn weighing 2,900 grams, what should the nurse do?
1. Maintain the infant’s temperature above 97.7°F.
2. Feed the infant glucose water every 3 hours until breastfeeding well.
3. Assess blood glucose levels every 3 hours for the first twelve hours.
4. Encourage the mother to breastfeed every 4 hours.
1. Maintain the infant’s temperature above 97.7°F.
194
A mother asks the nurse to tell her about the responsiveness of neonates at birth. Which of the following answers is appropriate? Select all that apply.
1. “Babies have a poorly developed sense of smell until they are 2 months old.”
2. “Babies respond to all forms of taste well, but they prefer to eat sweet things like
breast milk.”
3. “Babies are especially sensitive to being touched and cuddled.”
4. “Babies are nearsighted with blurry vision until they are about 3 months of age.”
5. “Babies respond to many sounds, especially to the high-pitched tone of the female
voice.”
2. “Babies respond to all forms of taste well, but they prefer to eat sweet things like
breast milk.”
3. “Babies are especially sensitive to being touched and cuddled.”
5. “Babies respond to many sounds, especially to the high-pitched tone of the female
voice.”
195
A mother, 1 day postpartum from a 3-hour labor and a spontaneous vaginal delivery, questions the nurse because her baby’s face is “purple.” Upon examination, the nurse
notes petechiae over the scalp, forehead, and cheeks of the baby. The nurse’s response should be based on which of the following?
1. Petechiae are indicative of severe bacterial infections.
2. Rapid deliveries can injure the neonatal presenting part.
3. Petechiae are characteristic of the normal newborn rash.
4. The injuries are a sign that the child has been abused.
2. Rapid deliveries can injure the neonatal presenting part.
196
A 2-day-old breastfeeding baby born via normal spontaneous vaginal delivery has just
been weighed in the newborn nursery. The nurse determines that the baby has lost
3.5% of the birth weight. Which of the following nursing actions is appropriate?
1. Do nothing because this is a normal weight loss.
2. Notify the neonatologist of the significant weight loss.
3. Advise the mother to bottle feed the baby at the next feed.
4. Assess the baby for hypoglycemia with a glucose monitor.
1. Do nothing because this is a normal weight loss.
197
Four newborns are in the neonatal nursery, none of whom is crying or in distress.
Which of the babies should the nurse report to the neonatologist?
1. 16-hour-old baby who has yet to pass meconium.
2. 16-hour-old baby whose blood glucose is 50 mg/dL.
3. 2-day-old baby who is breathing irregularly at 70 breaths per minute.
4. 2-day-old baby who is excreting a milky discharge from both nipples.
3. 2-day-old baby who is breathing irregularly at 70 breaths per minute.
198
A nurse is doing a newborn assessment on a new admission to the nursery. Which
of the following actions should the nurse make when evaluating the baby for
developmental dysplasia of the hip (DDH)? Select all that apply.
1. Grasp the baby’s legs with the thumbs on the inner thighs and forefingers on the
outer thighs.
2. Gently adduct and abduct the baby’s thighs.
3. Palpate the trochanter during hip rotation.
4. Place the baby in a fetal position.
5. Compare the lengths of the baby’s legs.
1, 2, 3, 5
199
A nurse notes that a 6-hour-old neonate has cyanotic hands and feet. Which of the
following actions by the nurse is appropriate?
1. Place child in an isolette.
2. Administer oxygen.
3. Swaddle baby in a blanket.
4. Apply pulse oximeter.
3. Swaddle baby in a blanket.
200
Using the Neonatal Infant Pain Scale (NIPS), a nurse is assessing the pain response of a newborn who has just had a circumcision. The nurse is assessing a change in which of the following signs/symptoms? Select all that apply.
1. Heart rate.
2. Blood pressure.
3. Temperature.
4. Facial expression.
5. Breathing pattern.
4. Facial expression.
| 5. Breathing pattern.
201
A nurse is teaching a mother how to care for her 3-day-old son’s circumcised penis. Which of the following actions demonstrates that the mother has learned the
information?
1. The mother cleanses the glans with a cotton swab dipped in hydrogen peroxide.
2. The mother covers the glans with antifungal ointment after rinsing off any discharge.
3. The mother squeezes soapy water from the wash cloth over the glans.
4. The mother replaces the dry sterile dressing before putting on the diaper.
3. The mother squeezes soapy water from the wash cloth over the glans.
202
Where should the nurse administer the vitamin K?
the anterior-lateral portion of the middle
third of the thigh from the trochanter to
the patella.
203
Which fontanelle closes at 6 to 8 weeks of age.
posterior
204
A neonate is in the active alert behavioral state. Which of the following would the nurse expect to see?
1. Baby is showing signs of hunger and frustration.
2. Baby is starting to whimper and cry.
3. Baby is wide awake and attending to a picture.
4. Baby is asleep and breathing rhythmically.
1. Baby is showing signs of hunger and frustration.
205
The nursery charge nurse is assessing a 1-day-old female on morning rounds. Which of the following findings should be reported to the neonatologist as soon as possible?
