High Risk Pregnancy, Postpartum, & Newborn

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Lowdermilk: Maternity Nursing, 8th Edition ch19-24

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

D. The nonstress test is one of the most widely used techniques to determine fetal well-being and is accomplished by monitoring fetal heart rate in conjunction with fetal activity and movements.

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

B. Maternal diabetes mellitus and postmaturity are two indications for performing a contraction stress test .Decreased fetal movement AND Intrauterine growth restriction, hx of prev stillborn are indicators for performing a contraction stress test; the size (small for gestational age) is not an indicator, nor is preterm labor. Although adolescent pregnancy and poor prenatal care are risk factors of poor fetal outcomes, they are not indicators for performing a contraction stress test.

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

A. Doppler blood flow analysis allows the examiner to study the blood flow noninvasively in the fetus and the placenta. It is a helpful tool in the management of high risk pregnancies because of intrauterine growth restriction (IUGR), diabetes mellitus, multiple fetuses, or preterm labor.

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

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

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

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

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

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

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

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

MSAFP levels have been used as a screening tool for ______________________________ in pregnancy.

NEURAL TUBE DEFECTS

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

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

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

D. Women with excellent glucose control and no blood vessel disease should have good pregnancy outcomes.

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

B. Congenital malformations account for 30% to 50% of perinatal deaths.

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

B. PKU is a cause of mental retardation in infants; mothers with PKU pass on phenylalanine through breast milk.

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

B. Bed rest may be ordered, with or without bathroom privileges. Bowel movements without stress or strain for the woman are promoted with stool softeners, diet, and fluid.

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

D. A reading of 60 mg/dl is too low. During hours of sleep glucose levels should not be under 60 mg/dl. Snacks before sleeping can be helpful.

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

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

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

D. These symptoms of cardiac decompensation may appear abruptly or gradually.

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

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

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

C. Epilepsy is the most common neurologic disorder accompanying pregnancy. The effects of pregnancy on epilepsy are unpredictable.

Less than 10% of women who are substance abusers receive treatment for their addiction during pregnancy. (T/F)

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

C. Spontaneous abortion is another name for miscarriage; by definition it occurs early in pregnancy.

The nurse is caring for a woman who is at 24 weeks of gestation with suspected severe preeclampsia. Which signs and symptoms would the nurse expect to observe? Select all that apply.
A. Decreased urinary output and irritability
B. Transient headache and +1 proteinuria
C. Ankle clonus and epigastric pain
D. Platelet count of less than 100,000/mm3 and visual problems
E. Seizure activity and hypotension

A,C,D

_________________________ is responsible for 10% to 15% of all maternal mortality and is the leading cause of infertility.

Ectopic Pregnancy

The condition in which the placenta is implanted in the lower uterine segment near or over the internal cervical os is _____________.

Placenta Previa

A laboring woman's amniotic membranes have just ruptured. The immediate action of the nurse would be to:
A. Assess the fetal heart rate (FHR) pattern.
B. Perform a vaginal examination.
C. Inspect the characteristics of the fluid.
D. Assess maternal temperature.

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

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

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

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

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

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

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

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

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

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

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

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

D. Self-care in a postterm pregnancy should include performing daily fetal kick counts three times per day. The mother should feel four fetal movements per hour. If fewer than four movements have been felt by the mother, she should count for 1 more hour. Fewer than four movements in that hour warrants evaluation. The options are normal findings at 42 weeks

____________________ is defined as long, difficult, or abnormal labor. It is caused by various conditions associated with the five factors affecting labor.

DYSTOCIA

Two hours after giving birth, a primiparous woman becomes anxious and complains of intense perineal pain with a strong urge to have a bowel movement. Her fundus is firm, at the umbilicus, and midline. Her lochia is moderate rubra with no clots. The nurse would suspect:
A. Bladder distention.
B. Uterine atony.
C. Constipation.
D. Hematoma formation.

D. Increasing perineal pressure along with a firm fundus and moderate lochial flow are characteristic of hematoma formation.

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

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

Which woman is at greatest risk for early postpartum hemorrhage (PPH)?
A. A primiparous woman (G2P101) being prepared for an emergency cesarean birth for fetal distress
B. A woman with severe preeclampsia on magnesium sulfate whose labor is being induced
C. A multiparous woman (G3P2002) with an 8-hour labor
D. A primigravida in spontaneous labor with preterm twins

B. Magnesium sulfate administration during labor poses a risk for PPH. Magnesium acts as a smooth muscle relaxant, thereby contributing to uterine relaxation and atony.

