On the second postpartum day, a client complains of burning, urgency, and frequency of urination. A urinalysis is obtained, and the results indicate the presence of a urinary tract infection. The nurse instructs the client regarding which measures to take for the prevention and treatment of the infection? Select all that apply.
1.Urinate frequently throughout the day.
2.
Fluid intake should be increased to at least 3000
mL/day.
3.
Prescribed medication must be taken until it is completed.
5.
Wipe the perineal area from front to back after urinating.
Rationale: The woman with a urinary tract infection must be encouraged to take the medication for the entire time it is prescribed. The woman also should be instructed to drink at least 3000 mL of fluid each day to flush the infection from the bladder and to urinate frequently throughout the day. Foods and fluids that acidify the urine need to be encouraged. The client is also taught to wipe the perineal area from front to back after urinating or having a bowel movement.
The nurse visits a client at home who delivered a healthy newborn 2 days ago. The client is complaining of breast discomfort. The nurse notes that the client is experiencing breast engorgement. The nurse provides which instructions to the client regarding relief of the engorgement? Select all that apply.
Feed the infant at least every 2 hours for 15 to 20 minutes on each side.
Apply moist heat to both breasts for about 20 minutes before a feeding.
Massage the breasts gently during a feeding, from the outer areas to the nipples.
Wear a supportive bra between feedings.
Rationale: During breast engorgement, the client should be advised to feed the infant frequently, at least every 2 hours, for 15 to 20 minutes on each side. The infant will have an easier time latching on if the client softens her breast and expresses her milk before a feeding. Instruct the client to apply moist heat to both breasts for about 20 minutes before a feeding. This can be done in the shower or with warm wet towels. During a feeding, it is helpful to massage the breast gently from the outer area to the nipple. This helps stimulate the let-down and flow of milk. The client also should be instructed to wear a supportive bra between feedings.
The nurse provides which instructions to the client following delivery regarding care of the episiotomy site to prevent infection? Select all that apply.
Take a warm sitz baths three times a day.
Wipe the perineum from front to back after voiding and defecation.
Use warm water to rinse the perineum after elimination.
Report a foul-smelling discharge.
Rationale: Warm sitz baths and cleansing with warm water are helpful for relieving pain, and these measures will promote cleanliness in the perineal area to prevent infection. The client should also be instructed to wipe the perineum from front to back after voiding and defecation to decrease the risk for contamination with microorganisms from the anus to the vagina. Warm water should be used to rinse the perineum after elimination. The client also should be instructed that the perineal pad should be changed after each elimination and may be changed in between.
The nurse is collecting data from a pregnant client in the second trimester of pregnancy who was admitted to the maternity unit with a suspected diagnosis of abruptio placentae. Which of the following findings are associated with abruptio placentae? Select all that apply.
Acute abdominal pain
A hard, "board-like" abdomen
Increased uterine resting tone on fetal monitoring
Uterine tenderness
Rationale: Painless, bright red vaginal bleeding in the second or third trimester of pregnancy is a sign of placenta previa. In abruptio placentae, acute abdominal pain is present. Uterine tenderness accompanies placental abruption, especially with a central abruption and trapped blood behind the placenta. The abdomen will feel hard and board-like on palpation as the blood penetrates the myometrium and causes uterine irritability. Observation of the fetal monitoring often reveals increased uterine resting tone, caused by placental abruption.
Which of the following are modes of heat loss in the newborn? Select all that apply.
Convection
Radiation
Conduction
Evaporation
Rationale: The newborn can lose heat through convection, radiation, conduction, and evaporation. Heat is not lost through urination.
A vaginal examination of a client in labor would specifically determine which of the following? Select all that apply.
Effacement
Dilation
Station
Rationale: The vaginal examination for a client in labor specifically determines effacement 0 to 100%, dilation 0 to 10 cm, and station -5 cm (above the maternal ischial spine) to + 5 cm (below the maternal ischial spine). Bloody show is the brownish or blood-tinged cervical mucus that may be passed preceding labor and is not a specific part of the assessment when performing a vaginal examination. Contraction effort is not determined by vaginal examination.