Select all that apply.
1. Blood in the diaper.
2. Grunting during expiration.
3. Deep red coloring on one side of the body with pale pink on the other side.
4. Lacy and mottled appearance over the entire chest and abdomen.
5. Flaring of the nares during inspiration.
2. Grunting during expiration.
| 5. Flaring of the nares during inspiration.
206
A mother calls the nurse to her room because “My baby’s eyes are bleeding.” The nurse notes bright red hemorrhages in the sclerae of both of the baby’s eyes. Which of the following actions by the nurse is appropriate at this time?
1. Notify the pediatrician immediately and report the finding.
2. Notify the social worker about the probable maternal abuse.
3. Reassure the mother that the trauma resulted from pressure changes at birth
and the hemorrhages will slowly disappear.
4. Obtain an ophthalmoscope from the nursery to evaluate the red reflex and condition of the retina in each eye.
3. Reassure the mother that the trauma resulted from pressure changes at birth
and the hemorrhages will slowly disappear.
207
The following four babies are in the neonatal nursery. Which of the babies should be seen by the neonatologist?
1. 1-day-old, HR 100 beats per minute, in deep sleep.
2. 2-day-old, T 97.7°F, slightly jaundiced.
3. 3-day-old, breastfeeding every 4 hours, jittery.
4. 4-day-old, crying, papular rash on an erythematous base.
3. 3-day-old, breastfeeding every 4 hours, jittery.
208
The nurse notes that a newborn, who is 5 minutes old, exhibits the following characteristics: heart rate 108 bpm, respiratory rate 29 rpm with lusty cry, pink body with
bluish hands and feet, some flexion. What does the nurse determine the baby’s Apgar score is?
1. 6.
2. 7.
3. 8.
4. 9.
3. 8.
209
A neonate, who is being admitted into the well-baby nursery, is exhibiting each of the
following assessment findings. Which of the findings should the nurse report to the primary health care provider? Select all that apply.
1. Harlequin sign.
2. Extension of the toes when the lateral aspect of the sole is stroked.
3. Elbow moves past the midline when the scarf sign is assessed.
4. Slightly curved pinnae of the ears that are slow to recoil.
5. Telangiectatic nevi.
3, 4
210
The mother notes that her baby has a “bulge” on the back of one side of the head. She calls the nurse into the room to ask what the bulge is. The nurse notes that the
bulge covers the right parietal bone but does not cross the suture lines. The nurse explains to the mother that the bulge results from which of the following?
1. Molding of the baby’s skull so that the baby could fit through her pelvis.
2. Swelling of the tissues of the baby’s head from the pressure of her pushing.
3. The position that the baby took in her pelvis during the last trimester of her
pregnancy.
4. Small blood vessels that broke under the baby’s scalp during birth.
4. Small blood vessels that broke under the baby’s scalp during birth.
211
The nurse is teaching the parents of a 1-day-old baby how to give a sponge bath.
Which of the following actions should be included?
1. Clean the eyes from outer canthus to inner canthus.
2. Cleanse the ear canals with a cotton swab.
3. Assemble all supplies before beginning the bath.
4. Check the temperature of the bath water with the fingertips.
3. Assemble all supplies before beginning the bath.
212
A nurse is providing anticipatory guidance to a couple regarding the baby’s immunization schedule. Which of the following statements by the parents shows that the
teaching by the nurse was successful? Select all that apply.
1. The first hepatitis B injection is given by 1 month of age.
2. The first polio injection will be given at 2 months of age.
3. The MMR (measles, mumps, and rubella) immunization should be administered
before the first birthday.
4. Three DTaP (diphtheria, tetanus, and acellular pertussis) shots will be given
during the first year of life.
5. The Varivax (varicella) immunization will be administered after the baby turns
one year of age.
1, 2, 4, 5
213
A nurse is advising the parents of a newborn regarding when they should call their
pediatrician. Which of the following responses show that the teaching was effective?
Select all that apply.
1. If the baby repeatedly refuses to feed.
2. If the baby’s breathing is irregular.
3. If the baby has no tears when he cries.
4. If the baby is repeatedly difficult to awaken.
5. If the baby’s temperature is above 100.4°F.
1, 4, 5
214
A nurse is providing anticipatory guidance to a couple before they take home their newborn. Which of the following should be included?
1. If their baby is sleeping soundly, they should not awaken the baby for a feeding.
2. If they take their baby outside, they should put sunscreen on the baby.
3. They should purchase liquid acetaminophen to be used when ordered by the pediatrician.
4. They should notify their pediatrician when the umbilical cord falls off.
3. They should purchase liquid acetaminophen to be used when ordered by the pediatrician.
215
A mucousy baby is being left with the parents for the first time after delivery. Which of the following should the nurse teach the parents regarding use of the
bulb syringe?