The first and most important nursing intervention when a nurse observes profuse postpartum bleeding is to:
A. Call the woman's primary health care provider.
B. Administer the standing order for an oxytocic.
C. Palpate the uterus and massage it if it is boggy.
D. Assess maternal blood pressure and pulse for signs of hypovolemic shock.

C. The initial management of excessive postpartum bleeding is firm massage of the uterine fundus. The other options are appropriate, however not the 1st thing that should be done.

What PPH conditions are considered medical emergencies that require immediate treatment?
A. Inversion of the uterus and hypovolemic shock
B. Hypotonic uterus and coagulopathies
C. Subinvolution of the uterus and idiopathic thrombocytopenic purpura (ITP)
D. Uterine atony and disseminated intravascular coagulation (DIC)

A. Inversion of the uterus and hypovolemic shock are considered medical emergencies. The others are serious conditions, but may not require immediate treatment

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

C. Mastitis is infection in a breast, usually confined to a milk duct. Most women who suffer this are first-timers who are breastfeeding.

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

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

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

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

Possible alternative and complementary therapies for postpartum depression (PPD) for breastfeeding mothers include (choose all that apply):
A. Acupressure.
B. Aromatherapy.
C. St. John's wort.
D. Wine consumption.
E. Yoga.

A,B,E

An infant was born 2 hours ago at 37 weeks of gestation, weighing 4.1 kg. The infant appears chubby with a flushed complexion and is very tremulous. The tremors are most likely the result of:
A. Birth injury.
B. Hypocalcemia.
C. Hypoglycemia.
D. Seizures.

C. Hypoglycemia is common in the macrosomic infant. Signs of hypoglycemia include jitteriness, apnea, tachypnea, and cyanosis.

The abuse of which of the following substances during pregnancy is the leading cause of cognitive impairment in the United States?
A. Alcohol
B. Tobacco
C. Marijuana
D. Heroin

A. Alcohol abuse during pregnancy is recognized as one of the leading causes of cognitive impairment in the United States.

A newborn was admitted to the neonatal intensive care unit after being delivered at 29 weeks of gestation to a 28-year-old multiparous, married, Caucasian female whose pregnancy was uncomplicated until premature rupture of membranes and preterm birth. The newborn's parents arrive for their first visit after the birth. The parents walk toward the bedside but remain approximately 5 feet away from the bed. The nurse's most appropriate action would be to:
A. Wait quietly at the newborn's bedside until the parents come closer.
B. Go to the parents, introduce himself or herself, and gently encourage them to come meet their infant; explain the equipment first, and then focus on the newborn.
C. Leave the parents at the bedside while they are visiting so they can have some privacy.
D. Tell the parents only about the newborn's physical condition and caution them to avoid touching their baby.

B. The nurse is instrumental in the initial interactions with the infant. The nurse can help the parents see the infant rather than focus on the equipment. The importance and purpose of the apparatus that surrounds their infant also should be explained to them.

With regard to injuries to the infant's plexus during labor and birth, nurses should be aware that:
A. If the nerves are stretched with no avulsion, they should recover completely in 3 to 6 months.
B. Erb palsy is damage to the lower plexus.
C. Parents of children with brachial palsy are taught to pick up the child from under the axillae.
D. Breastfeeding is not recommended for infants with facial nerve paralysis until the condition resolves.

A. It is true that if the nerves are stretched with no avulsion, they should recover completely in 3 to 6 months. However, if the ganglia are disconnected completely from the spinal cord, the damage is permanent. Erb palsy is damage to the upper plexus and is less serious than brachial palsy. Parents of children with brachial palsy are taught to avoid picking up the child under the axillae or by pulling on the arms. Breastfeeding is not contraindicated, but both the mother and infant will need help from the nurse at the start.

In appraising the growth and development potential of a preterm infant, nurses should:
A. Tell parents their child won't catch up until about age 10 (girls) to 12 (boys).
B. Correct for milestones such as motor competencies and vocalizations until the child is approximately 3 years of age.
C. Know that the greatest catch-up period is between 9 and 15 months postconceptual age.
D. Know that the length and breadth of the trunk is the first part of the infant to experience catch-up growth.

B.Corrections are made with a formula that adds gestational age and postnatal age. The infant, girl or boy, experiences catch-up body growth during the first 2 to 3 years of life. Maximum catch-up growth occurs between 36 and 40 weeks postconceptual age. The head is the first part of the infant to experience catch-up growth.