The clinic nurse is instructing a pregnant client in her first trimester about nutrition. The nurse would correct which of the following misunderstandings on the part of the client about nutrition during pregnancy?
Pregnancy greatly increases the risk of malnourishment for the mother.
Rationale: Although pregnancy poses some nutritional risk for the mother, the client is not at risk of becoming malnourished. Calcium is critical during the third trimester but must be increased from the onset of pregnancy. Intake of dietary iron is usually insufficient for most pregnant women, and iron supplements are routinely encouraged. Good nutrition during pregnancy significantly and positively influences fetal growth and development.
The nurse is checking a newborn's 1-minute Apgar score based on the following assessment. The heart rate is 160 beats/min; he has positive respiratory effort with a vigorous cry; his muscle tone is active and well-flexed; he has a strong gag reflex and cries with stimulus to the soles of his feet; his body is pink, with his hands and feet cyanotic. What is the newborn's 1-minute Apgar score?
9
The nurse is monitoring a preterm newborn for respiratory distress syndrome (RDS). Which of the following findings, if noted in the newborn, would alert the nurse to the possibility of this syndrome?
Tachypnea and retractions
Rationale: The neonate with RDS may present with clinical signs of cyanosis; tachypnea or apnea; nasal flaring; chest wall retractions; or audible expiratory grunts. Acrocyanosis is the bluish discoloration of the hands and feet and is not uncommon in the first few hours of life. The options "hypotension and bradycardia," "acrocyanosis and grunting," and "the presence of a barrel chest, with acrocyanosis" do not indicate clinical signs of respiratory distress syndrome.
The nurse is monitoring a newborn that was born to a client who abuses alcohol. Which of the following findings would the nurse expect to note when assessing this newborn?
Irritability
Rationale: Characteristic behaviors of the fetal alcohol syndrome (FAS) newborn are similar to the behaviors common to the drug-exposed newborn. These behaviors include irritability, tremors, poor feeding, and hypersensitivity to stimuli. Newborns with FAS are smaller at birth and present with failure to thrive. Head circumference and weight are most affected.
The nurse is providing instructions to the client of a breast-fed newborn who has hyperbilirubinemia. Which of the following instructions does the nurse provide to the client?
Increase the frequency of the breast-feeding.
Rationale: Breast-feeding should be initiated within 2 hours after birth and every 2 to 3 hours thereafter. Supplementation with water does not reduce hyperbilirubinemia and should be discouraged because supplemental feedings with water do not promote stool excretion. The infant should not be fed less frequently. It is not necessary to stop breast-feeding permanently.
The nurse is providing instructions to the client regarding cord care. Which of the following statements, if made by the client, indicates a need for further education?
"I need to fold the diaper above the cord to prevent infection."
Rationale: The cord should be kept clean and dry to decrease bacterial growth. The diaper should be folded below the cord to keep urine away from the cord. The cord should be cleaned two or three times a day using alcohol or other prescribed solution. Cord care is required until the cord dries up and falls off, usually between 7 and 14 days postpartum.
The nurse has provided instructions to a client on how to bathe her newborn. The nurse demonstrates the procedure to the client and on the following day asks the client to perform the procedure. Which of the following observations, if made by the nurse, indicates that the client is performing the procedure correctly?
The client begins to wash the newborn by starting with the eyes and face.
Rationale: Bathing should start at the eyes and face and with the cleanest area first. Next, the external ears and behind the ears are cleaned. The newborn's neck should be washed because formula, lint, or breast milk will often accumulate in the folds. Hands and arms are next, then the legs, with the diaper area washed last.
The nurse is performing an initial assessment on a newborn. On assessment of the newborn's head, the nurse notes that the ears are low-set. Which of the following nursing actions would be most appropriate initially?
Notify the physician.
Rationale: Low or oddly placed ears are associated with a variety of congenital defects and should be reported immediately. Although the findings would be documented, the most appropriate action would be to notify the physician. The options "arrange for hearing testing" and "cover the ears with gauze pads" are inaccurate and inappropriate nursing actions. "Document the findings" is not an initial action.