1. Suction the nostrils before suctioning the mouth.
2. Make sure to suction the back of the throat.
3. Insert the syringe before compressing the bulb.
4. Dispose of the drainage in a tissue or a cloth.
4. Dispose of the drainage in a tissue or a cloth.
216
The nurse is developing a teaching plan for parents who are taking home their 2-day-old breastfed baby. Which of the following should the nurse include in the plan?
1. Wash hands well before picking up the baby.
2. Refrain from having visitors for the first month.
3. Wear a mask to prevent transmission of a cold.
4. Sterilize the breast pump supplies after every use.
1. Wash hands well before picking up the baby.
217
It is time for a baby who is in the drowsy behavioral state to breastfeed. Which of the following techniques could the mother use to arouse the baby? Select all that apply.
1. Swaddle or tightly bundle the baby.
2. Hand express milk onto the baby’s lips.
3. Talk with the baby while making eye contact.
4. Remove the baby’s shirt and change the diaper.
5. Play pat-a-cake with the baby.
2, 3, 4, 5
218
A bottle-feeding mother is providing a return demonstration of how to burp the baby. Which of the following would indicate that the teaching was successful? Select all that apply.
1. The woman gently strokes and pats her baby’s back.
2. The woman positions the baby in a sitting position on her lap.
3. The woman waits to burp the baby until the baby’s feeding is complete.
4. The woman states that a small amount of regurgitated formula is acceptable.
5. The woman remarks that the baby does not need to burp after trying for one full minute.
1, 2, 4
219
A breastfeeding baby is born with a tight frenulum. Which of the following is an
important assessment for the nurse to make?
1. Integrity of the baby’s uvula.
2. Presence of maternal nipple damage.
3. Presence of neonatal tongue injury.
4. The baby’s breathing pattern.
2. Presence of maternal nipple damage.
220
A mother is told that she should bottle feed her child for medical reasons. Which of the following maternal disease states are consistent with the recommendation? Select all that apply.
1. Untreated, active tuberculosis.
2. Hepatitis B surface antigen positive.
3. Human immunodeficiency virus positive.
4. Chorioamnionitis.
5. Mastitis.
1, 3
221
A nurse has brought a 2-hour-old baby to a mother from the nursery. The nurse is going to assist the mother with the first breastfeeding experience. Which of the
following actions should the nurse perform first?
1. Compare mother’s and baby’s identification bracelets.
2. Help the mother into a comfortable position.
3. Teach the mother about a proper breast latch.
4. Tickle the baby’s lips with the mother’s nipple.
1. Compare mother’s and baby’s identification bracelets.
222
Which short-term goal is appropriate for a full-term, breastfeeding neonate?
1. The baby will regain birth weight by 4 weeks of age.
2. The baby will sleep through the night by 4 weeks of age.
3. The baby will stool every 2 to 3 hours by 1 week of age.
4. The baby will urinate 6 to 10 times per day by 1 week of age.
4. The baby will urinate 6 to 10 times per day by 1 week of age.
223
A mother is attempting to latch her newborn baby to the breast. Which of the following actions are important for the mother to perform to achieve effective breastfeeding? Select all that apply.
1. Place the baby on his or her back in the mother’s lap.
2. Wait until the baby opens his or her mouth wide.
3. Hold the baby at the level of the mother’s breasts.
4. Point the baby’s nose to the mother’s nipple.
5. Wait until the baby’s tongue is pointed toward the roof of his or her mouth.
2, 3, 4
224
The nurse is evaluating the effectiveness of an intervention when assisting a woman whose baby has been latched to the nipple only rather than to the nipple and the areola. Which response would indicate that further intervention is needed?
1. The client states that the pain has decreased.
2. The nurse hears the baby swallow after each suck.
3. The baby’s jaws move up and down once every second.
4. The baby’s cheeks move in and out with each suck.
4. The baby’s cheeks move in and out with each suck.
225
The parents and their full-term, breastfed neonate were discharged from the hospital. Which behavior 2 days later indicates a positive response by the parents
to the nurse’s discharge teaching? Select all that apply.
1. The parents count their baby’s diapers.
2. The parents measure the baby’s intake.
3. The parents give one bottle of formula every day.
4. The parents take the baby to see the pediatrician.
5. The parents time the baby’s feedings.
1, 4
226
A 2-day-old, exclusively breastfed baby is to be discharged home. Under what conditions should the nurse teach the parents to call the pediatrician?
1. If the baby feeds 8 to 12 times each day.
2. If the baby urinates 6 to 10 times each day.
3. If the baby has stools that are watery and bright yellow.
4. If the baby has eyes and skin that are tinged yellow.
4. If the baby has eyes and skin that are tinged yellow.
227
A nurse who is caring for a mother/newborn dyad on the maternity unit has identified the following nursing diagnosis: Effective breastfeeding. Which of the following would warrant this diagnosis?