During the initial acute distress phase of grieving, parents still must make unexpected and unwanted decisions about funeral arrangements and even naming the baby. The nurse's role should be to:
A. Take over as much as possible to relieve the pressure.
B. Encourage grandparents to take over.
C. Make sure the parents themselves approve the final decisions.
D. Let them alone to work things out.

C. The nurse is always the patient's advocate. Nurses can offer support and guidance and leave room for the same from grandparents. However, in the end nurses should strive to let the parents make the final decisions.

For clinical purposes, preterm and postterm infants are defined as:
A. Preterm before 34 weeks if appropriate for gestational age (AGA); before 37 weeks if small for gestational age (SGA).
B. Postterm after 40 weeks if large for gestational age (LGA); beyond 42 weeks if AGA.
C. Preterm before 37 weeks, postterm beyond 42 weeks, no matter the size for gestational age at birth.
D. Preterm, SGA before 38 to 40 weeks; postterm, LGA beyond 40 to 42 weeks.

C. Preterm and postterm are strictly measures of time—before 37 weeks and beyond 42 weeks respectively—regardless of size for gestational age.

A plan of care for an infant experiencing symptoms of drug withdrawal should include:
A. Administering chloral hydrate for sedation.
B. Feeding every 4 to 6 hours to allow extra rest.
C. Swaddling the infant snugly and holding the baby tightly.
D. Playing soft music during feeding.

C. The infant should be wrapped snugly to reduce self-stimulation behaviors and protect the skin from abrasions. Phenobarbital or diazepam may be administered to decrease central nervous system (CNS) irritability. The infant should be fed in small, frequent amounts and burped well to diminish aspiration and maintain hydration. The infant should not be stimulated (such as with music) because this will increase activity and potentially increase CNS irritability.

With regard to the classification of neonatal bacterial infection, nurses should be aware that:
A. Congenital infection progresses slower than nosocomial infection.
B. Nosocomial infection can be prevented by effective handwashing; early-onset infections cannot.
C. Infections occur with about the same frequency in boy and girl infants, although female mortality is higher.
D. The clinical sign of a rapid, high fever makes infection easier to diagnose.

B. Handwashing is an effective preventive measure for late-onset (nosocomial) infections because these infections come from the environment around the infant. Early-onset, or congenital, infections are caused by the normal flora at the maternal vaginal tract. Congenital (early-onset) infections progress more rapidly than nosocomial (late-onset) infections.

Which infant would be more likely to have Rh incompatibility?
A. Infant of an Rh-negative mother and a father who is Rh positive and homozygous for the Rh factor
B. Infant who is Rh negative and whose mother is Rh negative
C. Infant of an Rh-negative mother and a father who is Rh positive and heterozygous for the Rh factor
D. Infant who is Rh positive and whose mother is Rh positive

A. If the mother is Rh negative and the father is Rh positive and homozygous for the Rh factor, all the offspring will be Rh positive. Only Rh-positive offspring of an Rh-negative mother are at risk for Rh incompatibility. Only the Rh-positive offspring of an Rh-negative mother are at risk.

As a result of large body surface in relation to weight, the preterm infant is at high risk for heat loss and cold stress. By understanding the four mechanisms of heat transfer (convection, conduction, radiation, and evaporation), the nurse can create an environment for the infant that prevents temperature instability. While evaluating the plan that has been implemented, the nurse knows that the infant is experiencing cold stress when he or she exhibits:
A. Decreased respiratory rate.
B. Bradycardia followed by an increased heart rate.
C. Mottled skin with acrocyanosis.
D. Increased physical activity.

C. The infant has minimal-to-no fat stores. During times of cold stress the skin will become mottled, and acrocyanosis will develop, progressing to cyanosis. Even if the infant is being cared for on a radiant warmer or in an isolette, the nurse's role is to observe the infant frequently to prevent heat loss and respond quickly if signs and symptoms occur. The respiratory rate increases followed by periods of apnea. The infant initially tries to conserve heat and burns more calories, after which the metabolic system goes into overdrive. In the preterm infant experiencing heat loss, the heart rate initially increases followed by periods of bradycardia. In the term infant, the natural response to heat loss is increased physical activity. However, in a term infant experiencing respiratory distress or in a preterm infant, physical activity is decreased.

The nurse is caring for an infant born at 28 weeks of gestation. Which complication could the nurse expect to observe during the course of the neonate's hospitalization? Select all that apply.
A. Polycythemia
B. Respiratory distress syndrome
C. Meconium aspiration syndrome
D. Periventricular hemorrhage
E. Persistent pulmonary HTN
F. Patent ductus arteriosus

B,D,F

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