The nurse is preparing to assist in administering neonatal resuscitation with a ventilation bag and mask because the newborn is apneic, is gasping, and has a heart rate below 100 beats/min. The nurse understands that the number of ventilations per minute that will be delivered to this neonate is _____ breaths/min.
40 to 60
Rationale: If the infant is apneic or has gasping respirations after stimulation, or the heart rate is below 100 beats/min, positive pressure ventilation by bag and mask can be given. The anesthesia bag used for neonatal resuscitation should have a pressure gauge. Ventilations should be given at a rate of 40 to 60 breaths/min at pressures of 15 to 20 cm H2O.
The nurse is planning to administer an injection of vitamin K to a newborn. In preparing to administer the injection, the nurse would select which of the following injection sites?
The lateral aspect of the middle third of the vastus lateralis muscle
Rationale: The preferred injection site for vitamin K in the newborn is the lateral aspect of the middle third of the vastus lateralis muscle in the newborn's thigh. This is the preferred injection site because it is free of major blood vessels and nerves and is large enough to absorb the medication.
...
Rationale: The Moro reflex is elicited by a loud noise, such as a hand clap or a slap on the mattress. The neonate should respond (in sequence) with extension and abduction of the limbs, followed by flexion and abduction of the limbs and then by flexion and adduction of the limbs. This reflex disappears at 6 months of age. The rooting reflex is elicited by stimulating the perioral area with the finger. The palmar grasp reflex is elicited by stimulating the palm of the hand with firm pressure, and the plantar grasp reflex is elicited by stimulating the ball of the foot with firm pressure.
The postpartum client asks the nurse about the occurrence of afterpains. The nurse informs the client that afterpains will be especially noticeable:
During breast-feeding
Rationale: Afterpains are a normal occurrence and result from contractions of the uterus as it reduces in size during involution. Afterpains may be especially noticeable during breast-feeding because oxytocin is released in response to the infant's sucking. The other options are incorrect.
The nursing instructor is reviewing the plan of care with a student regarding care of a postpartum client. The instructor asks the nursing student about the taking-in phase according to Rubin's phases of regeneration. The student is asked about client behaviors that are most likely to occur during this phase. Which of the following responses, made by the student, indicates an understanding of this phase?
"The client is self-focused and talks to others about labor."
Rationale: Rubin has identified three phases of regeneration during the postpartum period. The taking-in phase occurs in the first 3 days postpartum, and the taking-hold phase occurs between days 3 to 10. During the taking-in phase, the new client is attempting to integrate her labor and birth experience. She tends to need sleep and feels fatigued, talks about labor, and is self-focused and dependent. In the taking-hold phase, the client is more active, independent, initiates activities, and partakes in mothering tasks. In the letting-go phase, the mother may grieve over the separation of the baby from part of her body.
The nurse is assisting a new client with learning how to care for her newborn. The nurse notes that the client is very fearful and reluctant to handle the newborn and notes that this is the client's first child. Which of the following nursing interventions will least likely assist in promoting mother-infant interaction and bonding?
Leaving the infant with the client so that she will be required to provide the care
Rationale: A client with no experience of handling infants may be fearful and reluctant to handle her newborn or to take on physical care on her own. Acceptance of her feelings and acknowledgment of the apprehension can help an unsure client begin to participate in caring for her newborn. Assistance will help the client become more at ease. Leaving the infant with the client so that she will be required to provide the care will produce additional apprehension.
The nurse is assigned to care for a client who has chosen to formula-feed her infant. The nurse will plan to instruct the client to:
Wear a supportive brassiere continuously for 72 hours.
Rationale: Wearing a supportive brassiere continuously for 72 hours postpartum will minimize breast engorgement. Any stimulation of the breasts (expression of milk, infant sucking) or increase in circulation (heating pad) will increase milk production or cause the blood vessels and lymphatics to engorge. Correction of nipple inversion will not be necessary if the mother chooses not to breast-feed her infant.