1. Baby’s lips are flanged when latched.
2. Baby feeds every 4 hours.
3. Baby lost 12% of weight since birth.
4. Baby’s tongue stays behind the gum line.
1. Baby’s lips are flanged when latched.
228
On admission to the maternity unit, it is learned that a mother has smoked 2 packs of cigarettes per day and expects to continue to smoke after discharge. The mother also states that she expects to breastfeed her baby. The nurse’s response should be based on which of the following?
1. Breastfeeding is contraindicated if the mother smokes cigarettes.
2. Breastfeeding is protective for the baby and should be encouraged.
3. A 2-pack-a-day smoker should be reported to child protective services for child
abuse.
4. A mother who admits to smoking cigarettes may also be abusing illicit substances.
2. Breastfeeding is protective for the baby and should be encouraged.
229
A breastfeeding mother who is 2 weeks postpartum is informed by her pediatrician that her 4-year-old has chickenpox (varicella). The mother calls the nursery nurse because she is concerned about having the baby in contact with the sick sibling. The mother had chickenpox as a child. Which of the following responses by the nurse is appropriate?
1. “The baby received passive immunity through the placenta, plus the breast milk
will also be protective.”
2. “The baby should stay with relatives until the ill sibling recovers from the episode
of chickenpox.”
3. “Chickenpox is transmitted by contact route so careful hand washing should
prevent transmission.”
4. “Because chickenpox is a spirochetal illness, both the child and baby should
receive the appropriate medications.”
1. “The baby received passive immunity through the placenta, plus the breast milk
will also be protective.”
230
A client is preparing to breastfeed her newborn son in the cross-cradle position.
Which of the following actions should the woman make?
1. Place a pillow in her lap.
2. Position the head of the baby in her elbow.
3. Put the baby on his back.
4. Move the breast toward the mouth of the baby.
1. Place a pillow in her lap.
231
A physician writes in a breastfeeding mother’s chart, “Ampicillin 500 mg q 6 h po. Baby should be bottle fed until medication is discontinued.” What should be the nurse’s next action?
1. Follow the order as written.
2. Call the doctor and question the order.
3. Follow the antibiotic order but ignore the order to bottle feed the baby.
4. Refer to a text to see whether the antibiotic is safe while breastfeeding.
4. Refer to a text to see whether the antibiotic is safe while breastfeeding.
232
A client asks whether or not there are any foods that she must avoid eating while breastfeeding. Which of the following responses by the nurse is appropriate?
1. “No, there are no foods that are strictly contraindicated while breastfeeding.”
2. “Yes, the same foods that were dangerous to eat during pregnancy should be
avoided. ”
3. “Yes, foods like onions, cauliflower, broccoli, and cabbage make babies very
colicky. ”
4. “Yes, spices from hot and spicy foods get into the milk and can bother your baby.”
1. “No, there are no foods that are strictly contraindicated while breastfeeding.”
233
A full-term neonate, Apgar 9/9, has just been admitted to the nursery after a cesarean delivery, fetal position LMA, under epidural anesthesia. Which of the following physiological findings would the nurse expect to see?
1. Soft pulmonary rales.
2. Absent bowel sounds.
3. Depressed Moro reflex.
4. Positive Ortolani sign.
1. Soft pulmonary rales.
234
A neonate has an elevated bilirubin and is slightly jaundiced on day 3 of life. What is
the probable reason for these changes?
1. Hemolysis of neonatal red blood cells by the maternal antibodies.
2. Physiological destruction of fetal red blood cells during the extrauterine period.
3. Pathological liver function resulting from hypoxemia during the birthing process.
4. Delayed meconium excretion resulting in the production of direct bilirubin.
2. Physiological destruction of fetal red blood cells during the extrauterine period.
235
The nurse observes a healthy woman of African descent expressing breast milk into her baby’s eyes. Which of the following responses by the nurse is appropriate at this time?
1. Report the abusive behavior to the social worker.
2. Advise the mother that her action is potentially dangerous.
3. Observe the mother for other signs of irrational behavior.
4. Ask the woman about other cultural traditions.
4. Ask the woman about other cultural traditions.
236
The nurse informs the parents of a breastfed baby that the American Academy of Pediatrics advises that babies be supplemented with which of the following vitamins?
1. Vitamin A.
2. Vitamin B12
3. Vitamin C.
4. Vitamin D.
4. Vitamin D.
237
A 2-day-old neonate received a vitamin K injection at birth. Which of the following signs/symptoms in the baby would indicate that the treatment was effective?
1. Skin color is pink.
2. Vital signs are normal.
3. Glucose levels are stable.
4. Blood clots after heel sticks.
4. Blood clots after heel sticks.
238
A nurse is about to administer the ophthalmic preparation to a newly born neonate. Which of the following is the correct statement regarding the medication?
1. It is administered to prevent the development of neonatal cataracts.
2. The medicine should be placed in the lower conjunctiva from the inner to outer canthus.
3. The medicine must be administered immediately upon delivery of the baby.
4. It is administered to neonates whose mothers test positive for gonorrhea during
pregnancy.
2. The medicine should be placed in the lower conjunctiva from the inner to outer
canthus.