The postpartum client who had a vaginal delivery of a healthy newborn has a prescription for a sitz bath. The nurse who is assisting the client tells the client that the sitz bath will:
Promote healing and provide comfort.
Rationale: Warm, moist heat is used after the first 24 hours following tissue trauma from a vaginal birth to provide comfort, promote healing, and reduce the incidence of infection. This is done with a sitz bath. Ice is used in the first 24 hours to reduce edema and to numb the tissue. Promoting a bowel movement is best achieved by ambulation.
The nurse is monitoring a new client in the fourth stage of labor for signs of hemorrhage. Which of the following signs, if noted in the mother, would indicate an early sign of excessive blood loss?
An increased pulse rate of 88 to 102 beats/min
Rationale: During the fourth stage of labor, the maternal blood pressure, pulse, and respiration should be checked every 15 minutes during the first hour. A rising pulse is an early sign of excessive blood loss, because the heart pumps faster to compensate for reduced blood volume. The blood pressure will fall as the blood volume diminishes, but a decreased blood pressure would not be the earliest sign of hemorrhage.
The nurse is providing instructions to the client who has been diagnosed with mastitis. Which of the following statements, if made by the client, indicates a need for further education?
"I need to stop breast-feeding until this condition resolves."
Rationale: In most cases, the client can continue to breast-feed with both breasts. If the affected breast is too sore, the client can pump the breast gently. Regular emptying of the breast is important in order to prevent abscess formation. Antibiotic therapy assists in resolving the mastitis within 24 to 48 hours. Additional supportive measures include ice packs, breast supports, and
analgesics.
The nurse is collecting data on clients who are in their first trimester of pregnancy. The nurse is concerned with identifying clients who may be at risk for the development of postpartum complications. Which of the following clients would be least likely at risk for the development of thrombophlebitis in the postpartum period?
A 26-year-old client with a family history of thrombophlebitis
Rationale: Certain factors create a risk for the development of thrombophlebitis. These factors include smoking; varicose veins; obesity; a history of thrombophlebitis; women who are older than 35 years or have had more than three pregnancies; and women who have had a cesarean birth. The client described in the correct option is least likely at risk for the development of a thromboembolic disorder because this client has a family history rather than a personal history of thrombophlebitis.
The nurse is monitoring the client for signs of postpartum depression. Which of the following, if noted in the client, would indicate the need for further assessment related to this form of depression?
The client constantly complains of tiredness and fatigue.
Rationale: Postpartum depression is not the normal depression that many new mothers experience from time to time. The client experiencing depression shows less interest in her surroundings and a loss of her usual emotional response toward the family. The client also is unable to show pleasure or love and may have intense feelings of unworthiness, guilt, and shame. The client often expresses a sense of loss of self. Generalized fatigue, complaints of ill health, and difficulty in concentrating also are present. The client would have little interest in food and experience sleep disturbances.
The nurse caring for a client with a diagnosis of subinvolution understands that which of the following is a primary cause of this diagnosis?
Retained placental fragments from delivery
Rationale: Retained placental fragments and infections are the primary causes of subinvolution. When either of these processes is present, the uterus has difficulty contracting. The presence of afterpains is an expected finding following delivery. The options "increased progesterone levels" and "increased estrogen levels" are not causes of subinvolution.
The nurse has determined that a postpartum client has physical findings consistent with uterine atony. The nurse plans to take which action first?
Massage the uterus until firm.
Rationale: When uterine atony occurs, the first nursing action would be to massage the uterus until firm. If this does not assist in controlling blood loss, then the physician is notified. Additionally, once bleeding is under control, the nurse would monitor the vital signs and estimate the amount of blood loss.
When participating in the planning of care of a postpartum client who plans to breast-feed her infant, the nurse realizes the importance of including which of the following in the teaching plan to prevent the development of mastitis?
Massage distended areas as the infant nurses.
Rationale: Massaging the distended areas as the infant nurses will encourage complete emptying of the breast and prevent milk stasis. Soap should not be used on the nipples because of the risk of drying or cracking. Each breast should be offered at each feeding to prevent milk stasis and to ensure adequate milk supply. If early signs of mastitis occur, the client usually will be instructed to nurse the infant more frequently, because infant sucking is thought to empty the breast more completely.