239
A certified nursing assistant (CNA) is working with a registered nurse (RN) in the neonatal nursery. Which of the following actions should the RN perform rather
than delegating it to the CNA?
1. Bathe and weigh a 1-hour-old baby.
2. Take the apical heart rate and respirations of a 4-hour-old baby.
3. Obtain a stool sample from a 1-day-old baby.
4. Provide discharge teaching to the mother of a 4-day-old baby.
4. Provide discharge teaching to the mother of a 4-day-old baby.
240
A full-term baby’s bilirubin level is 12 mg/dL on day 3. Which of the following neonatal behaviors would the nurse expect to see?
1. Excessive crying.
2. Increased appetite.
3. Lethargy.
4. Hyperreflexia.
3. Lethargy.
241
The nursing management of a neonate with physiological jaundice should be directed toward which of the following client care goals?
1. The baby will exhibit no signs of kernicterus.
2. The baby will not develop erythroblastosis fetalis.
3. The baby will have a bilirubin of 16 mg/dL or higher at discharge.
4. The baby will spend at least 20 hours per day under phototherapy.
1. The baby will exhibit no signs of kernicterus.
242
```
A 2-day-old baby’s blood values are:
Blood type, O– (negative).
Direct Coombs, negative.
Hematocrit, 50%.
Bilirubin, 1.5 mg/dL.
The mother’s blood type is A+. What should the nurse do at this time?
```
1. Do nothing because the results are within normal limits.
2. Assess the baby for opisthotonic posturing.
3. Administer RhoGAM to the mother per doctor’s order.
4. Call the doctor for an order to place the baby under bili-lights.
1. Do nothing because the results are within normal limits.
243
A 4-day-old baby born via cesarean section is slightly jaundiced. The laboratory reports a bilirubin assessment of 6.0 mg/dL. Which of the following would the
nurse expect the neonatologist to order for the baby at this time?
1. To be placed under phototherapy.
2. To be discharged home with the parents.
3. To be prepared for a replacement transfusion.
4. To be fed glucose water between routine feeds.
2. To be discharged home with the parents.
244
A mother tells the nurse that because of family history she is afraid her baby son
will develop colic. Which of the following colic management strategies should the
parents be taught? Select all that apply.
1. Small, frequent feedings.
2. Prone sleep positioning.
3. Tightly swaddling the baby.
4. Rocking the baby while holding him face down on the forearm.
5. Maintaining a home environment that is cigarette smoke–free.
1, 3, 4, 5
245
A baby is just delivered. Which of the following physiological changes is of highest priority?
1. Thermoregulation.
2. Spontaneous respirations.
3. Extrauterine circulatory shift.
4. Successful feeding.
2
246
____ is very high in vitamin A and also contains iron.
Broccoli
247
There is evidence to show that women who breastfeed their babies are less likely to develop ____ later in life.
type 2 diabetes
248
____ should be assessed before administering Methergine.
blood pressure
249
____ is an expected outcome of the administration of Methergine.
Cramping
250
____ will elevate sharply in the client’s bloodstream at the end of the third stage of labor
prolactin
251
A 3-day-breastfeeding client who is not immune to rubella is to receive the rubella
vaccine at discharge. Which of the following must the nurse include in her discharge
teaching regarding the vaccine?
1. The woman should not become pregnant for at least 4 weeks.
2. The woman should pump and dump her breast milk for 1 week.
3. Surgical masks must be worn by the mother when she holds the baby.
4. Antibodies transported through the breast milk will protect the baby.
1. The woman should not become pregnant for at least 4 weeks.
252
A 3-day-postpartum client questions why she is to receive the rubella vaccine before leaving the hospital. Which of the following rationales should guide the nurse’s response?
1. The client’s obstetric status is optimal for receiving the vaccine.
2. The client’s immune system is highly responsive during the postpartum period.
3. The client’s baby will be high risk for acquiring rubella if the woman does not
receive the vaccine.
4. The client’s insurance company will pay for the shot if it is given during the
immediate postpartum period.
1. The client’s obstetric status is optimal for receiving the vaccine.
253
A patient, G2 P1102, who delivered her baby 8 hours ago, now has a temperature of
100.2°F. Which of the following is the appropriate nursing intervention at this time?
1. Notify the doctor to get an order for acetaminophen.
2. Request an infectious disease consult from the doctor.
3. Provide the woman with cool compresses.
4. Encourage intake of water and other fluids.
4. Encourage intake of water and other fluids.
254
A G2 P2002, who is postpartum 6 hours from a spontaneous vaginal delivery, is
assessed. The nurse notes that the fundus is firm at the umbilicus, there is heavy
lochia rubra, and perineal sutures are intact. Which of the following actions should
the nurse take at this time?
1. Do nothing. This is a normal finding.
2. Massage the woman’s fundus.
3. Take the woman to the bathroom to void.
4. Notify the woman’s primary health care provider.
4. Notify the woman’s primary health care provider.
255
A client informs the nurse that she intends to bottle feed her baby. Which of the
following actions should the nurse encourage the client to perform? Select all that
apply.
1. Increase her fluid intake for a few days.
2. Massage her breasts every 4 hours.
3. Apply heat packs to her axillae.
4. Wear a supportive bra 24 hours a day.
5. Stand with her back toward the shower water.
4. Wear a supportive bra 24 hours a day.
| 5. Stand with her back toward the shower water.
256
A multigravid, postpartum woman reports severe abdominal cramping whenever she
nurses her baby. Which of the following responses by the nurse is appropriate?
1. Suggest that the woman bottle feed for a few days.
2. Instruct the patient on how to massage her fundus.
3. Instruct the patient to feed using an alternate position.
4. Discuss the action of breastfeeding hormones.
4. Discuss the action of breastfeeding hormones.
257
Which of the following statements is true about breastfeeding mothers as compared
to bottle-feeding mothers?
1. Breastfeeding mothers usually involute completely by 3 weeks postpartum.
2. Breastfeeding mothers have decreased incidence of diabetes mellitus later in life.
3. Breastfeeding mothers show higher levels of bone density after menopause.
4. Breastfeeding mothers are prone to fewer bouts of infection immediately
postpartum.
2. Breastfeeding mothers have decreased incidence of diabetes mellitus later in life.
258
A breastfeeding client, 7 weeks postpartum, complains to an obstetrician’s triage nurse that when she and her husband had intercourse for the first time after the delivery, “I couldn’t stand it. It was so painful. The doctor must have done something terrible to my vagina.” Which of the following responses by the nurse
is appropriate?
1. “After a delivery the vagina is always very tender. It should feel better the next
time you have intercourse.”
2. “Does your baby have thrush? If so, you should be assessed for a yeast infection in
your vagina.”
3. “Women who breastfeed often have vaginal dryness. A vaginal lubricant may
remedy your discomfort.”
4. “Sometimes the stitches of episiotomies heal too tight. Why don’t you come in to
be checked?”
3. “Women who breastfeed often have vaginal dryness. A vaginal lubricant may
remedy your discomfort.”
259
The nurse monitors his or her postpartum clients carefully because which of the
following physiological changes occurs during the early postpartum period?
1. Decreased urinary output.
2. Increased blood pressure.
3. Decreased blood volume.
4. Increased estrogen level.
3. Decreased blood volume.
260
A woman, 24 hours postpartum, is complaining of profuse diaphoresis. She has no
other complaints. Which of the following actions by the nurse is appropriate?
1. Take the woman’s temperature.
2. Advise the woman to decrease her fluid intake.
3. Reassure the woman that this is normal.
4. Notify the neonate’s pediatrician.
3. Reassure the woman that this is normal.
261
Which of the following laboratory values would the nurse expect to see in a normal
postpartum woman?
1. Hematocrit, 39%.
2. White blood cell count, 16,000 cells/mm3.
3. Red blood cell count, 5 million cells/mm3.
4. Hemoglobin, 15 grams/dL.
2. White blood cell count, 16,000 cells/mm3.
262
The nurse is discussing the importance of doing Kegel exercises during the postpartum period. Which of the following should be included in the teaching plan?
1. She should repeatedly contract and relax her rectal and thigh muscles.
2. She should practice by stopping the urine flow midstream every time she voids.
3. She should get on her hands and knees whenever performing the exercises.
4. She should be taught that toned pubococcygeal muscles decrease blood loss.
2. She should practice by stopping the urine flow midstream every time she voids.
263
The nurse is evaluating the involution of a woman who is 3 days postpartum. Which
of the following findings would the nurse evaluate as normal?
1. Fundus 1 cm above the umbilicus, lochia rosa.
2. Fundus 2 cm above the umbilicus, lochia alba.
3. Fundus 2 cm below the umbilicus, lochia rubra.
4. Fundus 3 cm below the umbilicus, lochia serosa.
4. Fundus 3 cm below the umbilicus, lochia serosa.
264
The day after delivery, a woman, whose fundus is firm at 1 cm below the umbilicus
and who has moderate lochia, tells the nurse that something must be wrong: “All
I do is go to the bathroom.” Which of the following is an appropriate nursing
response?
1. Catheterize the client per doctor’s orders.
2. Measure the client’s next voiding.
3. Inform the client that polyuria is normal.
4. Check the specific gravity of the next voiding.
3. Inform the client that polyuria is normal.
265
The nurse is caring for a client who had an emergency cesarean section, with her
husband in attendance, the day before. The baby’s Apgar was 9/9. The woman and
her partner had attended childbirth education classes and had anticipated having a
water birth with family present. Which of the following comments by the nurse is appropriate?
1. “Sometimes babies just don’t deliver the way we expect them to.”
2. “With all of your preparations, it must have been disappointing for you to have
had a cesarean.”
3. “I know you had to have surgery, but you are very lucky that your baby was born
healthy.”
4. “At least your husband was able to be with you when the baby was born.”