The nurse is preparing to listen to the apical heart rate of a newborn. The nurse performs the procedure and notes that the heart rate is normal if which of the following is noted?
A heart rate of 140 beats/min
Rationale: The normal heart rate in a newborn is 120 to 160 beats/min. The other options are incorrect.
The nurse is preparing to check the respirations of a newborn who was just delivered. The nurse performs the procedure and determines that the respiratory rate is normal if which of the following is noted?
A respiratory rate of 40 breaths/min
Rationale: Normal respiratory rate varies from 30 to 60 breaths/min when the infant is not crying. Respirations should be counted for 1 full minute to ensure an accurate measurement because the newborn is a periodic breather. Observing and palpating respirations while the infant is quiet promote accurate data collection.
The nurse is performing an assessment on a neonate. The nurse is preparing to measure the head circumference of the neonate. The nurse would:
Place the paper tape under the newborn's head, wrap around the occiput, and measure just above the eyes.
Rationale: To measure head circumference, the nurse should place the paper tape under the newborn's head and wrap the tape around the newborn's head, measuring just above the eyebrows so that the largest area of the occiput is included.
The nurse is checking the reflexes of a neonate. In eliciting the Moro reflex, the nurse would do which of the following?
Clap hands, or slap the mattress.
Rationale: The Moro reflex is elicited by a loud noise, such as a hand clap or a slap on the mattress. The neonate should respond (in sequence) with extension and abduction of the limbs, followed by flexion and abduction of the limbs and then by flexion and adduction of the limbs. This reflex disappears at 6 months of age. The rooting reflex is elicited by stimulating the perioral area with the finger. The palmar grasp reflex is elicited by stimulating the palm of the hand with firm pressure, and the plantar grasp reflex is elicited by stimulating the ball of the foot with firm pressure.
The nurse is planning to administer an injection of vitamin K to a newborn. In preparing to administer the injection, the nurse would select which of the following injection sites?
The lateral aspect of the middle third of the vastus lateralis muscle
Rationale: The preferred injection site for vitamin K in the newborn is the lateral aspect of the middle third of the vastus lateralis muscle
in the newborn's thigh. This is the preferred injection site because it is free of major blood vessels and nerves and is large enough to absorb the medication.
The nurse is monitoring a client with dysfunctional labor for signs of fetal or maternal compromise. Which of the following findings would alert the nurse to a compromise?
The passage of meconium
Rationale: Signs of fetal or maternal compromise include a persistent, nonreassuring fetal heart rate, fetal acidosis, and the passage of meconium. Maternal fatigue and infection can occur if the labor is prolonged but does not indicate fetal or maternal compromise. Progressive changes in the cervix and coordinated uterine contractions are a reassuring pattern in labor.
The nurse has developed a plan of care for a client experiencing dystocia and includes several nursing interventions in the plan. The nurse prioritizes the plan and selects which of the following nursing interventions as the highest priority?
Monitoring fetal status
`Rationale: The priority in the plan of care would include the intervention that addresses the physiological integrity of the fetus. Although providing comfort measures, changing the client's position frequently, and keeping the significant other informed of the progress of the labor are components of the plan of care,
fetal status is the priority.
The nurse has developed a plan of care for a client experiencing dystocia and includes several nursing interventions in the plan. The nurse prioritizes the plan and selects which of the following nursing interventions as the highest priority?
Monitoring fetal status
Rationale: The priority in the plan of care would include the intervention that addresses the physiological
integrity of the fetus. Although providing comfort measures, changing the client's position frequently, and keeping the significant other informed of the progress of the labor are components of the plan of care, fetal status is the priority.
The nurse is assisting in conducting a prenatal session with a group of expectant parents. One of the expectant parents asks, "How does the milk get secreted from the breast?" The best response by the nurse should be:
"Prolactin stimulates the secretion of milk, which is called lactogenesis."