2. “With all of your preparations, it must have been disappointing for you to have
had a cesarean.”
266
A post–cesarean section, breastfeeding client, whose subjective pain level is 2/5,
requests her as needed (prn) narcotic analgesics every 3 hours. She states, “I have
decided to make sure that I feel as little pain from this experience as possible.”
Which of the following should the nurse conclude in relation to this woman’s
behavior?
1. The woman needs a stronger narcotic order.
2. The woman is high risk for severe constipation.
3. The woman’s breast milk volume may drop while taking the medicine.
4. The woman’s newborn may become addicted to the medication.
2. The woman is high risk for severe constipation.
267
A nurse is assessing a 1-day-postpartum woman who had her baby by cesarean
section. Which of the following should the nurse report to the surgeon?
1. Fundus at the umbilicus.
2. Nodular breasts.
3. Pulse rate 60 bpm.
4. Pad saturation every 30 minutes.
4. Pad saturation every 30 minutes.
268
A client, G1 P1, who had an epidural, has just delivered a daughter, Apgar 9/9,
over a mediolateral episiotomy. The physician used low forceps. While recovering,
the client states, “I’m a failure. I couldn’t stand the pain and couldn’t even push
my baby out by myself!” Which of the following is the best response for the nurse
to make?
1. “You’ll feel better later after you have had a chance to rest and to eat.”
2. “Don’t say that. There are many women who would be ecstatic to have that baby.”
3. “I am sure that you will have another baby. I bet that it will be a natural delivery.”
4. “To have things work out differently than you had planned is disappointing.”
4. “To have things work out differently than you had planned is disappointing.”
269
The nurse is developing a standard care plan for postpartum clients who have had midline episiotomies. Which of the following interventions should be included in the plan?
1. Assist with stitch removal on third postpartum day.
2. Administer analgesics every four hours per doctor’s orders.
3. Teach client to contract her buttocks before sitting.
4. Irrigate incision twice daily with antibiotic solution.
3. Teach client to contract her buttocks before sitting.
270
A 1-day postpartum woman states, “I think I have a urinary tract infection. I have to go to the bathroom all the time.” Which of the following actions should the nurse take?
1. Assure the woman that frequent urination is normal after delivery.
2. Obtain an order for a urine culture.
3. Assess the urine for cloudiness.
4. Ask the woman if she is prone to urinary tract infections.
1. Assure the woman that frequent urination is normal after delivery.
271
The nurse is assessing the laboratory report on a 2-day postpartum G1 P1001. The woman had a normal postpartum assessment this morning. Which of the following
results should the nurse report to the primary health care provider?
1. White blood cells, 12,500 cells/mm3.
2. Red blood cells, 4,500,000 cells/mm3.
3. Hematocrit, 26%.
4. Hemoglobin, 11 g/dL
3. Hematocrit, 26%.
272
A bottle-feeding woman, 1 1/2 weeks postpartum from a vaginal delivery, calls the
obstetric office to state that she has saturated 2 pads in the past 1 hour. Which of the
following responses by the nurse is appropriate?
1. “You must be doing too much. Lie down for a few hours and call back if the
bleeding has not subsided.”
2. “You are probably getting your period back. You will bleed like that for a day or
two and then it will lighten up.”
3. “It is not unusual to bleed heavily every once in a while after a baby is born. It
should subside shortly.”
4. “It is important for you to be examined by the doctor today. Let me check to see
when you can come in.”
4. “It is important for you to be examined by the doctor today. Let me check to see
when you can come in.”
273
A client, 2 days postpartum from a spontaneous vaginal delivery, asks the nurse about
postpartum exercises. Which of the following responses by the nurse is appropriate?
1. “You must wait to begin to perform exercises until after your six-week postpartum
checkup.”
2. “You may begin Kegel exercises today, but do not do any other exercises until the
doctor tells you that it is safe.”
3. “By next week you will be able to return to the exercise schedule you had during
your prepregnancy.”
4. “You can do some Kegel exercises today and then slowly increase your toning
exercises over the next few weeks.”
4. “You can do some Kegel exercises today and then slowly increase your toning
exercises over the next few weeks.”
274
The nurse has taught a new admission to the postpartum unit about pericare. Which
of the following indicates that the client understands the procedure? Select all that apply.
1. The woman performs the procedure twice a day.
2. The woman washes her hands before and after the procedure.
3. The woman sits in warm tap water for ten minutes three times a day.
4. The woman sprays her perineum from front to back.
5. The woman mixes warm tap water with hydrogen peroxide.
2, 4
275
On admission to the labor and delivery unit, a client’s hemoglobin (Hgb) was
assessed at 11.0 g/dL, and her hematocrit (Hct) at 33%. Which of the following
values would the nurse expect to see 2 days after a normal spontaneous vaginal
delivery?
1. Hgb 12.5 g/dL; Hct 37%.
2. Hgb 11.0 g/dL; Hct 33%.
3. Hgb 10.5 g/dL; Hct 31%.
4. Hgb 9.0 g/dL; Hct 27%.
3. Hgb 10.5 g/dL; Hct 31%.
276
During a postpartum assessment, it is noted that a G1 P1001 woman, who delivered
vaginally over an intact perineum, has a cluster of hemorrhoids. Which of the following
would be appropriate for the nurse to include in the woman’s health teaching? Select all
that apply.
1. The client should use a sitz bath daily as a relief measure.
2. The client should digitally replace external hemorrhoids into her rectum.
3. The client should breastfeed frequently to stimulate oxytocin to reduce the size of
the hemorrhoids.
4. The client should be advised that the hemorrhoids will increase in size and
quantity with subsequent pregnancies.
5. The client should apply topical anesthetic as a relief measure.
1, 2, 5
277
Immediately after delivery, a woman is shaking uncontrollably. Which of the
following nursing actions is most appropriate?
1. Provide the woman with warm blankets.
2. Put the woman in the Trendelenburg position.
3. Notify the primary health care provider.
4. Increase the intravenous infusion.
1. Provide the woman with warm blankets.
278
One nursing diagnosis that a nurse has identified for a postpartum client is: Risk for intrauterine infection r/t vaginal delivery. During the postpartum period, which of
the following goals should the nurse include in the care plan in relation to this diagnosis? Select all that apply.
1. The client will drink sufficient quantities of fluid.
2. The client will have a stable white blood cell count.
3. The client will have a normal temperature.
4. The client will have normal-smelling vaginal discharge.
5. The client will take two or three sitz baths each day.
2, 3, 4
279
The nurse is developing a plan of care for the postpartum client during the “taking hold” phase. Which of the following should the nurse include in the plan?
1. Provide the client with a nutritious meal.
2. Encourage the client to take a nap.
3. Assist the client with activities of daily living.
4. Assure the client that she is an excellent mother.
4. Assure the client that she is an excellent mother.
280
A 2-day postpartum mother, G2 P2002, states that her 2-year-old daughter at home is very excited about taking “my baby sister” home. Which of the following is an appropriate response by the nurse?
1. “It’s always nice when siblings are excited to have the babies go home.”
2. “Your daughter is very advanced for her age. She must speak very well.”
3. “Your daughter is likely to become very jealous of the new baby.”
4. “Older sisters can be very helpful. They love to play mother.”
3. “Your daughter is likely to become very jealous of the new baby.”
281
A client who delivered a 3,900-gram baby vaginally over a right mediolateral episiotomy states, “How am I supposed to have a bowel movement? The stitches are right there!” Which of the following is the best response by the nurse?
1. “I will call the doctor to order a stool softener for you.”
2. “Your stitches are actually far away from your rectal area.”
3. “If you eat high-fiber foods and drink fluids you should have no problems.”
4. “If you use your topical anesthetic on your stitches you will feel much less pain.”
2. “Your stitches are actually far away from your rectal area.”
282
A client, G2 P1102, is 30 minutes postpartum from a low forceps vaginal delivery over a right mediolateral episiotomy. Her physician has just finished repairing the incision. The client’s legs are in the stirrups and she is breastfeeding her baby. Which
of the following actions should the nurse perform?
1. Assess her feet and ankles for pitting edema.
2. Advise the client to stop feeding her baby while her blood pressure is assessed.
3. Lower both of her legs at the same time.
4. Measure the length of the episiotomy and document the findings in the chart.
3. Lower both of her legs at the same time.
283
A maternity nurse knows that obstetric clients are most at high risk for cardiovascular compromise during the one hour immediately following a delivery because of which of the following?
1. Weight of the uterine body is significantly reduced.
2. Excess blood volume from pregnancy is circulating in the woman’s periphery.
3. Cervix is fully dilated and the lochia flows freely.
4. Maternal blood pressure drops precipitously once the baby’s head emerges.
2. Excess blood volume from pregnancy is circulating in the woman’s periphery.
284
The nurse must initiate discharge teaching with the couple regarding the need for an infant car seat for the day of discharge. Which of the following responses indicates that the nurse acted appropriately? The nurse discussed the need with the couple:
1. On admission to the labor room.
2. In the client room after the delivery.
3. When the client put the baby to the breast for the first time.
4. The day before the client and baby are to leave the hospital.
1. On admission to the labor room.
285
A client has been transferred to the post–anesthesia care unit from a cesarean delivery. The client had spinal anesthesia for the surgery. Which of the following interventions should the nurse perform at this time?
1. Assess the level of the anesthesia.
2. Encourage the client to urinate in a bedpan.
3. Provide the client with the diet of her choice.
4. Check the incision for signs of infection.
1. Assess the level of the anesthesia.
286
During a postpartum assessment, the nurse assesses the calves of a client’s legs. The nurse is checking for which of the following signs/symptoms? Select all that apply.
1. Pain.
2. Warmth.
3. Discharge.
4. Ecchymosis.
5. Redness.
1, 2, 5
OB
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